Background: Intra-articular calcaneus fractures are commonly sustained after high energy trauma. The gold standard management of this type of fractures is open reduction and plate fixation but the soft tissue complications are frequently high. The aim of this study is to evaluate the results of percutaneous reduction and fixation of intra-articular calcaneal fractures.
Methods: Between January 2014 and June 2017, 30 feet in (20 patients) with intra-articular fractures of the calcaneus were treated by closed reduction and percutaneous fixation in Zagazig university hospital in Egypt. The mean age at trauma was 30years (range 18–50 years). 75% of cases were males. All cases were assessed by X-ray and CT before and after surgery. Postoperative wound healing and clinical functional outcomes using American Orthopedic Foot and Ankle Society Hind foot Score were also evaluated. P-value < 0.05 is statistically significant.
Results: The mean follow up period was 24.4±7.1 (18 – 30 months). The post-operative mean of AOFAS score was 88±4.7 points. There were statistically significant improvement in the post-operative means of both Bohler’s and Gissane’s angles. Persistent post-operative pain was encountered in one case and another had completely resolved mild superficial infection without major skin complications or deep infection.
Conclusion: Percutaneous reduction and fixation of a properly selected intra-articular calcaneal fractures had satisfactory clinical and radiological results with minimal infection and soft tissue morbidities provided it is done by expert surgeon.
Keywords: Calcaneus fracture; minimal invasive; percutaneous
The incidence of calcaneal fractures is around 2% of all fractures with approximately 75% being intra-articular in the posterior subtalar joint. Most of calcaneal fractures occur in men (80-90%) at their prime working years resulting in major socio- economic impact.1
Essex-Lopresti classification is the widely used classification system. He described two different fracture patterns based upon the direction of the secondary fracture line, one with part of the posterior tuberosity attached to the articular fragment called tongue-type fracture and the other without tuberosity fragment which called joint-depression type fracture.2
There were many other classifications described based on the computed tomographic scans of the fracture, but the most frequently used classification system was described by Sander.3
This classification used the coronal images where the sustentaculum tali is visible and also the posterior subtalar joint is at its widest diameter and the calcaneal fracture is divided into four types according to the number of fracture lines that are more than 2 mm displacement in the posterior subtalar facet.4
The optimal management of displaced intra-articular calcaneus fractures is controversial and challenging to the majority of the orthopedic surgeons.5
Unfortunately, non-surgical treatment of the displaced intra-articular fracture resulted in suboptimal outcomes because of secondary arthritis and mal-union of the calcaneum.6
Operating in this area is a major problem because the calcaneus has delicate soft tissue envelope and irregular bony structure. However, operative intervention is beneficial to anatomically restore the posterior facet articular surface.7
Surgical management includes both the open reduction and internal fixation and percutaneous reduction and internal fixation. Most authors stated that open reduction and internal fixation for displaced intra-articular fractures of the calcaneus is the gold standard treatment option but it had high rates of wound complications and infection of up to 37% and 20%, respectively.8
Percutaneous fixation may have a role in this group of patients where there is a concern regarding wound healing and infection.9-10
The absolute indications for using less invasive approaches in management of calcaneal fractures were displaced Essex-Lopresti fractures, Sanders type II, III fractures and fracture variants with minimal posterior facet comminution. Relative indications include diabetic patients, smokers and obesity. Percutaneous techniques are favored in patients with peripheral vascular disease or severe soft tissue compromise. These techniques had lower complication rates than that occur with open reduction and plate fixation.11
The aim of this study is to evaluate the clinical and radiological results of percutaneous reduction and fixation of displaced intra-articular calcaneal fractures.
Patient and Methods
Informed consents and IRB approval were obtained. Between January 2014 and June 2017, 20 patients (30 fractures) with intra-articular fractures of the calcaneus were treated by closed reduction and percutaneous fixation in Zagazig university hospital in Egypt. According to the C.T classification by Sander, There were 12 type ?? fractures, 16 type ??? and 2 type IV fractures. The average age was 30 years (range 18–50 years). Fifteen patients were males and five were females. The right foot was injured in 8 patients, the left foot in 2 and both feet in 10 patients. There were two open fractures (Gustillo- Anderson grade ?). The mechanism of injury was a fall from height in 15 patients and Motor vehicle accidents in 5 patients. Highly comminuted fractures with central articular fragment depression, patients with other lower limb injuries and fractures more than 2 weeks were excluded from this study.
Clinical assessment was done for all cases regarding skin integrity, compartment syndrome, associated injuries and vascular status. Plain x- rays (lateral and axial views) were taken to evaluate subtalar joint and measure Bohler? s and Gissane ?s angles. All cases had C.T scan with 3 mm cuts (coronal, sagittal and axial) views for fracture classification, assessment of comminution and detection of depressed central articular segment.
The procedure was done in lateral position with the fractured limb uppermost under spinal or general anesthesia. Under fluoroscopic guidance, a schanz pin is inserted medially in the postero-inferior portion of the calcaneal tuberosity. Longitudinal traction through the schanz pin is applied to correct varus deformity of the tuberosity fragment. The displaced tuberosity fragment is corrected and held reduced to the sustentaculum tali with preliminary K- wires fixation; also reduction clamp is applied for temporary maintaining the reduction (figure 3).
A k-wire is used as a joy stick especially if there is partial articular depression and rotation in the lateral part of the posterior facet. The fragment is elevated by a wire inserted through the postero-lateral aspect of the Achilles tendon (figure 4).