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

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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.

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