PERCUTANEOUS VERSUS OPEN REDUCTION AND INTERNAL FIXATION OF LESS SEVERE INTRA-ARTICULAR CALCANEUS FRACTURES

Abstract

Displaced intra-articular fractures of the calcaneus need anatomic reduction of the joint surfaces and overall shape to restore function and minimize the risk of posttraumatic subtalar arthritis. The morbidity associated with extended approaches is a major concern. In the present study we compared the medium-term results after percutaneous reduction and screw fixation (PRSF) with that of open reduction and internal fixation (ORIF) for displaced fractures with less severe fracture patterns (Sanders type II).

Material and Methods: In a matched cohort study from March 1998 to October 2004 the results of 36 patients treated either with PRSF or ORIF for displaced Sanders type II calcaneal fractures and Tscherne grade 1–2 closed soft tissue injury were reviewed. Each group contained 3 female and 15 male patients. Mean patient age was 40.1 years in the PRSF and 42.6 years in the ORIF group. PRSF was carried out percutaneously with small fragment (3.5 mm) screws under arthroscopic and fluoroscopic control. ORIF was performed with a lateral plate via an extended lateral approach. Early ROM exercises of the ankle and subtalar joints were initiated for all patients at the first postoperative day. Patients were mobilized with partial weight-bearing for 6–8 weeks postoperatively in their own shoes. Detailed follow-up with clinical and radiographic evaluation was obtained for all patients at a mean of 23 months postoperatively.

Results: One patient (5.6%) from the ORIF group developed postoperative wound edge necrosis that responded well to conservative management with antiseptic dressings. In the PRSF group no complications were seen. Patients fully returned to work after 10.8 weeks in the PRSF group and 16.2 weeks in the ORIF group. Subjectively 17 of 18 patients (94%) in the PRSF group and 15 of 18 patients (83%) in the ORIF group rated their result as good to excellent at follow-up. The AOFAS Ankle Hindfoot Score averaged 93.8 for the PRSF group and 88.2 for the ORIF group (N. S.). The average Böhler angle improved from 13 to 25° in the PRSF group and from 10 to 26° in the ORIF group. Subtalar range of motion was significantly reduced in the ORIF group at the time of follow-up. Hindfoot eversion/inversion averaged 42.7° in the PRSF group and 33.6° in the ORIF group (p< 0.05).

Conclusions: Regardless of the treatment option, patients with less severe displaced intrta-articular calcaneal fractures can expect good to excellent results after anatomic reduction of the subtalar joint. Percutaneous screw fixation leads to earlier rehabilitation and better subtalar motion than open reduction and internal fixation via an extended lateral approach. Percutaneous fixation of these fractures should be contemplated for these fractures provided adequate control over the joint reduction either with subtalar arthroscopy or high -resolution (3D) fluoroscopy.