Minimally Invasive Three-Column Fixation for Displaced Intra-Articular Calcaneal Fractures

Category: Trauma; Hindfoot Introduction/Purpose: Calcaneus can be morphologically and biomechanically constructed of medial column, lateral column and a connecting beam acting as transverse column. The fracture of the three columns of intra-calcaneal depression fracture divides the calcaneus into four major fracture fragments, namely the anterior tuberosity fragment, the sustentaculum fracture fragment, the posterior articular fracture fragment, and the posterior tuberosity fracture fragment. Minimally invasive three column fixation with screws was designed to manage the displaced intraarticular calcaneal fractures without extensile exposure. The timely use of the external distraction is key to restore the morphological index of the calcaneus. Frequently, the posterior articular fragment was reduced and fixed through a tarsal sinus approach. Methods: Thirty-five patients with 37 feet (33 xSanders type II, 4 x type III) of acute displaced intraarticular calcaneal fractures were managed with minimally invasive three column fixation. Böhler’s angle, Gissane angle and calcaneal varus angle (CVA) were measured preoperatively and postoperatively. Functional outcomes were assessed based on American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score. Results: Thirty-five patients with average follow-up time of 8 (range 6–12) months were included. All incisions healed primarily with no incision-related complications. The radiographs demonstrated successful corrections of the Böhler’s angle, Gissane angle and CVA from preoperative status to postoperative status. At average 8-month follow-up, the mean AOFAS score was 90.2 + 17.7 (range 70–98) and considered as the good and excellent rate of 89.7%. Conclusion: Minimally invasive three-column fixation of calcaneal fracture is a three-dimensional fixation, which can effectively obtain and maintain the anatomical reduction of calcaneal alignment, length, height, width and posterior articular surface reduction. Timely use of the medial or lateral based external distraction and direct tarsal sinus incision approach can achieve full or near anatomical reduction of calcaneal fractures. Meanwhile the minimally invasive approach effectively avoided complications associated with lateral extensile incisions. There was no need for prolonged wait period before skin condition to improve which may complicate the reduction and fixation due to early malunion.