Minimal Invasive Techniques in Management Of Calcaneal Fractures

Abstract

The ideal treatment for intra-articular fractures of the calcaneus remains a matter of controversy, despite the advances in imaging diagnostics and surgical techniques. Several surgical techniques for treating displaced intra-articular fractures exist, and these include: conventional open reduction with internal fixation and minimally invasive techniques. Open reduction and internal fixation (ORIF) through an extensile lateral approach has been widely accepted and established as a standard treatment for displaced intra-articular calcaneal fractures. However, a fairly high wound-related complication rate has been reported with this approach, including wound edge necrosis, dehiscence, hematoma, infection and injury to the sural nerve. In an attempt to lower the complication rate, various minimally invasive techniques have recently been introduced, including external fixation, percutaneous fixation, arthroscopically assisted fixation, and minimal incision techniques via modified lateral (such as the sinus tarsi approach), longitudinal, or combined approaches. These techniques have been reported as effective in minimizing soft tissue trauma, thereby reducing the incidence of wound related complications. A comprehensive understanding of the clinical and radiographic anatomy of the calcaneus and its articulations is crucial when attempting less invasive procedures for intra-articular calcaneus fractures. The surgeon’s experience must also be considered when deciding the best surgical technique. The learning curve for Percutaneous reduction and fixation techniques is steep, with unsatisfactory results being difficult to manage and ultimately a number of patients needing subtalar fusion as a salvage procedure.

In conclusion, there is no universal treatment or surgical approach to all displaced intra-articular calcaneal fractures. The choice of treatment must be based on the characteristics of the patient, the type of fracture, degree of displacement, and subtalar incongruence which are the main indicators, as well as the condition of the soft tissues. These promising minimally invasive techniques may be beneficial in patients with soft-tissue compromise, multiple comorbidities such as smoking and diabetes mellitus, which directly influence the healing process, and displaced intraarticular fractures. However, further research is needed to determine the ideal candidates for these procedures, as well as long-term outcomes.