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What Is The Most Optimal Surgical Approach For Displaced Intraarticular Calcaneal Fractures?

Should one stick with the lateral extensile approach for surgical repair or consider a more minimally invasive procedure? With this question in mind, the authors review the evidence and provide pertinent insights on the evaluation and treatment of patients with displaced intraarticular calcaneal fractures.

The calcaneus is the most commonly fractured tarsus bone and accounts for one to two percent of all fractures in the body.1-3 Calcaneal fractures are generally high-energy and complex injuries that often result in increased calcaneal width, decreased height and varus angulation. This can lead to a number of poor patient outcomes without proper treatment. The treatment of displaced intra-articular calcaneal fractures (DIACFs) specifically remains a controversial topic without a gold standard treatment  protocol despite a number of relevant high-powered studies. Conservative treatment often results in poor functional outcomes and a higher incidence of subtalar joint arthrosis.4 Therefore, the question we aim to answer is how to best handle this type of fracture surgically.

The most common technique for displaced intra-articular calcaneal fractures is the lateral extensile approach, which involves utilizing an L-shaped or “hockey stick” incision along the posterior lateral heel. This technique allows good visualization and superior access to the fracture for reduction. However, this approach comes with a high incidence of wound healing complications ranging from 5.8 to 43 percent and a high incidence of sural neuritis among other complications.1,4,5 However, the use of minimally invasive approaches through the use of percutaneous fixation, external fixation or arthroscopic-assisted fixation may help limit some of these complications. The sinus tarsi approach, the most common minimally invasive technique surgeons use for these fractures, offers ease of utility and a low number of wound healing complications.1,5,6 

One needs to consider a number of different criteria before determining which approach is best for the patient. Before surgical planning occurs, it is important to obtain a complete patient history because comorbidities such as diabetes mellitus, vascular disease and history of smoking have a direct impact on the healing of these injuries. 

Additionally, it is important to classify the fracture as this will guide not only the prognosis but the surgical technique as well. Surgeons commonly use the Essex Lopresti classification for plain radiography of displaced intra-articular calcaneal fractures as opposed to the Rowe classification, which does not adequately depict intra-articular injuries. The Sanders classification is also an option for grading displaced intra-articular calcaneal fractures via computed tomography (CT). Having this information is key to success.

There are a number of high-powered studies that compare the lateral extensile approach versus a minimally invasive approach for intra-articular injuries. Furthermore, a recent meta-analysis published in 2020 summarized the data in these studies.1 This analysis included 17 randomized controlled trials (RCTs) and 10 retrospective studies ranging from 2007 to 2017. When only considering the randomized controlled trials, researchers found statistically significant differences in wound complications, superficial infection, sural nerve injury, and calcaneal height, all of which favored a minimally invasive approach to surgical management of these fractures.1  

After the first percutaneous operation by the German surgeon Westhues in 1934, a surgeons have used a considerable number of percutaneous and minimally invasive open techniques to treat calcaneal fractures. The indications for these surgeries depend on the severity of the calcaneal fracture. The Sanders classification breaks down the number and locations of articular fractures on coronal CT to arrive at a score to assist in evaluating this severity. Some indications for the minimally invasive approach are low energy injuries, joint depression greater than two mm, Sanders type 2 and 3 fractures, compromised soft tissue and blood supply.

The combination of closed reduction and percutaneous fixation is one type of minimally invasive approach one may use for Sanders type 1 injuries and the tongue-type “beak” fractures. These fracture fragments are usually large, being greater than one cm in size. Minimally invasive approaches can help with early reduction to prevent damage to the skin and are great for patients with peripheral vascular disease (PVD). Sanders type 2 and 3 fractures require open reduction and internal fixation via the sinus tarsi approach. 

One of the key elements in planning an incision is understanding blood supply and the vast network of vessels supplying the calcaneus and the surrounding integument. The lateral calcaneal artery, a branch of the peroneal artery, is the essential blood supply needed for incision healing after a calcaneal fracture. Angiosomes provide a description of blood flow by dividing anatomic units of tissue based on the artery that supplies that tissue.7 Choke vessels link neighboring angiosomes together via tributaries.7 Incision placement along these angiosomes can greatly benefit patient healing. However, these angiosomes may become compromised in trauma cases. 

The sinus tarsi incision is about two to four cm in length, starting at the tip of the lateral malleolus and extending down to the fourth metatarsal base. This minimally invasive approach has many advantages, including lowering wound complications, especially in cases of soft tissue and blood supply compromise. These procedures allow for direct visualization of the posterior facet, more effective treatment, reduced risk of sural neuritis and overall better postoperative outcomes via American Orthopaedic Foot and Ankle Society (AOFAS) scores in comparison to the lateral extensile approach.1 

In a systematic review, Hoeve and Poeze reviewed outcomes associated with different minimally invasive approaches and percutaneous techniques for calcaneal fractures over a 15-year span.8 This review included 46 studies, 1,776 patients and a total of 2,018 calcaneal fractures. These study authors found minimally invasive approaches and percutaneous techniques for calcaneal fractures resulted in significantly better AOFAS scores and increased Bohler's angles after treatment compared to external fixation and other techniques including K-wire fixation and suture button fixation.8 

In Conclusion 

While a minimally invasive option may be safe and effective for the treatment of calcaneal fractures, there is a steep learning curve to master this surgical approach. Some may argue the lateral extensile approach for calcaneal fractures was and remains the gold standard today. It is clear from the available literature that surgeons are still utilizing the lateral extensile approach for highly comminuted or Sanders type 4 fractures. However, for less complex fractures, there are surgical options available that yield satisfactory results with fewer complications. With emerging research, the gold standard of treatment may shift toward minimally invasive options. 

Dr. Burke is a second-year podiatric medicine and surgery resident at Mercy Hospital and Medical Center in Chicago.

Dr. Hook is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Foot and Ankle Surgery and is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice at Midland Orthopedic Associates and is the associate program director for the podiatric residency program at Mercy Hospital and Medical Center in Chicago.

Dr. Cheema is a third-year podiatric medicine and surgery resident at Mercy Hospital and Medical Center in Chicago.

Online Exclusives
By Kevin Burke, DPM, Jonathan Hook, DPM, FACFAS and Gurleen Cheema, DPM 
  1. Seat A, Seat C. Lateral extensile approach versus minimal incision approach for open reduction and internal fixation for displaced intra-articular calcaneal fractures: a meta-analysis. J Foot Ankle Surg. 2020;59(2):356-366.
  2. Wang J, Jinming M, Song Q. Calcaneal reduction forceps for minimally invasive treatment of calcaneal fractures: literature review and techniques. Int J Clin Exp Med. 2019;12(8):9582-9589.
  3. Majeed H, Barrie J, Munro W, McBride D. Minimally invasive reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular calcaneal fractures: a systematic review of the literature. Efort Open Rev. 2018;3(7):418-425.
  4. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82(2):225–250.
  5. Attilio B, Albo F, Giai Via A. Comparison between sinus tarsi approach and extensile lateral approach for treatment of closed displaced intra-articular calcaneal fractures: a multicenter prospective study. J Foot Ankle Surg. 2016;55(3):513-521.
  6. Nosewicz T, Knupp M, Barg A, et al. Miniopen sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography base study. Foot Ankle Int. 2012;33(11):925–933.
  7. Schwartz JM. Incision planning and placement in the lower extremity: considerations for dermal, soft tissue angiosomes. In: The Podiatry Institute Update 2012; The Proceedings of the Annual Meeting of the Podiatry Institute. Decatur, Ga: The Podiatry Institute;2012:179-184.
  8. Hoeve SV, Poeze M. Outcome of minimally invasive open and percutaneous techniques for repair of calcaneal fractures: a systematic review. J Foot Ankle Surg. 2016;55(6):1256–1263. 
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