Fractures of the calcaneus are challenging due to their complexity, limited soft tissue envelope, and prolonged rehabilitation time.1,2 Their economic impact is noteworthy, as most intra-articular calcaneal fractures occur in men during their early working years.3,4
Fractures of the calcaneus are the most frequent of tarsal bone fractures (65%), with an overall incidence of 2% of all fractures.5,6 These fractures, which are mostly intra-articular, are caused by high-velocity impact to the hindfoot, most commonly falls from heights.2,6
The optimal treatment of calcaneal fractures remains controversial.1,7,8 Conservative management is associated with articular surface malunion, leading to early painful posttraumatic arthritis, heel widening, and associated impingement of the peroneal tendons.9,10 Several studies have favored open reduction and internal fixation (ORIF), but soft tissue and other catastrophic complications such as sural neuritis were of concern.1,8,11 Closed reduction and percutaneous fixation has the advantage of restoring articular congruity similar to classic fixation, but there is less damage to the soft tissue and therefore less risk of complications.12,13
This prospective study sought to evaluate the functional and radiological results of a minimally invasive technique of closed or mini-open reduction and percutaneous K-wire fixation of Sanders type II or III calcaneal fractures.
Materials and Methods
This study involved a prospective consecutive case series of patients with displaced intra-articular calcaneal fractures, Sanders type II or III, who were treated with closed or mini-open reduction and percutaneous K-wire fixation from 2013 to 2016 at a single academic institution. Patients with Sanders type I or IV fractures, open fractures, infected blisters, or significant osteoporosis were excluded from the study. Forty patients with 44 fractures had completed a minimum of 2-year follow-up and were included in this study. The study received institutional review board and ethical committee approval, and informed consent was obtained from all patients.
Clinical evaluation was performed to check for soft tissue damage and the presence of any associated injuries. Radiological assessment was done using anteroposterior, axial, and lateral radiographs of the ankle and foot with evaluation of Bohler's angle and the angle of Gissane. Computed tomography was performed for all patients for classification and preoperative planning.
Preoperatively, the injured limb was elevated, cold compresses were applied, and anti-edematous drugs were administered to reduce tissue edema and facilitate reduction. Surgery was not attempted until swelling had adequately subsided and the skin wrinkles had appeared.
Spinal anesthesia was administered to all patients. One gram of third-generation cephalosporin antibiotic was administered with the induction of anesthesia. Patients were placed in a lateral position on a radiolucent table with the foot to be operated on uppermost. Bimanual compression across the calcaneus was applied to decrease the calcaneal width, and heel varus or valgus was corrected.
A Schanz screw was inserted into the posterior tuberosity and directed forward and downward to avoid penetrating the subtalar joint. Then, the Schanz screw was pushed downward to elevate the depressed fragment. Under C-arm guidance, restoration of Bohler's angle and reduction of the posterior facet were checked. Then, two 2-mm–diameter threaded K-wires were placed in a parallel fashion from the posteroinferior corner of the calcaneus across the posterior facet and into the talar body, transfixing the subtalar joint.
If the reduction of the articular surface was achieved, it was maintained by 2 crossing subchondral 2-mm threaded K-wires, 1 in the calcaneocuboid direction, and 1 in the calcaneonavicular direction (Figure 1). If the reduction was not satisfactory, a 1- to 2-cm–long transverse incision was made just below the level of the tip of the lateral malleolus under C-arm guidance. A small-tipped periosteal elevator was inserted through the incision and the lateral calcaneal wall until it reached the medial wall. It was then used to elevate the depressed fragment before K-wire fixation. Concomitant lateral wall and sustentacular fractures were fixed by separate K-wires. Finally, the small incision was sutured, the pins outside of the skin were cut, and a posterior splint was applied.
Intraoperative C-arm images. A Schanz screw was inserted into the calcaneal tuberosity and pushed downward to elevate the depressed fragment (A). Two K-wires were inserted from the posteroinferior corner of the calcaneus into the talar body, transfixing the subtalar joint (B). Reduction of the articular surface was maintained by 2 crossing subchondral K-wires (C).
Postoperative Clinical Follow-up
Postoperatively, anti-edematous drugs were administered and the injured limb was elevated over a pillow to decrease edema. Parenteral antibiotics were administered for 2 days, followed by oral antibiotics for another 3 days. Patients were followed at 2, 6, and 12 weeks; then every 3 months in the first year; and then every 6 months in the second year (Figure 2).
Preoperative (A), immediate postoperative (B), 3-month postoperative (C), and 1-year postoperative (D) lateral and axial ankle and foot radiographs of a 37-year-old man with a Sanders type II calcaneal fracture after a fall from height.
The splint and sutures were removed during week 2 postoperatively, and a below-the-knee cast was applied for 1 month. The cast and the K-wires were removed during week 6 postoperatively, and then the ankle and subtalar joints were put through full range of motion exercises with no weight bearing until week 12. Partial weight bearing was permitted after week 12 and gradually progressed to full weight bearing.
The clinical evaluation was based on the Maryland Foot Score6 and the visual analog scale (VAS) score for pain14 to assess the functional outcomes and patient satisfaction. Excellent and good scores were considered satisfactory, whereas fair and poor scores were considered unsatisfactory.
Postoperative Radiological Follow-up
Immediately after surgery, radiographs were obtained for assessment of the reduction, and Bohler's angle and the angle of Gissane were recorded.
At each follow-up visit, radiographs were obtained, Bohler's angle and the angle of Gissane were measured, and loss of reduction or posterior facet collapse were evaluated. Two independent investigators (M.K.M., O.G.) performed the measurements, with the mean of both measurements being recorded.
Data were statistically analyzed using SPSS version 25.0 (IBM, Armonk, New York). Descriptive statistics included number, percent, mean, and range. Qualitative data were analyzed using the chi-square test. Quantitative data were analyzed using a paired samples t test. Statistical significance was considered P<.05.
Of the 40 patients included in the study, 22 patients (55%) were men and 18 (45%) were women, with a mean age of 34.5 years (range, 19–56 years). Forty fractures (90.9%) were caused by falls from heights, while 4 (9.1%) were caused by motor vehicle accidents. Four patients had bilateral calcaneal fractures associated with fractures of the dorsolumbar spine without neurological injury.
According to the Sanders classification,15 26 fractures (59.1%) were type II and 18 (40.9%) were type III. Surgery was performed a mean of 6.4 days (range, 1–14 days) after injury. The mean operative time was 47 minutes (range, 40–55 minutes). Closed reduction was performed in 20 fractures (45.5%), while the mini-open reduction was performed in 26 fractures (54.5%). The mean postoperative hospital stay was 1.6 days (range, 1–3 days) (Table 1).
Patient Demographics and Baseline Data
The mean follow-up was 31.9 months (range, 25–47 months). The mean time to radiographic evidence of solid union was 8.7 weeks (range, 8–11 weeks). The mean time to full weight bearing was 13 weeks (range, 12–15 weeks).
Comparison of preoperative and postoperative radiographs showed improvement of the mean Bohler's angle from 14.6° (range, 11°–19°) to 27.5° (range, 21°–34°) (P<.001) and the mean angle of Gissane from 145.6° (range, 110°–159°) to 132.3° (range, 122°–140°) (P=.03) (Table 2). Follow-up radiographs showed no change in the measurements of both angles compared with the immediate postoperative measurements, with no loss of reduction or collapse of the posterior facet. Moreover, no patients developed subtalar osteoarthritis until the end of the follow-up period.
Measurements of Bohler's Angle and the Angle of Gissane
The Maryland Foot Score revealed 36 fractures (81.8%) with satisfactory results (28 excellent and 8 good) and 8 fractures (18.2%) with unsatisfactory results (8 fair and 0 poor). The fair results were obtained from 4 patients with bilateral calcaneal fractures associated with fractures of the dorsolumbar spine. Moreover, there was no difference in outcome between the closed reduction and the mini-open groups (P=.37). The mean VAS score for pain decreased from 7.1±0.7 (range, 5–9) preoperatively to 3.1±0.9 (range, 3–6) at 4 weeks postoperatively (P<.001) and to 1.4±0.5 (range, 1–3) when radiographic fracture healing was confirmed (P<.001).
Regarding complications, 2 fractures (4.5%) had pin tract infections. Good healing was obtained with treatment and continuous dressing. One case (2.3%) had widening of the heel postoperatively.
Intra-articular fractures of the calcaneus constitute approximately 75% of all calcaneal fractures and are associated with high morbidity.8,15 In the past, these fractures were predominantly treated conservatively. Such treatment was associated with morbid complications, including non-restoration of the articular surface, heel widening and shortening, and impingement of the peroneal tendons.2,6,16,17
Open reduction and internal fixation using the extensile lateral approach permits superior visualization of the subtalar joint and aids in the reduction of displaced fracture fragments.5,18 However, it is associated with a relatively high rate of soft tissue complications.7,8,19
The minimally invasive techniques have yielded satisfactory results, with a decreased rate of deep infection and wound-related complications.13,20 However, controversy exists regarding the optimal indications for open vs percutaneous fixation techniques and the long-term outcomes of both methods.8,19,20
In the current study, a minimally invasive procedure of closed or mini-open reduction and percutaneous K-wire fixation was used to treat patients with Sanders type II and III calcaneal fractures. K-wires are simple to insert, causing minimal heat necrosis of bone and soft tissue trauma, and they are temporary and easily removed in the outpatient clinic.21 After posterior facet reduction, 2 K-wires were placed from the posteroinferior corner of the calcaneus across the posterior facet and into the talar body, transfixing the subtalar joint. Two crossing subchondral K-wires were added. The K-wires maintained the posterior facet reduction. They were removed 6 weeks postoperatively so that ankle and subtalar range of motion exercises could begin.
All patients achieved improvement in Bohler's angle and the angle of Gissane postoperatively, with no loss of reduction or collapse of the posterior facet during follow-up. The mean time to full weight bearing was 13 weeks. According to the Maryland Foot Score, 81.8% of results were excellent and good and 18.2% were fair. There were no poor results at final follow-up. At a mean follow-up of 31.9 months, there were no cases of loss of reduction or collapse of the subtalar joint. Moreover, no patients developed subtalar osteoarthritis until final follow-up. This may have been due to the 2 K-wires crossing the subtalar joint, with a diameter of 2 mm, being small enough not to disrupt the articular cartilage and cause osteoarthritis, in addition to the accurate reduction obtained under C-arm guidance intraoperatively.
This study's excellent results coincided with those of Xia et al,22 who prospectively reviewed 38 displaced intra-articular calcaneal fractures managed with minimally invasive technique and reported excellent and good results in 95% of patients. Wang et al23 reported excellent and good results for 82.5% of patients in the minimally invasive group and 76.8% of patients in the ORIF group.
In the current study, 2 fractures (4.5%) had pin tract infections that healed with treatment and continuous dressing. No patients developed deep infection. This lower infection rate, compared with that of other studies in which the extensile lateral approach was used, may be attributed to the minimally invasive technique and the K-wires, which were removed after 6 weeks compared with extensive dissection and retained hardware in the ORIF groups. In the study by Sampath Kumar et al,24 7 of 23 fractures of the ORIF group (30.4%) had wound-healing problems: 3 (13%) had wound dehiscence, 1 (4.3%) had superficial infection, and 3 (13%) developed deep-seated infection. In the study by Backes et al,25 the postoperative wound infection rate was 25%, with 13.6% of the infections being deep. Zwipp et al26 and De Groot et al27 reported wound complication rates of 11% and 32% in patients treated with ORIF using the extensile lateral approach. In the study by Kinner et al,28 4 patients (20%) developed wound problems: 1 deep wound infection, 1 superficial wound infection, 1 necrosis of the wound edges, and 1 seroma. Moreover, in the study by Westphal et al,29 19 patients (13.3%) developed wound problems: 5 deep infections, 2 wound margin necroses, 10 small wound margin necroses, 1 superficial infection, and 1 hematoma.
The low infection rate in the current study coincided with that of the study by Abdelgaid,30 who evaluated 60 fractures that had been reduced with Steinmann pins and fixed with cannulated screws with no deep wound infections. Moreover, the current results were comparable to those of previous studies that used minimally invasive reduction and K-wire fixation for the treatment of intra-articular calcaneus fractures.3,21
The primary limitation of this study was the absence of a control group for comparison. Despite this limitation, this study provided evidence that the minimally invasive reduction and fixation of intra-articular calcaneal fractures using K-wires can achieve an excellent functional outcome with a low complication rate.
The minimally invasive technique of closed or mini-open reduction and percutaneous K-wire fixation of intra-articular calcaneal Sanders type II or III fractures described in this study has excellent functional and radiological outcomes. Further, it minimizes soft tissue complications and postoperative scar formation.
- Kiewiet NJ, Sangeorzan BJ. Calcaneal fracture management: extensile lateral approach versus small incision technique. Foot Ankle Clin. 2017;22(1):77–91. https://doi.org/10.1016/j.fcl.2016.09.013 PMID: doi:10.1016/j.fcl.2016.09.013 [CrossRef]28167066
- Wei N, Zhou Y, Chang W, Zhang Y, Chen W. Displaced intra-articular calcaneal fractures: classification and treatment. Orthopedics. 2017;40(6):e921–e929. https://doi.org/10.3928/01477447-20170907-02 PMID: doi:10.3928/01477447-20170907-02 [CrossRef]29116324
- Arora C, Jain AK, Dhammi IK. Outcome of percutaneous fixation of calcaneal fractures: a prospective analysis in an Indian population. J Foot Ankle Surg. 2019;58(3):502–507. https://doi.org/10.1053/j.jfas.2018.09.029 PMID: doi:10.1053/j.jfas.2018.09.029 [CrossRef]30685424
- Stulik J, Stehlik J, Rysavy M, Wozniak A. Minimally-invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006;88(12):1634–1641. https://doi.org/10.1302/0301-620X.88B12.17379 PMID: doi:10.1302/0301-620X.88B12.17379 [CrossRef]17159178
- Thordarson DB, Latteier M. Open reduction and internal fixation of calcaneal fractures with a low profile titanium calcaneal perimeter plate. Foot Ankle Int. 2003;24(3):217–221. https://doi.org/10.1177/107110070302400303 PMID: doi:10.1177/107110070302400303 [CrossRef]12793483
- Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am.2000;82(2):225–250. https://doi.org/10.2106/00004623-200002000-00009 PMID: doi:10.2106/00004623-200002000-00009 [CrossRef]10682732
- Su J, Cao X. Risk factors of wound infection after open reduction and internal fixation of calcaneal fractures. Medicine (Baltimore). 2017;96(44):e8411. https://doi.org/10.1097/MD.0000000000008411 PMID: doi:10.1097/MD.0000000000008411 [CrossRef]
- Clare MP, Crawford WS. Managing complications of calcaneus fractures. Foot Ankle Clin. 2017;22(1):105–116. https://doi.org/10.1016/j.fcl.2016.09.007 PMID: doi:10.1016/j.fcl.2016.09.007 [CrossRef]28167056
- Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84(10):1733–1744. https://doi.org/10.2106/00004623-200210000-00001 PMID: doi:10.2106/00004623-200210000-00001 [CrossRef]12377902
- Luo X, Li Q, He S, He S. Operative versus nonoperative treatment for displaced intra-articular calcaneal fractures: a meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2016;55(4):821–828. https://doi.org/10.1053/j.jfas.2016.01.035 PMID: doi:10.1053/j.jfas.2016.01.035 [CrossRef]27150233
- Wang XJ, Su YX, Li L, Zhang ZH, Wei XC, Wei L. Percutaneous poking reduction and fixation versus open reduction and fixation in the treatment of displaced calcaneal fractures for Chinese patients: a systematic review and meta-analysis. Chin J Traumatol. 2016;19(6):362–367. https://doi.org/10.1016/j.cjtee.2016.10.001 PMID: doi:10.1016/j.cjtee.2016.10.001 [CrossRef]
- Pan A, Chatterjee D, Garg AK, Mukhopadhyay KK, Banerjee K, Kumar S. Percutaneous fixation of displaced intra-articular calcaneal fracture. J Indian Med Assoc. 2011;109(6):412–414. PMID:22315771
- Meraj A, Zahid M, Ahmad S. Management of intra-articular calcaneal fractures by minimally invasive sinus tarsi approach: early results. Malays Orthop J. 2012;6(1):13–17. https://doi.org/10.5704/MOJ.1203.007 PMID: doi:10.5704/MOJ.1203.007 [CrossRef]25279036
- Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis. 1978;37(4):378–381. https://doi.org/10.1136/ard.37.4.378 PMID: doi:10.1136/ard.37.4.378 [CrossRef]686873
- Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intra-articular calcaneal fractures: results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993;(290):87–95. PMID:8472475
- Pozo JL, Kirwan EO, Jackson AM. The long-term results of conservative management of severely displaced fractures of the calcaneus. J Bone Joint Surg Br. 1984;66(3):386–390. https://doi.org/10.1302/0301-620X.66B3.6725350 PMID: doi:10.1302/0301-620X.66B3.6725350 [CrossRef]6725350
- Rammelt S, Sangeorzan BJ, Swords MP. Calcaneal fractures: should we or should we not operate?Indian J Orthop. 2018;52(3):220–230. https://doi.org/10.4103/ortho.IJOrtho_555_17 PMID: doi:10.4103/ortho.IJOrtho_555_17 [CrossRef]29887623
- Mehta CR, An VVG, Phan K, Sivakumar B, Kanawati AJ, Suthersan M. Extensile lateral versus sinus tarsi approach for displaced, intra-articular calcaneal fractures: a meta-analysis. J Orthop Surg Res. 2018;13(1):243. https://doi.org/10.1186/s13018-018-0943-6 PMID: doi:10.1186/s13018-018-0943-6 [CrossRef]30249288
- Kavin K, Vijay S, Devendra L, Kamran F. Patient satisfaction after open reduction and internal fixation through lateral extensile approach in displaced intra-articular calcaneal fractures (Sander's type II and III). J Clin Orthop Trauma. 2016;7(4):296–301. https://doi.org/10.1016/j.jcot.2016.06.007 PMID: doi:10.1016/j.jcot.2016.06.007 [CrossRef]27857507
- Wallin KJ, Cozzetto D, Russell L, Hallare DA, Lee DK. Evidence-based rationale for percutaneous fixation technique of displaced intra-articular calcaneal fractures: a systematic review of clinical outcomes. J Foot Ankle Surg. 2014;53(6):740–743. https://doi.org/10.1053/j.jfas.2014.03.018 PMID: doi:10.1053/j.jfas.2014.03.018 [CrossRef]24795208
- Walde TA, Sauer B, Degreif J, Walde HJ. Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2–10 years. Arch Orthop Trauma Surg. 2008;128(6):585–591. https://doi.org/10.1007/s00402-008-0590-1 PMID: doi:10.1007/s00402-008-0590-1 [CrossRef]18309507
- Xia S, Wang X, Lu Y, Wang H, Wu Z, Wang Z. A minimally invasive sinus tarsi approach with percutaneous plate and screw fixation for intra-articular calcaneal fractures. Int J Surg. 2013;11(10):1087–1091. https://doi.org/10.1016/j.ijsu.2013.09.017 PMID: doi:10.1016/j.ijsu.2013.09.017 [CrossRef]24103451
- Wang Q, Li X, Sun Y, Yan L, Xiong C, Wang J. Comparison of the outcomes of two operational methods used for the fixation of calcaneal fracture. Cell Biochem Biophys. 2015;72(1):191–196. https://doi.org/10.1007/s12013-014-0436-0 PMID: doi:10.1007/s12013-014-0436-0 [CrossRef]25561280
- Sampath Kumar V, Marimuthu K, Subramani S, Sharma V, Bera J, Kotwal P. Prospective randomized trial comparing open reduction and internal fixation with minimally invasive reduction and percutaneous fixation in managing displaced intra-articular calcaneal fractures. Int Orthop. 2014;38(12):2505–2512. https://doi.org/10.1007/s00264-014-2501-0 PMID: doi:10.1007/s00264-014-2501-0 [CrossRef]25139716
- Backes M, Schepers T, Beerekamp MS, Luitse JS, Goslings JC, Schep NW. Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach. Int Orthop. 2014;38(4):767–773. https://doi.org/10.1007/s00264-013-2181-1 PMID: doi:10.1007/s00264-013-2181-1 [CrossRef]
- Zwipp H, Rammelt S, Amlang M, Pompach M, Dürr C. [Operative treatment of displaced intra-articular calcaneal fractures]. Oper Orthop Traumatol. 2013;25(6):554–568. https://doi.org/10.1007/s00064-013-0246-3 PMID: doi:10.1007/s00064-013-0246-3 [CrossRef]24317115
- De Groot 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. https://doi.org/10.1016/j.injury.2013.06.014 PMID: doi:10.1016/j.injury.2013.06.014 [CrossRef]23870395
- Kinner BJ, Best R, Falk K, Thon KP. Is there a reliable outcome measurement for displaced intra-articular calcaneal fractures?J Trauma.2002;53(6):1094–1101. https://doi.org/10.1097/00005373-200212000-00011 PMID: doi:10.1097/00005373-200212000-00011 [CrossRef]12478034
- Westphal T, Piatek S, Halm JP, Schubert S, Winckler S. Outcome of surgically treated intra-articular calcaneus fractures: SF-36 compared with AOFAS and MFS. Acta Orthop Scand. 2004;75(6):750–755. https://doi.org/10.1080/00016470410004148 PMID: doi:10.1080/00016470410004148 [CrossRef]
- Abdelgaid SM. Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures. Foot Ankle Surg. 2012;18(3):164–179. https://doi.org/10.1016/j.fas.2011.07.005 PMID: doi:10.1016/j.fas.2011.07.005 [CrossRef]22857958
Patient Demographics and Baseline Data
|Sex, No. (%)|
| Male||22 (55)|
| Female||18 (45)|
|Age, mean (range), y||34.5 (19–56)|
|Side, No. (%)|
| Right||20 (45.5)|
| Left||24 (54.5)|
|Mechanism of injury, No. (%)|
| Fall from height||40 (90.9)|
| Motor vehicle accident||4 (9.1)|
|Sanders classification, No. (%)|
| Type II||26 (59.1)|
| Type III||18 (40.9)|
|Time to surgery, mean (range), d||6.4 (1–14)|
|Operative time, mean (range), min||47 (40–55)|
|Hospital stay, mean (range), d||1.6 (1–3)|
Measurements of Bohler's Angle and the Angle of Gissane
|Preoperative||Immediate Postoperative||6-mo Postoperative||12-mo Postoperative|
|Angle of Gissane||145.6°±5.12°||132.3°±6.68°||132.5°±6.42°||132.4°±4.88°|