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Treatment of Displaced Intra-Articular Calcaneal Fractures with Closed Reduction and Percutaneous Screw Fixation
T. Tomesen, MD1; J. Biert, MD, PhD1; J.P.M. Frölke, MD, PhD1
1 Department of Surgery 690, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500HB Nijmegen, The Netherlands. E-mail address for J.P.M. Frölke: j.frolke@chir.umcn.nl
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Investigation performed at the Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

A commentary by Daniel C. Farber, MD, is linked to the online version of this article at jbjs.org.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 May 18;93(10):920-928. doi: 10.2106/JBJS.H.01834
A commentary by Daniel C. Farber, MD, is available here
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Surgical treatment of displaced intra-articular fractures of the calcaneus is a standard procedure in many institutions. To avoid soft-tissue complications, several minimally invasive procedures have recently been introduced. The aim of this study was to assess the percutaneous treatment of displaced intra-articular calcaneal fractures with use of one of these techniques.


All patients who underwent percutaneous screw fixation according to the method of Forgon and Zadravecz between 1998 and 2006 were selected. Postoperative infections were recorded. During follow-up, pain, functional outcome, range of motion, and change in footwear were evaluated with the use of the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients also completed a general health status form (Short Form-36 [SF-36]) and a visual analog scale (VAS) for patient satisfaction. Subsequent subtalar arthrodesis and the removal of irritating screws were performed when indicated.


We reviewed the cases of thirty-seven patients who had a combined total of thirty-nine displaced intra-articular calcaneal fractures and a follow-up period of at least twenty-four months. Five wound infections occurred, two of which were superficial and three of which were deep. At a mean follow-up time of sixty-six months, the mean AOFAS and MFS scores were 84 and 86 points, respectively, of 100 possible points. The mean score on the SF-36 was 76 points, and the mean score on the visual analog scale for patient satisfaction was 7.9 points of 10 possible points. Twenty-nine patients (78%) were able to wear normal shoes. At the time of follow-up, subtalar arthrodesis had been performed in two patients and seventeen patients (46%) had undergone an uncomplicated removal of painful screws. No substantial correlation was found between the severity of the fracture (Sanders classification) or the quality of the reduction when correlated with functional outcome parameters.


We consider the technique of Forgon and Zadravecz to be an excellent option for the treatment of displaced intra-articular calcaneal fractures in selected patients despite the frequent need for screw removal following fracture-healing.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Tim Schepers, Lucas M.M. Vogels, Dennis den Hartog
    Posted on June 20, 2011
    Letter to the Editor
    Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands Department of Surgery-Traumatology

    To The Editor:With great interest we read the article by Tomesen et al. considering the percutaneous reduction and screw fixation of 39 calcaneal fractures in 37 patients. We agree with the authors that the percutaneous treatment of displaced intra-articular calcaneal fractures is a valuable addition to the various treatment modalities for intra-articular calcaneal fractures with overall positive functional outcome (1). Although the complication rates, i.e. deep infections, reported in this study are higher than previously reported studies for percutaneous calcaneal surgery, the literature suggests that outcome has been similar for percutaneous treatment compared to open reduction and internal fixation via the extended lateral approach with even overall less wound complications (2). While the authors do not find a correlation between the accuracy of the reduction (due to the small group of patients?) it is known from literature that an anatomical reduction confirmed with post-operative CT-imaging correlates with improved outcome in displaced intra-articular calcaneal fractures (3). Suggestions for better reduction might be the use of peroperative 3D-scanning or subtalar joint arthroscopy, which has shown high outcome scores in percutaneous reduction and internal fixation (4). One of the main drawbacks the authors report of the current technique described is a 40% need for implant removal. With respect to this need for implant removal, Zadravecz uses headless-distraction screws since approximately 2005 resulting in a low removal rate (5). Furthermore the authors state there were only two slight modifications to the technique of Forgon and Zadravecz, there are however several. Zadravecz uses a three-point distraction technique (talus-cuboid and talus-calcaneus), he applies the distraction on both sides of the foot to facilitate the correction of varus deformity, and uses a blunt punch from plantar to correct step-off in the posterior talo-calcaneal joint, followed by the Cotton technique on the lateral wall to reduce width (5). In conclusion, the discussion should not be whether percutaneous is a good technique, because that has been proven in numerous previous and larger studies. Nor should the discussion be whether percutaneous is better than open reduction. But the main, still unanswered, question is when to use which technique in a certain patient with a certain fracture-type. Conservative management, internal fixation (via a percutaneous approach, limited lateral approach, or via an extended lateral approach), and primary arthrodesis are all valuable techniques when used in the right patient with the right fracture-type. Future treatment should be tailored to the individual patient and his/her fracture, as not all calcaneal fractures are suitable to a single operative technique. References 1. Schepers T, van Lieshout EM, Ginai AZ, Mulder PG, Heetveld MJ, Patka P. Calcaneal fracture classification: a comparative study. J Foot Ankle Surg 2009;48-2:156-62. 2. DeWall M, Henderson CE, McKinley TO, Phelps T, Dolan L, Marsh JL. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma 2010;24-8:466-72. 3. Song KS, Kang CH, Min BW, Sohn GJ. Preoperative and postoperative evaluation of intra-articular fractures of the calcaneus based on computed tomography scanning. J Orthop Trauma 1997;11-6:435-40. 4. Woon CY, Chong KW, Yeo W, Eng-Meng Yeo N, Wong MK. Subtalar Arthroscopy and Fluorosocopy in Percutaneous Fixation of Intra-Articular Calcaneal Fractures: The Best of Both Worlds. J Trauma 2011. 5. Kadas I, Szita J, Zadravecz G, Hangody L, Doczi J. Stabilization of calcaneus fractures in a closed manner with a distraction screw. Joint Dis Rel Surg 2008;19-1:45-9.

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