SLR - March 2021 - John J. Kim

Arthroscopic-Assisted Percutaneous Fixation of Intra-Articular Calcaneal Fractures Using an Intraoperative Distraction Device

Reference: Gao D, Wong TM, Fang C, Leung FK, Li X, Jia B, Wang Y, Yu B. Arthroscopic-Assisted Percutaneous Fixation of Intra-Articular Calcaneal Fractures Using an Intraoperative Distraction Device. J Orthop Surg (Hong Kong). 2021 Jan-Apr;29(1):2309499020979095. doi: 10.1177/2309499020979095. PMID: 33410380.

Level of Evidence: IV

Scientific Literature Review

Reviewed By: John J. Kim, DPM
Residency Program: Mercy Hospital & Medical Center – Chicago, IL

Podiatric Relevance: The management of intra-articular calcaneal fractures can  be challenging. ORIF using the lateral extensile approach provides adequate exposure and reduction but is associated with high risk of post-operative soft tissue complications. Because of this, MIS and arthroscopic-assisted approaches have become increasingly popular over the past decade. This case series reviews the effectiveness of a MIS technique using percutaneous distraction and subtalar arthroscopy. 

Methods: This was a retrospective case series including 453 patients with 507 displaced intra-articular calcaneal fractures. CT scans were performed for preoperative planning. Surgical technique: A two-point talocalcaneal distractor was placed both medially and laterally and was used to dis-impact and partially restore the depressed fracture fragment. For superior displaced posterior tuberosity fractures, a tibiocalcaneal distractor was used. Then a 2.7 millimeters arthroscope was inserted into the subtalar joint and the calcaneal articular surface was reduced, fixated with screws, and confirmed by fluoroscopy. Then, both the distractor and manual reduction were utilized to restore the calcaneal body. Immediate post-op CT scans were taken, and all complications were recorded. The outcomes measures included post-operative Bohler’s angle, VAS scores and AOFAS scores at final follow up. 

Results: Fifty-nine patients had complete clinical data and follow up for at least 12 months. There was a significant difference between preoperative and immediate postoperative Bohler’s Angle (2.029 +/- 6.870 degrees vs. 16.382 +/- 9.787 degrees). There was no significance in immediate post-operative Bohler’s angle and at final follow up. According to Sanders criteria, there was good or excellent reduction quality (</=2 millimeters gap or step-off) of the subtalar joint in 93 percent of fractures. There was significant correction in the calcaneal body reduction (medial wall) from 5.691 +/- 2.469 millimeters preoperatively to 1.662 +/- 1.589 millimeters postoperatively based on CT. Final follow up VAS and AOFAS scores were 2.235 +/- 1.161 and 86.485 +/- 6.107, respectively. 

Conclusions: The authors conclude that arthroscopic assistance provides direct visualization and precise reduction of the articular surface of the subtalar joint. Additionally, the use of a two-point fixation device allows easy and quick facilitation of the arthroscope, contributing to a shorter operation time compared to other reported arthroscopic techniques using other distractors. While the average post-operative Bohler’s angle was only 16 degrees, the study reported good short-term functional outcome scores. Intra-articular calcaneal fractures present with various fracture patterns, making surgical correction challenging. Using MIS and arthroscopic techniques for these fractures is also technically demanding. However, when used effectively, it may lead to good functional outcomes while decreasing the risk of soft-tissue complications. 

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