Minimally Invasive Treatment of Displaced Intra-Articular Calcaneal Fractures

Minimally Invasive
Treatment of Displaced
Intra-Articular Calcaneal
Fractures
Brandon G. Wilkinson, MD, John Lawrence Marsh, MD*
KEYWORDS
Displaced intra-articular calcaneal fractures Minimally invasive Limited approach
Percutaneous reduction
KEY POINTS
Outcomes of minimally invasive surgical techniques are well documented and show good
articular reductions and functional outcomes and have a very low incidence of wound
complications and surgical site infections.
Minimally invasive techniques can be applied broadly but have particular advantages in patients
with higher than usual risk to soft tissues.
Early timing for surgery plays a role in the effectiveness of minimally invasive surgery as mobile
fracture fragments and ligamentotaxis are crucial to the success of indirect reduction and
fixation.
INTRODUCTION: NATURE OF THE achieving the fracture reduction goals versus

PROBLEM the goals of avoiding further soft tissue
compromise and complications.
There are very few fractures that have precipi- Extensile lateral approaches for open reduc-
tated such debate about treatment as the dis- tion and internal fixation have been used, as
placed intra-articular calcaneus fracture this approach allows the fracture to be directly
(DIACF). DIACFs result from high-energy reduced and the fracture fragments in the poste-
trauma, and surgical treatment requires under- rior facet to be visualized. However, extensile
standing of the complex calcaneal anatomy and approaches are often complicated by high rates
fracture characteristics, and high regard must of wound breakdown and infection.1–7 In efforts
be placed on associated soft tissue injury for to avoid soft tissue complications and preserve
optimal surgical outcomes. The best surgical blood supply, innovative less-invasive tech-
treatment techniques have been the topic of niques have been developed targeting reducing
debate for several decades and remain contro- and fixing the joint while minimizing further
versial. The goals of any operative reduction damage to the soft tissue envelope. In broad
and fixation technique are the same: restora- terms, these techniques include minimally inva-
tion of subtalar joint congruence, Bohler angle, sive percutaneous stabilization with pins/screws,
calcaneal height, alignment, and width while arthroscopic-assisted reduction and internal fixa-
minimizing the chances for soft tissue complication, and limited incision sinus tarsi open reduc-
tions. The fundamental basis of different treat- tion and internal fixation.
ments hinge on how much weight to place on
Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, University of Iowa, 200
Hawkins Drive, Iowa City, IA 52242, USA
* Corresponding author.
E-mail address: [email protected]
Orthop Clin N Am - (2020) -–-

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2 Wilkinson & Marsh
INDICATIONS/CONTRAINDICATIONS evidence shows that reasonable reductions can

be obtained and maintained using these tech-
Indications for surgical treatment of calcaneal niques. For instance, Stulik and colleagues8
fractures depend on the fracture pattern, de- showed excellent reduction (less than 2 mm
gree of displacement, characteristics of the pa- articular displacement), low wound complica-
tient, and the patient’s preferences. Fracture tions, and good functional outcomes using
patterns with large fragments and wide closed reduction and K-wire fixation and with a
displacement are ideal for treatment. These are mean follow-up of 43.4 months. A comparative
patterns in which there is substantial opportunity study (by the senior author of this article) be-
to improve the position and obtain solid fixation. tween the extensile lateral and minimally inva-
Minimally displaced fractures have good out- sive percutaneous approach assessed 125
comes without surgery and extensively commi- patients with intra-articular calcaneus fractures.
nuted fractures present challenges for any There was no difference in the Bohler angle,
technique of surgical treatment. loss of fracture reduction at fracture healing,
Patient characteristics are always important, need for late subtalar fusion, and implant
and elderly patients with decreased activity removal. However, this study showed a consis-
levels and patients who have diabetes or are tent theme: there was a significant decrease in
smokers are not good candidates for surgery. soft tissue complications in the group treated
Percutaneous approaches are safer than exten- with minimally invasive percutaneous screw
sile open reduction and therefore can be chosen fixation.9
for a wider range of patient risk profiles. In addi-
tion to avoiding further soft tissue compromise, Arthroscopic Assisted Reduction and Internal
minimally invasive techniques may also be Rotation
favored in the multiply comorbid or tenuous To directly visualize the intra-articular fracture
trauma patient, or in patients with diabetes, pe- lines, minimize soft tissue injury, and preserve
ripheral vascular disease, obesity, or smokers blood supply, arthroscopic assisted reduction
who are baseline susceptible to poor wound and internal fixation has been proposed by
healing. It must be noted, however, that timing some investigators. Sivakumar and colleagues10
may play a role in the effectiveness of minimally showed that a combination of arthroscopic and
invasive surgery, as mobile fracture fragments percutaneous reduction techniques resulted in
and ligamentotaxis are crucial to the success of 87.5% of cases with less than 2 mm articular con-
indirect reduction and fixation. gruity postoperatively and favorable results
Patient preferences should always be consid- compared with prior literature. Advocates for
ered in the decision to operate. The evidence arthroscopic assistance find significant advan-
supports that the differences in outcomes be- tages of continuous monitoring of the subtalar
tween operative and nonoperative techniques joint, improvement of subtalar joint reduction,
are narrow enough that patients should be given accessibility for joint debridement, removal of
a choice on whether to intervene. When this is loose osteochondral fragments, and identifying
done, some patients will choose nonoperative screw penetration into the joint.10–13 Caution
treatment. must be used because the fluid necessary to
maintain the ability to directly visualize the frac-
MINIMALLY INVASIVE TECHNIQUES ture may lead to increased soft tissue swelling
Percutaneous Reduction and Screw Fixation from fluid extravasation. In addition, there is sig-
(Authors’ Preferred Method) nificant technical difficulty and potential for
Some investigators advocate avoiding any inci- increased surgical time and added costs that
sions other than percutaneous puncture wounds should not be overlooked.
to minimize soft tissue injury. The reduction is
entirely judged using fluoroscopy. The reduction Limited Open Sinus Tarsi Approach
is performed using percutaneously inserted in- Limited open sinus tarsi approach has been pro-
struments to control, lever, and apply traction posed to limit soft tissue dissection while still
to displaced fragments all with the goal of cor- allowing fracture reduction/plate stabilization.
recting calcaneal varus, calcaneal pitch, lateral This technique requires a small 2-cm to 4-cm si-
displacement, and elevation of the depressed nus tarsi incision to directly visualize the poste-
posterior facet. Fixation is performed using a rior facet and anterior lateral fragments to
wide variety of devices including Kirschner wires assist optimal fracture reduction. With this tech-
(K-wires), Steinmann pins, external fixator, and nique, a specially contoured plate is often
cannulated and noncannulated screws. The inserted through the incision to obtain fixation.
Displaced Intra-Articular Calcaneal Fractures 3
Kikuchi and colleagues14 showed that the Bohler Correct patient positioning and
angle was successfully restored and calcaneal fluoroscopy
width was narrowed with low soft tissue compli- Percutaneous fracture reduction
cation rates. Nosewicz and colleagues15 showed Percutaneous noncannulated screw
good joint reduction and no loss of reduction at fixation
final follow-up on computed tomography scans Postoperative care
by use of a mini open sinus tarsi approach. In a
randomized controlled trial, Xia and col- Step 1: Correct Patient Positioning on
leagues16 compared the extended lateral Fluoroscopy
approach with limited sinus tarsi and percuta- Patient positioning and ensuring the ability to
neous plate fixation. Their results showed obtain clear fluoroscopic views are imperative
decreased surgical times and fewer wound com- to this approach:
plications in the sinus tarsi approach. Most
importantly, functional scores and radiographic The patient is placed in the lateral
parameters were equivalent at final follow-up. decubitus position on a radiolucent
These findings have been corroborated by operative table with a long foot
many other studies in the literature.17–19 overhang (Maquet or 4085 bed)
accommodating for large C-arm access.
The well-leg is positioned down and
SURGICAL TECHNIQUE/PROCEDURE
anterior, with the operative extremity
Authors’ Preferred Surgical Technique
posterior and elevated on a ramp of
Minimally invasive percutaneous reduction and
firm blankets or Bone Foam ensuring
screw fixation.
a perfect lateral position of the
operative foot and ankle. The operative
Preoperative Planning
extremity is subsequently prepped with
Thorough planning with assessment of fracture
ChloraPrep scrub, and draped with a
characteristics with appropriate imaging are
down drape, impervious “sticky U”
crucial to intervene successfully. Adequate imag-
drape, and 2 large U extremity drapes.
ing of the calcaneus including lateral, Broden,
The operating surgeon is positioned
and hindfoot view are imperative for under-
posterior to the patient enabling optimal
standing of the fracture characteristics and
position for fracture reduction and screw
displacement. These images will be used fluoro-
placement (Fig. 1).
scopically during the procedure so understand-
Three basic fluoroscopic views are
ing them ahead is critical. Contralateral
required to do this procedure.
calcaneus films will be of help during intraopera-
Fluoroscopic views should be confirmed
tive determination of restoration of calcaneal
before prepping and draping of the
pitch, Bohler angle, and confirm surgical restora-
tion of calcaneal height and alignment to the
contralateral side. Advanced imaging with
computed tomography scans in semi-coronal
and axial planes increases the ability to under-
stand the fracture fragments. Some surgeons
also use 3-dimensional images.
Expedited operative intervention is necessary
with preference within 7 to 10 days to ensure
fragment mobility, as closed manipulation of
fracture fragments through the percutaneous
approach becomes increasingly difficult with
longer delays. Indirect fracture reduction after
2 weeks is difficult through the authors’
preferred technique. Given minimal soft tissue
insult with this technique, swelling and ecchy-
mosis should not disqualify a patient from early
intervention with this technique.
Patient Positioning/Approach/Procedure
There are 4 essential steps to the percutaneous
approach, including the following: Fig. 1. Patient and surgeon positioning.
4 Wilkinson & Marsh
patient. Positioning the fluoroscopy unit are placed parallel from posterior into the
angling in approximately 45 from the facet fragment taking care to avoid the
anterior and caudal aspect of the patient Achilles insertion and angled anteriorly in
affords easy access to the lateral, lateral line with the fragment deformity (Fig. 5A).
oblique (Broden) view, with fluoroscopy They should be advanced inferior to and
in the vertical position (Figs. 2 and 3). to the level of the distal portion of the
Visualization of the subtalar joint is best displaced facet on the tongue fragment.
obtained by the lateral oblique view (see When seen on the Harris view, the
Fig. 3) with the C-arm rolled back Steinmann pins will be aligned parallel and
approximately 30 with slight cant in the central body of the calcaneus
toward the foot of the bed. Posterior spaced by approximately 2 to 3 cm
facet and subtalar joint visualization can (Fig. 5B and C).
further be fine-tuned by differing Using the inserted Steinmann pins, the
amounts of rotation and canting. With posterior fragment is reduced with
the fluoroscopy unit angled 45 to the downward pressure, valgus, and
foot of the bed, easy access to the apposition of the fragment firmly against
hindfoot view (Harris view) (Fig. 4) is the articular surface of the talus (Fig. 6).
obtained by rolling the fluoroscopy unit A hemostat is often used under the
back and beneath the corner of the anterior portion of the fragment, lifting
table to the horizontal position with the it, to facilitate this reduction. Through
surgeon holding the foot in dorsiflexion. this maneuver, the posterior facet is
These simple movements of the C-arm reduced, which also reduces the small
allow excellent views of the calcaneus tuberosity fragment, eliminating the
and subtalar joint without need for need for manipulation of this fragment
manipulation of the foot or leg, which separately. The medial wall should be
can potentially compromise provisional reduced. When the facet fragment is a
reduction and fixation throughout the tongue-type, the tuberosity fragment is
procedure. small. Provisional fixation is with long K-
wires inserted into the anterior calcaneus
Step 2: Percutaneous Fracture Reduction under fluoroscopic control. Occasionally,
Percutaneous techniques for both joint depres- the Steinmann pins are inserted into
sion and tongue-type calcaneal fractures are dis- the talus when there is inadequate
cussed separately, as they are different entities anterior calcaneal bone to hold the
and require different reduction techniques. tuberosity reduction. This happens in the
setting of exceptionally large tongue-
Tongue-type fractures type fractures. The Steinmann pins can
be left in place for several weeks for
Two large (4-mm) threaded Steinmann pins fractures with significant displacement.
are used for reduction of the posterior Screw fixation is described later in this
tuberosity fragment. The Steinmann pins article.
Fig. 2. Lateral view. Fig. 3. Lateral oblique (Broden) view.
Fig. 4. (A) Fluoroscopy in the horizontal position to obtain the hindfoot (Harris) view. (B) Hindfoot view. Surgeon
aids in view by dorsiflexing the patient’s ankle.
Fig. 5. (A) Steinman pin placement. (B) Fluoroscopic view of Steinman pin placement (lateral view). (C) Fluoro-
scopic view of Steinman pin placement (hindfoot view).
6 Wilkinson & Marsh
Fig. 6. (A) Tongue-type tuberosity reduction maneuver (position 1) (Yellow arrows indicate direction of surgeon
force for manipulation of fragments). (B) Tongue-type tuberosity reduction maneuver (position 2) (Yellow arrows
indicate direction of surgeon force for manipulation of fragments). (C) Fluoroscopic view of tongue-type tuberosity
reduction maneuver (position 1). (D) Fluoroscopic view of tongue-type tuberosity reduction maneuver (position 2).
Joint depression type fractures dimension. It is helpful to angle the

corkscrew slightly superior to help
Correct sequence of reduction maneuvers facilitate correction of the varus
is necessary to obtain adequate articular deformity of the hindfoot (Fig. 7A–D).
reduction. It is important to note that With a corkscrew properly inserted, and
you cannot reduce the posterior facet using the hindfoot view, manipulate the
without first reducing the tuberosity as tuberosity out to length, correct varus
the first step in the procedure, as the and lateral displacement by posterior
displaced tuberosity is physically in the directed force, valgus and medial
way. In addition, provisional fixation with pressure (Fig. 7E). This maneuver can be
K-wires should be well thought out in supplemented by placing a laparotomy
efforts to not block subsequent screw sponge at the base of the corkscrew and
paths for definitive fixation. Reduction of plantar flexing the ankle. To reduce
the tuberosity is facilitated by insertion lateral displacement of the tuberosity, it
of a large corkscrew used as a powerful is helpful to place the medial malleolus
tool for manipulation. The corkscrew is on a stack of firm towels to allow for
placed lateral to medial in the medial directed pressure on the
tuberosity. Insertion of the corkscrew tuberosity fragment with the corkscrew.
should be posterior in the tuberosity and Tilting the corkscrew into valgus will
centered in the anterior and posterior correct the varus deformity, as judged
Fig. 7. (A) Corkscrew insertion. (B) Corkscrew insertion illustrating slight superior angulation on insertion. (C) Fluo-
roscopic view of corkscrew insertion (lateral view). (D) Fluoroscopic view of corkscrew insertion (hindfoot view). (E)
Arrows indicate reduction forces applied by the surgeon. The surgeon places a laparotomy sponge at the base of
the corkscrew to assist in distraction. With a combination of distraction, medially directed force, and valgus, the
surgeon corrects length, lateralization, and varus malalignment of the calcaneus.
by the tuberosity medial wall alignment laterally inserted curved hemostat

on the Harris view (see Fig. 7C). placed directly beneath the rotated facet
Occasionally it is requisite to use a small fragments (Fig. 8). If facet fragment
Cobb elevator or a hemostat inserted mobilization is difficult, this is likely due
from a small lateral incision and to an inadequately reduced tuberosity
navigated through the fracture fragment and confirmation of tuberosity
fragments to manipulate the medial fragment reduction should be revisited.
sustentaculum and translate the With fluoroscopic confirmation of facet
tuberosity against the instrument (a fragment reduction, 0.45-mm K-wires are
shoehorn type of technique) if the subsequently used for provisional
preceding measures are inadequate. fixation. These K-wires should be placed
The reduced tuberosity fragment as lateral to medial, beginning slightly
confirmed by fluoroscopic views is posterior and inferior to the distal fibula
subsequently provisionally fixed with with the goal of capturing the reduced
multiple K-wires (minimum of 3) placed facet fragment and fixing it to the intact
medially and inferior in the tuberosity medial sustentaculum (see Fig. 8D).
and efforts to not block subsequent Adequate pin placement and facet
reduction of the facet fragments. K-wire reduction maintenance is confirmed on
placement and reduction is again the lateral and lateral oblique views of
confirmed on fluoroscopic views. the subtalar joint.
With the posterior tuberosity reduced
and provisionally fixed with K-wires, Step 3: Percutaneous Noncannulated Screw
reduction of the articular facet fragment Fixation
is done using the lateral and lateral Percutaneous screw fixation is used for definitive
oblique views as the working views. The fixation of the reduced facet and tuberosity frag-
facet fragment is then reduced with ments. Screw start points, as well as final screw
superior directed pressure with a placement, should be well visualized and
8 Wilkinson & Marsh
Fig. 8. (A) Curved hemostat is used to elevate the articular surface (white arrow illustrating unreduced position). (B)
Yellow arrow illustrating the reduced position after hemostat manipulation. (C) Hemostat reduction of articular sur-
face on lateral oblique view (white arrow illustrating facet in unreduced position). (D) Hemostat manipulation leads
to reduced facet (yellow arrow) and provisional fixation with K-wire.
confirmed on all fluoroscopic views to ensure wall and possible injury to the flexor
proper placement and avoidance of joint pene- hallucis longus tendon. Partially threaded
tration. The authors prefer noncannulated screws with usual length of 35 to 45 mm
screws, as the drill bit provides superior tactile are placed from lateral to medial
feedback facilitating appropriate screw trajec- capturing the facet fragment and
tory and then placement: compressing it to the sustentacular
fragment (Fig. 9). The lateral view
The facet fragment is addressed first facilitates correct screw entry point,
using 3.5-mm or 4.0-mm partially while the lateral oblique view allows
threaded noncannulated screws. As accurate navigation of the screw into the
mentioned previously, the tactile sustentaculum. Screw length is best
feedback of the 2.5-mm drill is depicted with use of the hindfoot view.
particularly helpful in identifying The tuberosity is then fixed with long fully
entrance into the sustentacular piece, as threaded 3.5-mm screws (minimum of 2,
well as minimizing breach of the medial maximum of 4 screws) (Fig. 10). It is
tuberosity fragment are best judged on

the lateral view. Care should be taken to
avoid medial sustentacular breech, as
well as a prominent screw head on the
tuberosity fragment to limit potential
damage to the flexor hallucis longus
tendon and dissatisfaction with
prominent screw heads once swelling
resolves.
In tongue-type fractures, many similar
screw paths are used. It is important the
tongue fragment is well fixed. Anterior
screws beneath the posterior facet into
the sustentaculum secure the front of
the tongue, and long screws from the
back of the tongue fragment to the front
of the calcaneus are needed. Screws also
may be directed from the top of the
Fig. 9. Screw fixation of the facet fragment. Note the
tongue into the bottom of the
K-wire positioned to next fix the tuberosity fragment
into the medial sustentaculum. calcaneus. In these cases, additional
fixation can be achieved with inferiorly
directed cancellous screws compressing
imperative that the screws fix the the tongue fragment with the posterior
tuberosity fragment to both the medial tuberosity fragment.
sustentaculum as well as the anterior Diligent fluoroscopy using the lateral,
process of the calcaneus and, as such, oblique lateral, and hindfoot views
multiple fluoroscopic views are necessary should be used to confirm all screw
for correct screw placement. In general, positions and lengths, as well as
65-mm to 85mmm screw lengths are maintenance of fracture reduction before
used and inserted using a power driver. leaving the operating room.
The screws are inserted from posterior
lateral in the tuberosity directed slightly
Step 4: Postoperative Care
superior and medial to engage the
sustentaculum. In contrast to the facet The operative extremity is placed in a
fragment, the length of screws for the short leg plaster splint with awareness of
Fig. 10. Screw fixation of facet and tuberosity fragments on (A) lateral view and (B) hindfoot view. White and yellow
arrows indicate facet screws and tuberosity screws respectively.
10
Table 1
Summary of results of limited minimally invasive approach techniques
Wilkinson & Marsh

Classification Mean
Study, Year (Sanders) Technique Age, y % Female Follow-up, mo Outcomes
De Vroome Type II 28% Percutaneous 51 23 Not reported. AOFAS

& van der Linden,20 Type III Median follow-up 69% good-excellent
2014 56% 72 mo 31% fair-poor
Type IV 15% 100% tongue-type had
good-excellent
outcomes
2.4% infection rate
Tomersen et al,21 Type II 26% Percutaneous 54 30 66 AOFAS
2011 Type III 73% good-excellent
39% 27% fair-poor
Type IV 34%
DeWall et al,9 Type II 39% Percutaneous 40 20 21.9 Average SF-36 score: 47.1
2010 Type III Foot Function index: 66.6
33% Deep infection 0%
Type IV 6% Superficial infection 6%
Not specified
22%
Walde et al,22 Type II 16% Percutaneous 46 28 68 Zwipp score
57% 39% fair-poor
Type IV 27%
Schepers et al,23 Type II 38% Percutaneous 46 28 35 AOFAS
28% 28% fair-poor
Type IV 28%
Stulik et al,8 Type II 61% Percutaneous 44 15 43 Creighton-Nebraska
2006 Type III Health Foundation
30% Assessment score
Type IV 9% 72% good-excellent
28% fair to poor
1.7% deep infection rate
McGarvey et al,24 Type II 33% Percutaneous 42 23 25 AOFAS average score 66
2006 Type III 1 external fixation
27%
Type IV 30%
Kikuchi et al,14 Type II 36% Limited sinus tarsi 43 14 8 Restoration of Bohler
2013 Type III angle and calcaneal
32% width in all cases.

Type IV 32% 13.6% superficial infection.
Nosewicz et al,15 Type II 9 Limited sinus tarsi 45 14 32 No loss of reduction at
2012 Type III 13 1 percutaneous final follow-up.
screw fixation AOFAS 86
Superficial wound
infection 14%
Ebraheim et al,25 Type II 67% Limited Sinus Tarsi 42 24 29 Mean AOFAS 77.6,
2000 Type III 1 Percutaneous Infection 8.5%
23.6% fixation
Type IV 9.4%
Xia et al,16 2014 Less invasive: Limited sinus tarsi Less Less 19 Decreased surgical
Type II 66% vs extensile lateral invasive: 38 invasive: 4 time and wound
Displaced Intra-Articular Calcaneal Fractures

Type III 42% Extensile Extensile complications in ST
Extensile lateral Lateral: 37 Lateral: 4 group.
Type II 63% Maryland Foot Scores in
Type III 45% ST group. No difference
in radiographic parameters
between groups.
Zhang et al,17 Less invasive: Limited sinus tarsi Less Less 27 Decreased wound
2014 Type II 46% vs modified longitudinal invasive: 40 invasive: 11 complications and operative
Type III approach Extensile Extensile time in less invasive group.
33% Lateral: 41 Lateral: 13 Equivalent AOFAS scores.
Type IV 20%
Extensile Lateral
Type II 40%
Type III
38%
Type IV 22%
(continued on next page)
11
12
Table 1
(continued )
Wilkinson & Marsh

Classification Mean
Study, Year (Sanders) Technique Age, y % Female Follow-up, mo Outcomes
18
Kline et al, Less invasive: Less invasive Less Less Less No difference in Foot
2013 Type II 61% vs extensile lateral invasive: 46 invasive: 21 invasive: 28 Function index, VAS,
Type III 39% Extensile Extensile Extensile or satisfaction rates.
Extensile Lateral lateral: 42 lateral: 15 lateral: 31 No difference in Bohler
Type II 53% angle. Significant decrease
Type III 47% in wound complications and
secondary procedures in
less-invasive group.
Weber et al,19 Less invasive: Limited sinus tarsi Less Not reported Less Decreased surgical time in
2008 Type II 83% vs extensile lateral invasive: 43 invasive: 31 sinus tarsi group,
Type III 17% Extensile: 40 Extensile: 19 equivalent functional
Extensile lateral outcomes. Increase ROH
Type II 77% in sinus tarsi group.
Type III 23%
Sivakumar et al,10 Type II 56% ARIF 45 22 18 AOFAS 89% good-excellent.
2014 Type III 11% fair-poor.
22%
Type IV 22%
Woon et al,11 Type II 100% ARIF 43 22 24 Residual intra-articular
2011 incongruity less than 1 mm.
Improvement in Medical
Outcomes Study 36 SF,
VAS, and AOFAS.
Gavlik et al,12 Type II 100% ARIF 40 15 14 No wound complications.
2002 AOFAS 93.7.
No loss of reduction at final
follow-up.
Abbreviations: AOFAS, The American Orthopedic Foot & Ankle Society; ARIF, Arthroscopic assisted Reduction and Internal Fixation; ROH, removal of hardware; SF-36, short form 36
question survey; VAS, visual analogue scale.
ankle alignment depending on the extensile lateral approach, and an increasing

fracture type. To avoid undue stress on number of surgeons are using these techniques
tongue-type injuries, the ankle is for most or all DIACFs. The method of percuta-
splinted and 20 of plantarflexion. Joint neous reduction and screw fixation described
depression–type fractures are placed in this article was developed by the senior author
with the ankle in neutral alignment. and has been his sole method of operative treat-
Postoperative radiographs are performed ment of DIACF for more than 20 years. This tech-
to better visualize the final product. nique requires relatively early surgery, which is
Computed tomography scans can crucial to successful percutaneous manipulation
additionally be used to further evaluate of fracture fragments. Debate remains about
articular reduction and screw placement. the optimal treatment of displaced intra-
The patient will return for a 2-week articular calcaneal fractures, but minimally
postoperative visit for a wound check invasive surgical techniques have been widely
and suture removal. Patients are then adopted by many surgeons. We predict that as
transitioned into a removable cast boot imaging and other techniques continue to
with physical therapy to begin active improve, more and more calcaneal fractures
ankle and subtalar range-of-motion will be treated by these appealing safer
exercises. In cases of severely displaced techniques.
fractures, the patient is transitioned into
a short leg cast for 4 to 6 weeks. We DISCLOSURE
recommend a total of 8 weeks of
nonweightbearing for any operative B.G. Wilkinson: Nothing to Disclose. J.L. Marsh: Oxford
calcaneus fracture. Press, Biomet Trauma, Wright Medical – All Royalties.
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Minimally Invasive Treatment of Displaced Intra-Articular Calcaneal Fractures

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Minimally Invasive

INTRODUCTION: NATURE OF THE achieving the fracture reduction goals versus

Orthop Clin N Am - (2020) -–-

INDICATIONS/CONTRAINDICATIONS evidence shows that reasonable reductions can

Fig. 2. Lateral view. Fig. 3. Lateral oblique (Broden) view.

Joint depression type fractures dimension. It is helpful to angle the

by the tuberosity medial wall alignment laterally inserted curved hemostat

tuberosity fragment are best judged on

Wilkinson & Marsh

De Vroome Type II 28% Percutaneous 51 23 Not reported. AOFAS

32% width in all cases.

Displaced Intra-Articular Calcaneal Fractures

Wilkinson & Marsh

ankle alignment depending on the extensile lateral approach, and an increasing

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