Point-Counterpoint: Should You Perform Minimal Incision Or Extensile Lateral Incision For Calcaneal Fractures?

Author(s): 
Keith D. Cook, DPM, FACFAS, and Matthew L. German, DPM; George F. Wallace, DPM, MBA

Minimal incision.

These authors note that using a minimal incision can facilitate anatomic reduction for calcaneal fractures and leads to fewer post-op complications than the extensile lateral incision.

By Keith D. Cook, DPM, FACFAS, and Matthew L. German, DPM Calcaneal fractures rank as the most common fractures of the tarsal bones of the foot and comprise an estimated 2 percent of all fractures of the body.1 Approximately 75 percent of all calcaneal fractures are intra-articular with involvement of the posterior subtalar joint and have been associated with a poor prognosis.2,3    Complications associated with intra-articular calcaneal fractures are well documented and include chronic pain and edema, malunion, varus deformity of the calcaneus, degenerative changes in the subtalar joint and soft tissue complications. Multiple studies have shown a decrease in the rate of these complications, especially degenerative subtalar joint changes, when these fractures are anatomically reduced.4-6    Based on the location of the traditional extensile lateral incision, there has historically been a high rate of wound healing complications in open reduction and internal fixation (ORIF) of these fractures. The rate of wound edge necrosis is reportedly as high as 18 percent and infection rates are as high as 20 percent.4-6 A recent study found the postoperative wound complication rate for standard extensile lateral incision to be 17.8 percent (87 out of 490 procedures).5 Of these 87 wound complications, the authors found a high rate of surgical site infections with 25 cases of soft tissue infection and 11 cases of osteomyelitis. Fifty-nine of these cases required an additional surgical treatment, including debridement, hardware removal or free flap coverage of the wound.    Multiple studies continue to show a high wound complication rate despite the use of a “no touch technique” and meticulous dissection when utilizing the extensile lateral incision. Authors have proposed more minimally invasive techniques to reduce this risk.7 Various authors have described percutaneous fixation, arthroscopically assisted fixation, external fixation, calcaneoplasty and minimal incision techniques from multiple different approaches.

A Closer Look At The Minimal Incision Technique And Current Research

The senior author’s preferred technique is a minimally invasive open approach over the sinus tarsi. This approach is probably the most utilized minimally invasive technique. Surgeons can perform fracture reduction and fixation through this approach with the use of screws, plates and/or percutaneous transarticular pins.8-9    To determine the adequacy of reduction through this technique, Nosewicz and colleagues performed a case series in which they evaluated fracture reduction through computed tomography (CT) scan imaging, immediately following the procedure and at least one year postoperatively.8 The immediate postoperative CT scans showed excellent reduction of the posterior facet in 23 percent of the cases, good reduction in 41 percent, fair reduction in 27 percent and poor reduction in 9 percent. Seven of the eight patients with fair or poor reduction had a higher degree of comminution. At greater than one year of follow-up, no loss of reduction of the posterior facet or calcaneocuboid joint had occurred. The authors also measured the AOFAS hindfoot score at one-year follow-up with a mean score of 86 (range 57-100). Results were excellent in 9 of 19 patients, good in 7 of 19 patients, fair in 1 of 19 patients and poor in 2 of 19 patients.    To compare outcomes of percutaneous screw fixation with bone cement versus the traditional extensile lateral approach, Chen and colleagues developed a prospective randomized trial of 78 patients with displaced intra-articular calcaneal fractures.10 Patients were part of either an ORIF without bone graft group or a percutaneous reduction with bone graft group. In the ORIF group, surgeons applied a surgical drain to minimize the risk of hematoma and wound dehiscence. The patients who had percutaneous reduction with a bone graft could bear partial weight at six weeks and reached full weightbearing at 11 weeks postoperatively. This is in comparison to those who had ORIF, could bear partial weight at eight weeks and reached full weightbearing at 12 weeks.    Clinical outcomes showed improved recovery, subtalar joint motion and ankle joint motion in the percutaneous reduction group.10 One could attribute this to patients being allowed to bear weight earlier than their counterparts and that earlier weightbearing did not result in more frequent loss of fixation. Perhaps more importantly, wound complications occurred in 12 percent of those undergoing ORIF and only 3 percent of those undergoing percutaneous fixation. Two patients in the ORIF group had to have an additional operation for deep soft tissue debridement.    Finally, to compare outcomes of intra-articular calcaneal fractures treated with extensile lateral incisions versus those treated with the minimally invasive sinus tarsi approach, Kline and coworkers performed a retrospective case series of 112 calcaneal fractures over a three-year period.11 In the extensile lateral incision group, 29 percent of the patients developed wound complications. This is in comparison to 6 percent of the patients in the minimally invasive group. Seven of the patients in the extensile lateral incision group required additional debridement in the operating room in comparison to zero in the minimally invasive group. Also, the extensile lateral incision group required significantly more secondary procedures as 18 of the 79 patients required 25 additional procedures in comparison to the minimally invasive group, in which only one of the 33 patients required a single, secondary surgery.    At an average of 31 months follow-up, functional status was not significantly different between the two groups.11 Final radiographic views of Gissane and Bohler’s angles were also not significantly different between these two researched groups.    The approach that the senior author uses is a “lazy S” incision laterally over the sinus tarsi. Surgeons can perform reduction of the fracture fragments through the incision with the assistance of a Steinmann pin they place percutaneously into the posterior calcaneus to act as a joystick to distract the subtalar joint and correct the varus deformity. Perform fixation with screws and a small plate as needed through the incision, and insert a fully threaded screw from the posterior heel in a superior direction, stopping a few millimeters below the posterior facet. The senior author has noted a significant reduction in edema with minimal wound complications and a faster return to normal shoe gear and activities when utilizing this technique.

In Conclusion

Some surgeons may argue that one should master the extensile lateral approach prior to performing minimal incision reduction. However, this may not be in the patient’s best interest and can be comparable to performing an open appendectomy versus a laparoscopic appendectomy. The open technique results in more discomfort and slower recovery.    The recent literature demonstrates that one can obtain anatomic reduction of joint depression calcaneal fractures with the minimally invasive sinus tarsi approach along with a quicker return to activities, lower rates of wound healing complications and a decreased number of secondary procedures. Accordingly, we conclude that surgeons should favor a minimal incision approach over the extensile lateral incision.    Dr. Cook is the Director of Podiatric Medical Education at University Hospital in Newark, N.J. He is a Fellow of the American College of Foot and Ankle Surgeons.    Dr. German is the Chief Resident within the Podiatric Residency Program at University Hospital in Newark, N.J. References 1. O’Connell F, Mital MA, Rowe CR. Evaluation of modern management of fractures of the os calcis. Clin Orthop Relat Res. 1972 Mar-Apr;83:214-223. 2. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39(157):395-419. 3. Eastwood DM, Phipp L. Intra-articular fractures of the calcaneum: why such controversy? Injury. 1997;28:247-259. 4. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Orthop Trauma. 1999; 13(5):369-72. 5. Ding L, He Z, Xiao H, Chai L, Xue F. Risk factors for postoperative wound complications of calcaneal fractures following plate fixation. Foot Ankle Int. 2013;34(9):1238-1244. 6. Wang Q, Chen W, Su Y, Pan J, Zhang Q, Peng A, Wu X, Wang P, Zhang Y. Minimally invasive treatment of calcaneal fracture by percutaneous leverage, anatomical plate, and compress bolts – The clinical evaluation of cohort of 156 patients. J Trauma. 2010;69(6): 1515-1522. 7. Schuberth JM, Cobb MD, Talarico RH. Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. J Foot Ankle Surg. 2009;48(3):315-322. 8. Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, Hintermann B. Mini-open sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: A prospective Computed Tomograph-based study. Foot Ankle Int. 2012;33(11):925-933. 9. Ebraheim NA, Elgafy H, Sabry FF, Freigh M, Abou-Chakra IS. Sinus tarsi approach with trans-articular fixation for displaced intraarticular fractures of the calcaneus. Foot Ankle Int. 2000;21(2):105-113. 10. Chen L, Zhang G, Hong J, Lu X, Yuan W. Comparison of percutaneous screw fixation and calcium sulfate cement grafting versus open treatment of displaced intra-articular calcaneal fractures. Foot Ankle Int. 2011;32(10): 979-985. 11. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. Foot Ankle Int. 2013;34(6): 773-780.

Extensile lateral incision.

This author cites the extensile lateral incision’s versatility and direct visualization, saying the technique is a necessary foundation for other methods of calcaneal fracture surgery.

By George F. Wallace, DPM, MBA The extensile lateral incision for open reduction internal fixation (ORIF) of displaced calcaneal fractures first attained popularity from research by Benirschke and Sangeorzan in 1993.1 Since then, surgeons have utilized it as the incision of choice for adequate exposure to the calcaneus, specifically the lateral wall and posterior facet.    Due to its position and precarious angiosomes in the area, the incision is not without its complications, with wound healing complications approaching 20 to 40 percent in some studies.2,3 Authors have described modifications to decrease the incidence of complications, especially the ubiquitous dehiscence. All the problems with this incision have led to the development of new approaches, namely smaller incisions and, in some instances, even percutaneous techniques.4-6 Calcaneal plates have evolved to match the placement and size of these new incisions.    This begs the question: In light of the myriad complications and seemingly high rate of the same, why continue with the extensile lateral approach for ORIF of calcaneal fractures?    Calcaneal fractures that are displaced comprise upward of 2 percent of all fractures.3 Current literature suggests ORIF treatment.7

Why Treating Calcaneal Fractures Can Be Trying Even For Experienced Surgeons

Even in experienced hands, calcaneal fractures are complex. They require awareness of the spatial relationships of the various anatomical parts and how one maneuvers them into anatomic alignment. Researchers have shown that establishing Bohler’s angle to normal parameters of 25 to 40 degrees is a decisive factor in more favorable long-term results.8    There is a steep learning curve to repositioning with Sanders and colleagues suggesting performing 35 to 50 calcaneal fracture surgeries before one becomes comfortable with these fractures.9 Naturally, the greater the number of cases the surgeon performs, the more competent he or she should become. However, in spite of experience, displaced calcaneal fractures are humbling. When faced with one, I still take a bone model and review the anatomy, the maneuvers necessary to align everything, and review computed tomography and plain film studies. This preparation does help but it is still a taxing surgery.

A Closer Look At The Advantages Of Extensile Lateral Incisions

The percutaneous or small incision methods for ORIF of calcaneal fractures may be viable alternatives to the extensile lateral incision, especially in high-risk patients such as those with diabetes, smokers and patients with open fractures, as discussed by Hammond and Crist.4 What happens intraoperatively when any of the percutaneous methods fail to restore Bohler’s angle and/or decrease calcaneal varus? Will the skill set be available to convert to an extensile lateral incision? In other words, surgeons should master the extensile lateral incision first before attempting percutaneous surgery.10    The extensile lateral incision allows direct visualization. When is this critical? Specifically, this incision is better suited for severely comminuted fractures with multiple fractures through the posterior facet in various planes. The facet may be so impacted that its relocation would be next to impossible with any incision but the extensile lateral one. As an attending for a residency program at a Level 1 trauma center, I can tell you that for those patients not deemed to be high-risk, residents learn and do ORIF of calcaneal fractures through the extensile lateral incision. This provides a foundation for anatomical reduction. The transition to a percutaneous or small incision approach then more easily occurs and one can more easily understand its various nuances. Most fractures here fit the criteria for the extensile lateral incision.    Robust long-term studies comparing function via both methods are lacking, not necessarily because of a paucity of literature but primarily due to the relative short duration in which surgeons have utilized percutaneous and small incision approaches. Studies are needed with large cohorts to state definitively which incision approach is better.6 What happens if there is no difference between each?    DeGroot and colleagues had a complication rate of 32 percent when they employed a modified extensile lateral incision for patients with calcaneal fractures.3 The mid- and long-term outcomes were not affected by the various reported complications.    Intuitively, one can mitigate complications with the extensile lateral incision by operating on the area during “low tide.” Edema is minimal, skin lines are present, the pinch test is positive and fracture blisters, especially hemorrhagic ones, are nowhere near the incision site. Gone are the days when there was emergent treatment for calcaneal fractures, unless there is an open fracture or temporary stability is needed via external fixation. When the “low tide” is present, then one can perform the definitive surgery. There is usually a three-week window for the ORIF to take place. Note how timing plays an important part when assessing these fractures.7    The extensile lateral incision after the initial skin incision then goes straight to bone. The surgeon meticulously handles the flap, reflects it and holds it appropriately in a “no-touch” manner. The vertical arm of the incision should not meet the horizontal arm at 90 degrees but should be gently curved. This may help to reduce the apical dehiscence that so often occurs.11 After completion of the ORIF, when suturing the flap, place all sutures toward the apex.    The aforementioned suggestions will never lead to a zero complication rate. However, by selecting the right patients, adhering to the surgical principles, ensuring correct timing and paying attention to surgical and closure details, one can lower the complication rate.7    The extensile lateral incision is versatile, provides wide-ranging exposure and, to date, is the workhorse for ORIF of calcaneal fractures. Within a training program, surgeons should not abandon it but perform it as a foundation upon which to build other methods. Fonseca and colleagues, looking at general surgery training, came to a similar conclusion, contrasting open versus laparoscopic surgery.12 Journal clubs will provide future papers comparing the various methods as they are published. The foot and ankle surgeon is well aware of complications with any surgical approach, no matter the chosen method. One should deal with any complications appropriately.

In Conclusion

In my hands, the extensile lateral incision offers complete exposure to this difficult fracture and the opportunity with imaging to get the calcaneus back together as anatomically as possible. The residents have to be exposed to this incisional approach, ideally before introducing any other methods to their surgical armamentarium. Until further studies are available, this incision will be the one of choice.    Dr. Wallace is the Director of the Podiatry Service and the Medical Director of Ambulatory Care Services at University Hospital in Newark, NJ. References 1. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Clin Orthop Rel Res. 1993; 292:128-34. 2. Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: A cadaveric injection study. J Orthop Trauma. 1999; 13(2):73-7. 3. DeGroot R, Frima AJ, Schepers T, Roerdink WH. Complications following the extended lateral approach for calcaneal fractures do not influence mid- to long-term outcome. Injury. 2013; 44(11):1596-1600. 4. Hammond AW, Crist BD. Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: A case series. Injury. 2013; 44(11):1483-5. 5. Rammelt S, Amlang M, Barthel S. Intraarticular calcaneal fractures. Clin Orthop Relat Res. 2010; 468(4):983-90. 6. DeWall M, Henderson CE, McKinley TO, Phelps T, et al. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma. 2010; 24(8):466-76. 7. Nork SE, Buckley RE. Hindfoot: Calcaneus and talus. In: Ruedi TP, Buckley RE, Moran CG (eds): AO Principles of Fracture Management. AO Publishing, Davos Platz Switzerland, 2007, pp. 899-916. 8. Loucks C, Buckley R. Bohler’s Angle: Correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma. 1999; 13(8):554-8. 9. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 1993; 290:87-95. 10. Swanson SA, Clare MP, Sanders RW. Management of intra-articular fractures of the calcaneus. Foot Ankle Clin NA. 2008; 13(4):659-78. 11. Walter JH, Goss LR, Rockett MS. Calcaneal fractures. In: Gumann G (ed): Fractures Of The Foot And Ankle. Elsevier, Philadelphia, 2004, pp. 213-64. 12. Fonseca AL, Reddy V, Longo WE, Udelsman R, et al. Operative confidence of graduating surgery residents: a training challenge in a changing environment. Am J Surgery. 2014; 207(5):797-805.    For further reading, see “A Guide To Minimally Invasive Fracture Management” in the August 2007 issue of Podiatry Today, “How To Evaluate And Treat Calcaneal Fractures” in the November 2005 issue or “Plantar Calcaneal Spurs: Is Surgery Necessary?” in the May 2006 issue. To access the archives, visit www.podiatrytoday.com.

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