SLR - September 2021 - Hendrik Ryan Tan

Long-term Results of Displaced Intra-articular Calcaneal Fractures Treated with Minimal Invasive Surgery Using Percutaneous Screw Fixation

Reference: Driessen M, Edwards M, Biert J, Hermans E. Long-term Results of Displaced Intra-articular Calcaneal Fractures Treated with Minimal Invasive Surgery Using Percutaneous Screw Fixation. Injury. 2021 Apr;52(4):1054-1059. doi: 10.1016/j.injury.2020.12.003. Epub 2020 Dec 24. PMID: 33388150.

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Hendrik Ryan Tan, DPM, MHA
Residency Program: North Colorado Medical Center – Greeley, CO

Podiatric Relevance: With the complexity and diverse treatment options of calcaneal fractures, displaced intra-articular calcaneal fractures (DIACF) remain a challenge for foot and ankle surgeons. Open reduction internal fixation (ORIF) or percutaneous screw fixation (PSF) are well documented surgical options to address this. ORIF is classically performed with the extended lateral approach (ELA), providing good exposure and visualization of the subtalar joint, however, it is associated with a high wound complication rate. Thus, the sinus tarsi approach (STA) gained popularity as it offers a lower wound healing complication, shorter time to surgery and a shorter operative time. Studies show that ORIF using the STA and the PSF technique resulted in a better correction of the Bohler angle and functional outcomes. The PSF technique described by Forgon and Zadravecz has shown promising functional outcomes and a low-complication rates in a 5-year study. The aim of this study was to assess the postoperative outcomes of PSF in terms of mobility, foot function, stability, pain, and patient satisfaction after 15-20 years.

Methods: This was a retrospective study of 46 patients with a DIACF, classified as either Sanders type II, III or IV, who underwent PSF. Pre- and post-op measurements of the Bohler angle were collected and compared with the measurements on succeeding follow up radiographs after 6 weeks, and at 3, 6, and 12 months. All radiographs were evaluated by one of the senior authors. The American Orthopaedic Foot & Ankle Society (AOFAS) score, Maryland Foot Score (MFS), general health Status Form (SF 36), and the Visual Analog Scale (VAS) questionnaires were used to evaluate patient reported functional outcomes, range of motion, pain and changes in footwear. Patients with a nondisplaced intra-articular fracture, open fractures, and were < 18 years of age at trauma were excluded.

Results: Forty-six patients who underwent PSF completed the questionnaires. The mean pre- and post- operative Bohler angles were 10 and 26 degrees respectively. Average follow-up period was 16 years. At the follow-up, average AOFAS, MFS, SF 36 and VAS scores were 76, 74, 63 and 7.7 points respectively.  Surgical site infection was observed in 3 patients (10%), and a deep infection was noted in three patients (10 percent).  All patients with deep infections were active smokers. Patients with Sanders type IV fractures had the worst scores for patient satisfaction with an average VAS score of 6.8.  Those with type II and III fractures had scores 8 and 7.8 out of 10 points, respectively.

Conclusions: The authors concluded that long-term postoperative functional outcomes after PSF for DIACF, show relatively good functional outcomes at a follow up at 15-20 years post-op. There was a decline in the average AOFAS and MFS scores by 8 percent and 11 percent, respectively, and a decrease by 0.1 points in patient satisfaction compared with the results at five years postoperatively in a previous study conducted at the same facility. PSF should be considered as a good option in patients with DIACF, especially in patients with Sanders II and III fractures, due to long term good functional outcomes.

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