Question:
In patients with a displaced intra-articular calcaneal fracture (DIACF), how does percutaneous reduction, cannulated screw fixation, and calcium sulfate cement grafting (PR + CSC) compare with the standard approach of open reduction and internal fixation (ORIF) of a plate through an extended lateral approach?
Design:
Randomized (unclear allocation concealment), blinded (outcome assessors), controlled trial with mean twenty-four-month follow-up.
Setting:
A university-affiliated hospital in Shanghai, China.
Patients:
Ninety patients who had DIACF including Sanders Type IIB, Type IIC, and Type III. Other inclusion criteria were unilateral fracture, closed fracture, and surgery possible within seven days of injury. Exclusion criteria were known infection; medical contraindication (severe vascular or neurologic injury or diabetes); or Sanders Type IV, Sanders Type IIA, or open fractures. Seventy-eight patients (87%) (mean age, thirty-two years; 56% men) completed follow-up.
Intervention:
Patients were allocated to PR + CSC (n = 45) or ORIF without grafting (n = 45). In the PR + CSC group, the tuberosity was crossed with a 6.5-mm Schanz pin to reduce the height and length of the calcaneus. Another 6.5-mm Schanz pin was put into the fragment with the displaced posterior facet. In Sanders Type-III fractures, a third pin was introduced percutaneously through the lateral cortex of the inferior aspect of the calcaneus to unlock and push up any remaining depressed parts of the subtalar joint surface. Once the Böhler angle and articular surface were reduced, two Kirschner wires were inserted to sustain the reduced joint surface. Two more Kirschner wires were introduced in different directions to fix the primary and secondary fracture line. The Kirschner wires were then replaced with 6.5-mm and 3.5-mm cannulated screws. The cement was advanced through the channel made by the first Schanz pin under fluoroscopic guidance and slowly injected into the bone void created after the reduction. Partial weight-bearing with use of a plaster cast was allowed at six weeks, and full weight-bearing was allowed at eleven weeks after surgery. Patients in the ORIF group had reduction under direct visualization with the fracture fixed with screws and a calcaneal plate. Partial weight-bearing with a plaster cast was allowed at eight weeks, and full weight-bearing was allowed at twelve weeks after surgery.
Main outcome measures:
The outcome measures were blood loss, maintenance of reduction according to the Böhler angle, reduction in the width of the calcaneus, change in calcaneal length, subtalar and ankle joint motion, infection, and the American Orthopaedic Foot & Ankle Society (AOFAS) score (maximum 100, higher scores indicate better outcome) and the Maryland Foot Score (MFS) (maximum 100, higher scores indicate better outcome).
Main results:
When compared with patients in the ORIF group, patients in the PR + CSC group had less blood loss, greater subtalar and ankle motion, and higher AOFAS and MFS scores (Table). There was no difference between groups with regard to wound infection, change in Böhler angle, reduction of calcaneal width, or recovery of calcaneal length (Table).
Conclusion:
In patients with a displaced intra-articular calcaneal fracture, PR + CSC was superior to ORIF in maintaining subtalar and ankle motion, reducing blood loss during and after surgery, and improving function.
Sources of funding: No external funding.
For correspondence: Dr. W. Yuan, Department of Orthopedics, Chang Zheng Hospital, Second Military Medical University, Feng Yang Road 415, Shanghai 200003, China. E-mail address: surgeonyuanwen@126.com
For a glossary of terms for evidence-based orthopaedics, go to jbjs.org/ebo_glossary.
Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
Some patients with displaced intra-articular calcaneal fractures undergo surgical treatment with the hope of a better outcome compared with that obtained with a nonoperative approach. The most widely used surgical technique is open reduction and internal fixation through an extended lateral approach, which is associated with the risk of wound complications. Less invasive or percutaneous approaches have been proposed, but, without comparative and preferably randomized trial evidence, these proposals are only speculative1.
In their randomized trial, Chen et al. reported that a limited surgical approach led to greater ankle and subtalar motion and improved clinical outcome at an average of twenty-four months after injury. There was also a nonsignificant trend toward fewer wound complications with the less-invasive approach. The ability to achieve and maintain overall fracture reduction without plate fixation is consistent with other reports in the literature2.
There are two important issues that this study does not address. First, directly visualizing the fragments through open approaches theoretically leads to more accurate articular reduction, which in turn may result in less subtalar arthrosis. It is not clear whether articular reduction or arthrosis was assessed in this study. Second, these minimally invasive techniques are demanding and it is uncertain whether even high-volume surgeons can be expected to be equally facile with both techniques. The number of study surgeons, their previous experiences with the techniques, and how the randomized patients were assigned to the surgeons were not described.
In conclusion, the results of this study support the trend toward less-invasive approaches for some intra-articular calcaneal fractures.