Percutaneous reduction, internal fixation yields good results in calcaneal fractures

Tissue-sparing procedure offers low complication rate, minimal arthritic change.

PHOENIX — Percutaneous reduction and internal fixation may provide good functional and clinical results with a low risk of complications for patients with intra-articular calcaneal fractures.

In a prospective study of 20 patients with intra-articular calcaneal fractures who underwent the procedure, Paul Y. Shonnard, MD, of Reno, Nev., found an average fracture reduction of 23.9° and had no infections or wound complications at an average follow-up of 4 years. He also found that all of the fractures maintained reduction and showed minimal arthritic change. The patients also reported maximum Kerr foot scores for pain relief at rest and activities of daily living.

"This appears to be a safe and reliable method to obtain reduction, which was able to regain the preinjury calcaneal morphology," Shonnard said during a presentation at the Orthopaedic Trauma Association meeting. "It is a minimally invasive and soft tissue-sparing procedure with a low complication rate, high level of function at final follow-up and appears to be a viable option for patients with intra-articular calcaneus fractures."

Single surgeon experience

The study included patients at an average age of 49.6 years who received percutaneous reduction and internal fixation performed by a single surgeon. To obtain the reduction, Shonnard said he used the underside of the talus to manipulate the posterior facet fragments and inserted a Cobb elevator through a lateral incision to lift the facet.

After stabilizing the fragment with cannulated screws, he created an incision underneath the tendon and internally fixed the fracture with lag screws. An additional screw was also positioned down the length of the calcaneus. Rehabilitation included immobilization with bulky Jones splints and non-weightbearing for 6 to 8 weeks.

Radiographic review and clinical evaluations revealed good outcomes with the procedure. The researchers found that the average Bohler's angle increased from 6.2° preoperatively to 30.1° postoperatively. Fluoroscopic images taken at 20°, 30° and 40° also revealed an average fracture gap of less than 1 mm.

"Reductions were maintained in all fractures without significant subsidence," Shonnard said. "[And] there's minimal arthritic changes at follow-up."

More pain at work

The researchers also assessed patient-reported outcomes for pain at rest, daily activity, walking and work using the Kerr foot scoring system. While the patients reported perfect scores for pain at rest and daily activity, the researchers found lower scores for the work and walking components of the system.

"At work, there were some complaints in terms of prolonged standing at 8 hours," Shonnard said. He also noted that one patient required a cane for ambulation, which decreased the overall walking score.

For more information:
Shonnard PY, Putnam BS, Litchfield SB. Percutaneous reduction and internal fixation of intra-articular calcaneus fractures. #22. Presented at the Orthopaedic Trauma Association 22nd Annual Meeting. Oct. 4-7, 2006. Phoenix.
Paul Y. Shonnard, MD, Reno Orthopaedic Clinic, 555 N Arlington Ave, Reno, NV 89503-4724, 775-788-5283, pshonnard@renoortho.com.