SLR - February 2013 - Waters
Reference: Wu Z, Su Y, Chen W, Zhang Q, Liu Y, Li M, Wang H, Zhang Y. Functional outcome of displaced intra-articular calcaneal fractures: a comparison between open reduction/internal fixation and a minimally invasive approach featured an anatomical plate and compression bolts.J Trauma Acute Care Surg. 2012 Sep;73(3):743-51.
Scientific Literature Review
Reviewed by: David Waters, DPM
Residency Program: St. John Hospital and Medical Center
Podiatric Relevance:
Approximately 75 percent of calcaneal fractures are displaced intra-articular fractures. Sequelae of displaced intra-articular fractures include arthritis and arthrosis of the subtalar joint, infection, and delayed wound healing. These all can lead to disabling conditions. Traditionally these fractures have been treated with ORIF via an extensile L-shaped incisional approach. This approach gives superior access and ease of manipulation and reduction of the fracture fragments. This lateral incisional approach has been reported to have an average complication rate around 16 percent with the greater percentage of these being soft tissue complications. On the other hand, the concern with minimally invasive reports is incomplete reduction and fixation, especially in complex fracture patterns. This study proposes a minimally invasive protocol utilizing percutaneous leverage and anatomic plate and compression bolts and compares functional outcomes and complications.
Methods:
Three hundred eighty-three displaced intra-articular calcaneal fractures were retrospectively reviewed. One hundred seventy feet were treated with traditional ORIF from 2004-2006 and 213 feet were treated with minimally invasive calcaneal internal compression from 2007-2009. Patients were followed at six, 12, and 24 weeks and 12 months post-op and then yearly after that with a mean follow-up of 12 months. All patients in both groups underwent the same postoperative rehabilitation protocol. Good reduction was noted as restoration of length and height, Bohler’s angle back to normal range of 25-40 degrees, absence of inversion or eversion of the calcaneus, and posterior articular facet step off less than three millimeters. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot score was used for functional evaluation at 12 months follow-up. Patients were further divided based on the Sanders classification, and functional outcomes were compared. The AOFAS was divided into four categories: 90-100 was graded excellent; 80 to 89 as good; 70 to 79 as fair; and less than 70 as poor.
Results:
The overall complication rate was 6.57 percent in the minimally invasive group and 15.89 percent in the traditional ORIF group which demonstrated statistical significance. The average measurement of Bohlers angle postoperatively was 28.51 traditional and 27.76 minimally invasive. Radiographic evidence of posttraumatic arthritis was noted in 24 cases in the minimally invasive group and 22 cases in the traditional ORIF group. The average time to return of partial progressive to full weight bearing was 5.64 weeks for the minimally invasive group and 9.38 weeks for the traditional ORIF group, which was statistically significant. Together, 134 of 383 (34.99 percent) of feet had excellent results, 195 of 383 (50.91 percent) had good results, 40 of 383 (10.44 percent) fair results and 14 of 383 (3.66 percent) poor results. In the minimally invasive group, excellent to good results were achieved in 185 of 213 (86.85 percent); Sanders type 2: 114 of 115 (99.13 percent); type 3: 63 of 74 (85.14 percent); and type 4: eight of 24 (33.33 percent). In the traditional ORIF group 144 of 170 (84.71 percent) had good to excellent results; type 2: 89 of 92 (96.74 percent); type 3: 49 of 61 (80.33 percent); type 4: six of 17 (35.3 percent). The mean AOFAS score was 86.53 in the minimally invasive group and 85.59 in the traditional ORIF group with no statistical difference. Of the four subjective variables, the minimally invasive group did statistically better with activity limitation and walking surface.
Conclusions:
The sequelae of displaced intra-articular calcaneal fractures can be disabling. Functional outcomes are an important criteria to consider when deciding on surgical approach to this complex injury. This minimally invasive approach has shown to provide as good if not better functional results than true open techniques. It provides an effective alternative to treatment for displaced intra-articular calcaneal fractures.