Calcaneal fractures

Last evidence check Nov 2013

Gissane described percutaneous elevation of depressed intra-articular fractures and this formed the basis of Essex-Lopresti’s classic 1951 paper. He elevated his tongue-type fractures with a percutaneous Gissane spike. Joint-depression fractures were reduced by a limited open approach before being fixed with a spike. Unfortunately he did not separate the fracture types in his results.

Percutaneous reduction

There has been increased interest in percutaneous or limited open reduction techniques recently, often with arthroscopic assistance (Tornetta 2000, Ebraheim 2000, Gavlik et al 2002, Rammelt 2002). Essex-Lopresti's technique is used to reduce tongue-type fractures. Joint depression fractures are reduced with an elevator introduced through the sinus tarsi or a punch passed through the inferior surface of the bone. Post-reduction stabilisation has been achieved with K-wires (Stulik et al 2006), a unilateral fixator (Magnan et al 2006) or a ring fixator (Paley and Fischgrund, Talarico 2004, McGarvey et al 2006).

DeWall (2010) reported a comparison between the outcomes of 83 calcaneal fractures treated by percutaneous reduction and screw fixation and of 42 fractures treated by conventional ORIF. One surgeon principlly used percutaneous treatment, th other ORIF. Reduction was assessed by plain films and was similar (not always complete) in both groups. Clinical resultsusing the FFI and SF36 were similar, but only a limited subgroup was assessed. There were 6/42 deep infections and 9/42 wound complications in the ORIF group compared with 0/83 and 5/83 in the percutaneous group.

Rammelt (2010) selected 61 Sanders type 2 fractures for percutaneous reduction, using arthroscopic control in 33 type 2A and 2B fractures. Five fractures could not be reduced percutaneously and underwent ORIF. Mean follow-up was 29 months and the results were compared with historic, comparable controls who underwent ORIF. Quality of reduction was comparable. There was one wound dehiscence in the ORIF group and no wound complications in the percutaneous group. The percutaneous group had better subtalar movement and less time off work and the AOFAS hidfoot scores were comparable.

Chen (2011) randomised 78 patients to ORIF or percutaneous reduction and fixation with screws and calcium phosphate cement. The quality of reduction of the overall calcaneal dimensions was equivalent and patients who had closed treatment had better AOFAS hindfoot scores, Maryland Foot Scores and ankle and subtalar range of movement. Although the authors studied articular reduction with post-op CT, the results are not presented in the paper. Power calculations and randomisation procedures are also obscure.

Sinus tarsi approach

Ebraheim (2000) described a less invasive approach in the sinus tarsi. Although they used trans-articular fixation, other authors have used a variety of percutanous fixaton methods. Schepers (2011) reported a systematic review of 8 series, citing good-to-excellent functional results in 75%, significant wound complications in 4.8%, subtalar fusion in 4.3% and one sural nerve injury over 5 series. All but one were retrospective series. Two similar series have subsequently appeared (Nosewicz 2012, Kikuchi 2013). Nosewicz noted that 3-part fractures tended to be less well reduced than 2-part.

Weber (2008) compared 24 patients who had reduction through a sinus tarsi approach with a hostorical control group who had an extensile lateral approach. Reduction was comparable, the AOFAS scores showed no significant difference, there were fewer soft tissue complications and reduced operating time in the sinus tarsi group.

Kline (2013) compared 33 fractures reduced through a sinus tarsi approach with 79 using the extended lateral approach. Allocation was by surgeon preference but the groups were comparable for age, smoking, workers' compensation status and fracture type. Wound complications occurred in 29% of the extended lateral approach group compared with 6% of the sinus tarsi group (p=0.005), secondary procedures in 23% and 3% (p=0.007) and sural nerve problems in 4% and 3% (NS). Fewer than half the patients returned for clinical review, but of those that did there were no differences in Foot Function Index, SF36, VAS pain score or satisfaction rating.

Results appear similar to those of open reduction and internal fixation, possibly with lower rates of serious infection. The technique is demanding, particularly in joint depression or comminuted fractures which seem to do slightly less well. The joint fragments are not always fully reduced, but this may not adversely affect the results. Unfortunately there is only one RCT of modest quality which found better results in minimal-invasive surgery than ORIF. Given that there seems little difference between ORIF and non-surgical treatment in the best trials, a high-quality trial comparing minimally invasive surgery with non-surgical treatment seems required. The Netherlands trial was intended to compare ORIF, minimally invasive surgery and non-surgical treatment but owing to recruitment problems may not be completed.