Background
Open reduction and internal fixation is considered the gold standard for displaced intra-articular calcaneal fractures, however there is a move towards minimally invasive and percutaneous surgery. The difficulty in treatment arises from the need to restore anatomy of the calcaneum – including the calcaneal height, width, and the joint articular surface. Outcomes thus far have not been very encouraging due to complications such as wound breakdown, stiffness, and chronic pain. Newer methods such as percutaneous fixation or minimally invasive methods through the sinus tarsi have been developed to mitigate these risks.
Objectives: This is a descriptive study aims to look at the radiological outcomes, namely the Bohler and Gissane angles in intra-articular calcaneal fractures using percutaneous fixation methods to determine if reduction is improved after surgery and maintained.
Materials And Methods
A retrospective review of the electronic medical records of patients who underwent percutaneous fixation of intraarticular calcaneal fractures by a single surgeon with use of intraoperative image intensifier in our institution was done from January 2017 to December 2019. Information such as the pre and post operative Bohler and Gissane angles, Sanders classification, age, gender and mechanism of injury were recorded. Data was recorded with a minimum of 3 month follow up after the surgery.
Results
There were 23 patients, with a total of 26 calcaneal fractures. Of them, there were 22 males and 1 female. 3 patients had bilateral calcaneal fractures. The mean age is 45.7 years old, with a range from 27-70 years old. The most common mechanism of injury was a fall from height, at 83.3%. There were 4 (15.4%) Sanders IIA, 4 (15.4%) IIB, 2 (7.69%) IIC, 9 (34.6%) IIIAC, 3 (11.5%) IIIAB and 4 (15.4%) IV. The mean pre-operative Bohlers angle was 16.2 (±9.47) and mean immediate post-operative Bohlers angle was 25.6 (±7.61). The mean pre-operative Gissane angle was 109.9 (±9.09), and mean post operative Gissane angle was 113 (±7.12). In the short-term post operative period of 3 to 8 months, the mean Bohlers angle was 26.7 (±8.10) and the mean Gissane angle was 113 (±8.04).
Discussion
Percutaneous fixation is a viable option for fixation of comminuted intraarticular calcaneal fractures. In Sanders III fractures, traditionally most would opt for open fixation and not percutaneous fixation. There are currently limited studies on use of percutaneous fixation in Sanders III type fractures. Hence we aim to look at the use of percutaneous fixation in comminuted intraarticular calcaneal fractures and maintenance of initial reduction in the post operative period. In our study, the Bohler and Gissane angles were maintained. This suggests that the percutaneous fixation allows even the comminuted fractures to heal while maintaining the reduction reliably, providing good radiological outcomes. Restoring the anatomical considerations of the calcaneum in turn aid in providing the patient with a functional and shoeable foot. Advantages of percutaneous fixation include less wound complications and also allowing for earlier surgery, faster rehabilitation and shorter length of inpatient stay.
Conclusion
Percutaneous fixation of intraarticular calcaneal fixation is a reliable method even for dealing with comminuted fracture patterns such as Sanders type III, while minimising complications, especially wound complications. This is a small study which would benefit from a larger patient population. Percutaneous fixation proves to be an asset in the arsenal for every orthopaedic surgeon.