Percutaneous treatment of less severe intraarticular calcaneal fractures

Abstract

Percutaneous treatment of calcaneal fractures is intended to reduce soft tissue complications and postoperative stiffness of the subtalar joint. We assessed the complications, clinical hindfoot alignment, motion, functional outcome scores, and radiographic correction of percutaneous arthroscopically assisted reduction and screw fixation of selected, less severe fractures. We performed percutaneous reduction and screw fixation in 61 patients with Type II (Sanders et al.) calcaneal fractures. In 33 of 61 patients with displaced intraarticular fractures (types IIA and IIB), anatomic reduction of the subtalar joint was confirmed arthroscopically; these patients form the basis of this report. We observed no wound complications or infections. In two patients, one prominent screw was removed after 1 and 3 years, respectively. In one patient, arthroscopic arthrolysis was performed 1 year after the index procedure. Twenty-four of 33 patients (73%) were followed a minimum of 24 months (mean, 29 months; range, 24-67 months). The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score at last followup was 92.1 (range, 80-100). Böhler's angle and calcaneal width were reduced close to the values of the uninjured side. We believe percutaneous fixation is a reasonable alternative for moderately displaced Type II fractures provided adequate control over anatomic joint reduction with either subtalar arthroscopy or high-resolution (3-D) fluoroscopy.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

The method of percutaneous leverage with a pin introduced into the calcaneal tuberosity as first described by Westhues in 1934 and employed today together with subtalar arthroscopy. Note the arthroscope in the anterolateral portal (AL), the position of the posterolateral portal (PL) with respect to the lateral malleolus (LM) and the line of the tuberosity-joint angle drawn with skin marker.

Fig. 2A–J

(A) Radiographs, (B) coronal and (C) axial CT scans of an active 76-year-old woman show a Type IIB fracture of the right calcaneus sustained after falling from a ladder in her home. Surgery was performed 3 days after injury. Arthroscopy was employed (D) to remove minor bone fragments from the subtalar joint, (E) to assess displacement and (F) control percutaneous reduction that was achieved with the Westhues method and (G) a sharp elevator introduced percutaneously and controlled fluoroscopically. Fixation was achieved with 3.5- and 4.5-mm cancellous screws. Restoration of the calcaneal shape and adequate screw placement was controlled with intraoperative (H) lateral, (I) 20° Brodén, and (J) axial views.

Fig. 3A–H

Clinical photographs illustrate 3-year followup of the same patient as shown in Fig. 2. The patient here is 79 years old and has no pain or limitations during activities of daily living. She enjoys Nordic walking and smaller hikes. (A) The soft tissues have healed without complications and the sites of the stab incisions for the arthroscopic portals and screws are barely visible. A plantigrade foot with no soft tissue swelling is seen (B) clinically and (C) on pedogram. Active range of motion of the (D) hindfoot is close to the uninjured side while (E) ankle motion is normal. Weight-bearing (F) lateral and (G) axial radiographs show good hindfoot alignment despite some subsidence of the thalamic portion; (H) the Brodén view reveals a slight irregularity but no step-off in the posterior joint facet.