Closed reduction and percutaneous screw fixation with early rehabilitation versus cast immobilization in minimally displaced sanders type II–III calcaneal fractures: a two-center retrospective comparison of treatment protocols

BACKGROUND: Minimally displaced intra-articular calcaneal fractures are commonly managed with cast immobilization, but prolonged immobilization may delay recovery and contribute to hindfoot stiffness. This study compared mid-term clinical and radiographic outcomes of two institutional protocols for minimally displaced Sanders type II-III calcaneal fractures: closed reduction and percutaneous screw fixation with earlier range-of-motion exercises versus cast immobilization. METHODS: This two-center retrospective cohort study included 87 patients treated between January 2018 and February 2024 with a minimum 24-month follow-up. Fifty-three patients underwent closed reduction and percutaneous fixation using two 5-mm headless cannulated screws, with range-of-motion exercises beginning at 2 weeks. Thirty-four patients were treated nonoperatively with short-leg cast immobilization for 6 weeks. The primary outcome was the Foot and Ankle Ability Measure (FAAM), including Activities of Daily Living and Sports subscales. Secondary outcomes included the AOFAS Ankle-Hindfoot score, visual analog scale pain score, and serial radiographic measurements. RESULTS: Pre-treatment demographic, fracture, follow-up, and radiographic characteristics were comparable between groups. At final follow-up, the fixation and earlier rehabilitation protocol was associated with higher FAAM Activities of Daily Living, FAAM Sports, and AOFAS scores. VAS pain was lower in unadjusted analysis but was not significant after adjustment. Final Böhler and Gissane angles were higher in the fixation group. The fixation group also showed greater calcaneal height increase and calcaneal length decrease from pre-treatment to final follow-up. All fractures united. No wound-healing complications or surgical-site infections occurred after fixation; posterior implant-entry-site irritation occurred in three patients and required implant removal after union. CONCLUSION: In selected minimally displaced Sanders type II-III calcaneal fractures, the institutional protocol including closed reduction, percutaneous screw fixation, and earlier rehabilitation was associated with better mid-term functional outcomes and more favorable radiographic parameters than cast immobilization. Prospective comparative studies are needed to evaluate fixation, cast immobilization, and functional nonoperative rehabilitation strategies.