Radiographic Outcomes for Intra-Articular Calcaneus Fractures Treated with a Two-Incision Medial and Lateral Minimally Invasive Approach

Abstract

Category: Trauma Introduction/Purpose: Calcaneus fractures are serious injuries that can have disabling outcomes. Achieving anatomic reduction and minimizing postoperative complications are crucial to successful treatment. Recent literature has focused on minimally invasive techniques; however, there are concerns about the ability of such techniques to reliably achieve anatomic reduction. The extensile lateral approach has demonstrated high rates of postoperative soft tissue complications. This study reviews the radiographic and clinical outcomes of a two-incision (medial and sinus tarsi), minimally invasive approach for displaced intra-articular calcaneus fractures treated by a single surgeon. We hypothesized that this technique would provide successful radiographic reduction with minimal complications. Methods: A retrospective radiographic and chart review was performed on patients with displaced intra-articular calcaneus fractures that underwent open reduction and internal fixation with a medial and sinus tarsi approach. The surgical procedure utilizes a medial incision with a push-pull technique facilitating anatomic reduction of the calcaneal tuberosity due to the stability of the medial cortex, thus re-establishing calcaneal length and height and eliminating heel varus. Reduction of the tubercle allows for reduction of the posterior facet through a sinus tarsi approach. Posterior screws were utilized for cases with severe comminution. Primary outcome measures included radiographic angular and linear dimensions and the rate of post-operative wound complications. Secondary outcomes included rate of nonunion, secondary surgeries, and other complications. Demographic data included the patient’s age, gender, mechanism of injury, injured extremity, time to surgery, smoking and diabetes history, presence of fracture blisters, and time to follow-up. Patients were followed to radiographic union. Results: Twenty-two patients (age 50.6 +/- 16.1 years) met the inclusion criteria. Preoperatively, 11 were Sanders IIA, 7 Sanders IIB, 1 Sanders IIIAB, 2 Sanders IIIAB, and 1 Sanders IV. Two (9.1%) had a superficial wound infection treated with local wound care. Two patients underwent removal of hardware (posterior screws). There were no cases of nonunion, osteomyelitis, deep infection, tibial nerve injury, or loss of fixation. The preoperative Bohler’s angle averaged 11.3 +/- 10.0 (range -5 to 36) degrees and the postoperative Bohler’s angle averaged 30.3 +/- 7.6 (range 16 to 40) degrees (p < 0.05). Calcaneal height measured 4.6 +/-0.41 (range 4.2 to 5.2) cm preoperatively and 4.96 +/- 0.48 (range 4.3 to 5.8) cm postoperatively (p < 0.05). No patients underwent a subtalar fusion. Conclusion: The goals of any approach for calcaneus fractures are to obtain anatomic fracture reduction and stable fixation while minimizing postoperative complications. Our study demonstrates a significant improvement in radiographic calcaneal alignment utilizing a novel minimally invasive medial and sinus tarsi approach to intra-articular calcaneus fractures. Our postoperative complication rate is at or below that published for other techniques. In conclusion, the two-incision, medial and sinus tarsi approach provides a significant improvement in calcaneal alignment and is a safe and technically attainable approach in the management of intra-articular calcaneus fractures.