Percutaneous Fixation of Calcaneus Fractures is Associated with Increased Complications Compared to Open Reduction and Internal Fixation

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Calcaneal fractures are high-energy injuries commonly managed via percutaneous fixation or open reduction and internal fixation (ORIF). While ORIF has historically been considered the standard of care, the more invasive approach compared to percutaneous methods of fixation carries a theoretical increased risk of complications including infection, dehiscence, and damage to nearby structures. In contrast, minimally invasive percutaneous techniques may reduce soft tissue disruption and incidence of infection, but comparative outcomes are unclear. This study evaluated short-term and long-term outcomes focusing on a composite any adverse event and individual complications. We aimed to determine whether percutaneous or open fixation are associated with higher adverse event rates at both 90 days and 2 years. Methods: We performed a retrospective analysis using the TriNetX research network, which aggregates deidentified electronic medical records from 105 healthcare organizations. Patients undergoing calcaneal fracture fixation were identified via CPT codes for percutaneous skeletal fixation (CPT 28406, n = 1,296) and ORIF (CPT 28415 and 28420, n = 12,101). Two cohorts were defined and propensity score–matched on age, sex, race, and type 2 diabetes mellitus, yielding 1,213 matched pairs. Primary endpoints included a composite any adverse event and individual complications; endpoints with ≤10 events in either group were excluded. Rates, odds ratios (ORs), and p values were calculated for outcomes at 90 days and 2 years. Results: At 90 days, the composite adverse event rate was significantly higher in the percutaneous group (14.2% vs. 10.8%; OR 1.31, 95% CI: 1.06–1.62; p = 0.012) and remained elevated at 2 years (20.1% vs. 14.6%; OR 1.31, 95% CI: 1.06–1.62; p = 0.012). Significantly higher rates in the percutaneous group were observed for transfusion (90 days: 3.6% vs. 1.4%; p = 0.004), emergency department visits (12.6% vs. 6.0%; p < 0.001), and sepsis (1.3% vs. 0.3%; p = 0.007) at both time points. There were no statistically significant differences for dehiscence, pulmonary embolism, acute myocardial infarction (MI), deep vein thrombosis (DVT), surgical site infection (SSI), or hematoma at 90 days or 2 years. Conclusion: Percutaneous calcaneal fracture fixation was associated with significantly higher composite adverse event rates at both 90 days and 2 years, driven by increased risks of transfusion, emergency department visits, and sepsis. These findings suggest that while open fixation is a more invasive approach and often indicated for more severe injuries, it is associated with a lower risk of short-term and long-term postoperative complications compared to percutaneous fixation. These results also indicate that surgeons may be utilizing percutaneous fixation methodologies in patients deemed higher risk from a surgical candidacy standpoint.