SLR - July 2021 - Matthew A. Pitre

Minimally Invasive Surgery for Intra-Articular Calcaneus Fractures: A 9-Year, Single-Center, Retrospective Study of a Standardized Technique Using A 2-Point Distractor

Reference: Rodemund C, Krenn R, Kihm C, Leister I, Ortmaier R, Litzlbauer W, Schwarz AM, Mattiassich G. Minimally Invasive Surgery for Intra-Articular Calcaneus Fractures: A 9-Year, Single-Center, Retrospective Study of a Standardized Technique Using A 2-Point Distractor. BMC Musculoskelet Disord. 2020 Nov 14;21(1):753. 

Level of Evidence:
Level IV

Scientific Literature Review

Reviewed By: Matthew A. Pitre, DPM
Residency Program: Geisinger Community Medical Center – Scranton, PA

Podiatric Relevance: Management of calcaneal fractures often proves challenging to the podiatric surgeon due to their propensity to be intra-articular, multi fragmentary and comminuted. Controversy exists surrounding the appropriate primary intervention for intra-articular calcaneal fractures due to a lack of a standardized treatment protocol. Primary treatment modalities include open reduction internal fixation (ORIF), minimally invasive approaches, and primary subtalar joint arthrodesis. This aim of this study was to describe an operative technique utilizing a two-point distractor to aid in performing minimally invasive fixation of both open and closed intra articular calcaneal fractures. The authors compared those results to that of ORIF with regard to complications and need for revision surgery evaluating benefit of one technique over the other. This could potentially guide operative treatment selection in surgical calcaneal fractures.

Methods: A level 4 retrospective data analysis was performed on 298 patients who were treated at the Trauma center Linz, Austria between 01/01/2007 -01/01/2016 for unilateral or bilateral, open or closed calcaneal fractures, treated operatively or conservatively. Patients with at least a 12-month follow-up were included in the study. Demographic data, cause of injury, time from injury to surgery, treatment modality, need for revision surgery, and complications were analyzed. Complications were defined as difficulty in wound healing, unplanned hardware removal due to irritation of soft tissue, or progression to subtalar joint arthrodesis. A Chi square statistical analysis was used to compare descriptive variables between the minimally invasive and ORIF treatment groups.

Results: The number of conservatively treated versus operatively treated patients was 86 and 212 respectively. Of the 212 surgically treated, 182 were treated via a minimally invasive technique utilizing two-point distractor and the remainder (30) were treated via ORIF or other methods, which did not utilize a two-point distractor. Wound healing complications requiring revision were 2.8 percent and 16.7 percent in the minimally invasive group versus the open treatment group respectively. This difference was statistically significant. The rate of secondary subtalar joint arthrodesis was 4.7 percent across both treatment modalities. No functional scores were utilized to assess surgical outcomes between surgical treatment groups.

Conclusions: This study demonstrated that utilizing a minimally invasive technique via a two-point distractor is a viable surgical approach in that there is a statistically significant decrease in wound healing complications when compared to open approaches without an increase in development of subtalar joint arthrosis. This study is limited in that no functional measurements were used to assess patient outcomes post surgically. Additionally, the short 12-month follow-up does not allow for full evaluation of long-term complications and outcomes with the minimally invasive approach. 

Educational Opportunities