SLR - May 2013 - John Y. Suh
Reference: Kline AJ, Anderson RB. Minimally Invasive Technique Versus an Extensile Lateral Approach for Intra-articular Calcaneal Fractures. Foot and Ankle International. March 2013.
Scientific Literature Review
Reviewed by: John Y. Suh, DPM
Residency Program: Temple University Hospital
Podiatric Relevance: The optimal management and treatment of calcaneal fractures remains somewhat controversial. Although the lateral extensile approach for calcaneal fractures allows for great visualization of the posterior facet, high wound complication rates have been reported even with meticulous wound care. Some have advocated non-operative treatment due to high complication rates and variable outcomes with surgical treatment. Now with the advancement of technology, minimally invasive techniques have been developed to aid in fracture reduction with minimal soft tissue disruption. With this is mind, the authors of this study compared the lateral extensile approach to a minimal invasive technique. The authors in particular focused on postoperative wound healing and also functional outcome.
Methods: A retrospective review was performed on 112 calcaneal fractures. All fractures met the inclusion criteria which were that all fractures were closed, a Sanders II or III type fracture, and minimum age of 18 years. Seventy-three fractures were treated with the standard lateral extensile approach and 29 fractures were treated with a minimally invasive technique as described by Holmes. This technique involved a sinus tarsi incision for visualization of the posterior facet and manipulation and restoration of length with a Schantz pin. Percutaneous cannulated screws were then used to maintain the reduction. All patients were contacted for follow-up and further assessment at a later date. A total of 47 patients (31 from the lateral extensile approach and 16 from the minimally invasive approach) returned and answered three questionnaires (VAS, FFI, SF-36) assessing functional outcome. An orthopaedic surgeon also performed a clinical and radiographic assessment at this research visit.
Results: The two patients groups had similar demographics in terms of age, gender, tobacco use and worker’s compensation status. Wound complications were higher in the lateral extensile group with a complication rate of 29 percent, with 9 percent requiring surgical intervention. The minimally invasive group had a wound complication rate of 6 percent with none requiring surgery. In the 47 patients that followed-up for the research visit, the 16 patients had slightly better functional outcome scores compared to the 31 lateral extensile group. The minimally invasive group scored better in the FFI, SF-36 and VAS questionnaires but the differences were not statistically significant. Eighty-four percent of the patients in the lateral extensile group were pleased with their outcome compared to 94 percent in the minimally invasive group. Radiographic assessment showed a 100 percent union in all patients with no significant difference in the final postoperative Bohlers and Gissane’s angle.
Conclusion: The authors in this study conclude that a minimally invasive technique for the treatment of calcaneal fractures provides similar clinical results as the lateral extensile approach but does not come with risk of wound complications. The author also does note that there is no great data on long-term outcomes of the minimally invasive technique compared to the lateral extensile approach.