Various percutaneous and minimally invasive techniques have been introduced because of the skin and wound complications associated with open surgical techniques for the treatment of intra-articular calcaneal fractures. Forgon and Zadravecz combined several lessinvasive techniques for percutaneous reduction and fixation through the use of an external distractor.4
In this study, the outcome of the percutaneous treatment according to Forgon and Zadravecz of patients with a displaced intra-articular calcaneal fracture was evaluated over the long term.
Patients in this study achieved a good to excellent result in 42% to 72% of cases, according to the use of three different outcome scores. The range of motion of the ankle joint was nearly normal, and the range of motion of the subtalar joint was approximately 70% compared with the uninjured side.
A limitation of this study is the absence of a control group treated with a different method. In the level-1 setting where the study was conducted, no other technique was implemented, thus removing the possibility of a concurrent control group. Migrants, the homeless, and patients receiving psychiatric treatment were mostly lost to follow-up; however, their fracture characteristics and patient characteristics were not significantly different from the patients analyzed. Murhagnan showed an equivalent level of patients lost to follow-up, however they found that the attenders and nonattenders in a calcaneal fracture trial constituted two significantly different groups. It is therefore not prudent to extrapolate the results of this study to all patients who were treated in the study period; this constitutes a second limitation.20
The largest published series of patients treated with the percutaneous distractor method comprised 265 cases and presented good to excellent results in approximately 85% of patients.21
Differences in study parameters and outcome scores make it difficult to compare the results as presented by Forgon and Zadravecz and those of this study.
The functional results presented in this study appear to be slightly less favorable than those reported for open reduction and internal fixation (ORIF) groups in the literature, but appear to be better than those for conservatively treated patients.10
The infection and wound complication rates in this study appear similar to those of ORIF and the infections that occurred at the insertion site of the traction pins were not severe. Historically complication rates as high as 30%–40% have been reported for ORIF. Reports from the last 5 to 10 years show a superficial skin infection or wound dehiscence rate of about 10%. Deep infections such as osteomyelitis occur at a lower rate.24
The largest prospective, randomized multicenter study of Buckley et al. in 2002 showed a superficial infection and wound complication rate of 17% and a deep infection rate of 5% for ORIF.2
With a 15% arthrodesis rate, our study results appear more favorable than those for conservatively treated patients, but less favorable than for open reduced and fixated fractures.2
Buckley et al. showed that the need for arthrodesis was 4% in the ORIF group versus 20% in the conservatively treated group.2
Many studies point out restrictions at the subtalar joint for both surgically and conservatively treated fractures. The average range of motion is approximately halved compared with the uninjured foot.26
The more favorable results presented in this study are supported by the findings of other authors.27
The percutaneous approach minimizes secondary trauma to the soft tissues, which may lead to less scar tissue formation around the ankle and subtalar joint and may thus lead to less stiffness of the joint.19
In conclusion, this study confirms that the function of the calcaneus and subtalar joint can be restored by percutaneous reduction and fixation in patients with a displaced intra-articular calcaneal fracture. Despite similar infectious complication rates and higher secondary arthrodesis rates compared with open procedures, the good outcome scores and the preservation of the subtalar range of motion at 3-year follow-up indicate little benefit of open procedures, as reported in the literature, over percutaneous reduction and fixation.