Displaced, intra-articular fractures of the calcaneus: Review of non-operative management, open reduction internal fixation and novel minimally invasive techniques

Abstract

Calcaneal fractures comprise 1–2 % of all fractures and typically occur in younger, working age male patients. These injuries result in a significant burden to the patient in terms of residual pain, inability to work or participate in sports, difficulty with shoe wear and secondary reconstructive surgery such as subtalar arthrodesis. They also result in a significant burden to the healthcare system. Calcaneal fractures can be sub-classified into extra-articular and intra-articular, two-thirds of calcaneal fractures involve the articular facets of the subtalar joint. The treatment of displaced intra-articular calcaneal fractures is controversial, with many authors recommending non-operative treatment. The concerns with this approach include painful malunion, articular surface disruption, heel varus and increased calcaneal width, with a significant rate of secondary reconstructive surgery. Traditional operative approaches for calcaneal fractures allowed the surgeon to restore anatomic parameters, but have been associated with high rates of soft tissue complications, up to 40 % in some series. Newer, less invasive techniques for fixation allow the surgeon to obtain a similar anatomic reduction with reduced tissue compromise. We performed a systematic literature search which identifed forty articles on which this review is based. In this review article we discuss the background of displaced, intra-articular calcaneal fractures and compare the current knowledge base of operative vs. non-operative management. We then compare and contrast the three common surgical approaches used for treatment of these injuries: the extensile lateral approach, the sinus tarsi approach and newer percutaneous/minimally invasive techniques. At the current time, the sinus tarsi approach is the mainstay for treating these fractures, with most authors favouring this over the extensile lateral approach. There is momentum for adoption of newer minimally invasive techniques which show promising results, with reduced soft tissue complications and satisfactory functional outcomes.