Results after Percutaneous and Arthroscopically Assisted Osteosynthesis of Calcaneal Fractures

CATEGORY: Arthroscopy, Trauma INTRODUCTION/PURPOSE: Surgical treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of infection and soft tissue complications. During the last years there was a trend towards less invasive fixation methods. Percutaneous and arthroscopically assisted calcaneal osteosynthesis (PACO) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. We have performed this technique since 2014 in selected Sanders II and III fractures. METHODS: We conducted a clinical and radiographic follow-up of 19 patients with 20 calcaneal fractures which had been treated by PACO with a minimum follow-up of 12 months. The follow-up rate was 66% (19 of 29 patients). 18 men and 1 woman with a median age of 44 years (range, 21-65) and a follow-up period of 18 months (12-33) were examined. There were 11 Sanders II and 9 Sanders III fractures. Radiographs of all feet were obtained at final follow-up to evaluate the reduction of the fractures as well as the presence of osteoarthritis of the subtalar joint. Our primary outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcomes were the Calcaneus Fracture Scoring System (CFSS), the Manchester- Oxford Foot Questionaire (MOxFQ), the Visual Analog Scale (VAS) for pain and the incidence of complications. RESULTS: The patients were operated on after a median of 4 days after injury (range, 1-12). The operation time was 139.5 minutes (98-234). The patients were discharged 3 days (1-6) postoperatively. Postoperative radiographs showed a Böhler angle of 29.5 degrees (0-40). However, the follow-up radiographs showed subsidence of the fractures and a Böhler angle of 21 degrees (-16-36). 95% of the operated feet showed signs of posttraumatic subtalar osteoarthritis. There were no wound healing complications. Two patients were reoperated with screw removal due to prominent screws. The AOFAS score was 85 (50-100), the CFSS score 85 (26-100), the MOxFQ score 26.6 (0-73.4). The VAS pain score was 0 (0-5.7) at rest and 4 (0-8.2) during activity. CONCLUSION: Only a few articles have reported the outcome after percutaneous artroscopically assisted calcaneal osteosynthesis. Our results suggest that PACO gives good clinical results and a reduced risk of complications in selected calcaneal fractures. However, since this technique is technically challenging and has a steep learning curve, we expect to be able to further improve our results over time. Prospective longterm studies will be necessary to better document the potential advantages and limitations of this operating technique.