Foot & Ankle International - September 2019 - 1064

1064

Foot & Ankle International 40(9)

Table 2. Radiographic Parameters.
Measurement
Bohler's angle, deg (range)
Angle of Gissane, deg (range)
Calcaneal height, mm (range)
Calcaneal length, mm (range)

Preoperative

Postoperative

P Value

12.9 (−5 to 36)
124.9 (100-146)
45.1 (36-53)
77.3 (60-89)

31.7 (16-40)
123.8 (104-146)
49.6 (42-58)
78.1 (67-89)

<.001
>.05
<.001
>.05

Table 3. Complications of Treatment.
Complication
Numbness (calcaneal sensory branch)
Superficial wound infection
Deep wound infection
Subtalar arthritis
Symptomatic hardware
Symptomatic Haglund deformity

No.
1
2
1
1
2
1

(P > .05). All fractures had less than 1mm of posterior
facet joint displacement.

Complications
The complications are summarized in Table 3. One patient
(3.1%) had postoperative numbness related to the medial
incision in the calcaneal branch sensory nerve distribution. Three (9.4%) patients experienced a wound infection. One (3.1%) patient had a deep infection and required
surgery for irrigation and debridement. There were 2
(6.2%) patients with superficial infections requiring only
oral antibiotics and local dressing care for resolution. Both
superficial infections were related to the medial incision.
The deep infection that required surgical irrigation and
debridement was of the lateral incision. One (3.1%) patient
developed subtalar pain that was treated with subtalar
joint steroid injections. Two (6.2%) patients returned to
the operating room for removal of symptomatic hardware,
one of whom also underwent partial excision of the posterior calcaneus (excision of Haglund deformity). No
patients experienced nonunion or malunion, had a loss of
reduction, reported complications related to trans-Achilles
Schanz pin, or reported flexor hallucis longus irritation
from the medial plate.

Discussion
The management of intra-articular calcaneus fractures
remains controversial. There are numerous factors that
influence a surgeon's decision regarding which approach to
use, including fracture pattern, patient comorbidities such
as smoking and diabetes, skin condition, and time from
injury to presentation. The goal of all approaches is

to minimize soft tissue trauma while achieving anatomic
fracture reduction and stable fixation. Minimally invasive
approaches offer decreased risk of wound complications,
though success in achieving the operative goal of anatomic
fracture reduction is still under review. Our study reports on
the radiographic and clinical results of 32 patients with displaced, intra-articular calcaneus fractures treated with a
minimally invasive, 2-incision (medial and sinus tarsi)
approach. The 2-incision surgical approach evaluated in the
current study demonstrated a statistically significant
improvement in Bohler's angle and calcaneal height. Our
results are similar to those of other studies reporting radiographic outcomes from minimally invasive approaches of
displaced, intra-articular calcaneal fractures. Our study
found an average preoperative Bohler's angle of 12.9
degrees and a postoperative angle of 31.7 degrees. Scott
et al showed an improvement in Bohler's angle from 7.7
degrees preoperatively to 25.5 degrees postoperatively
using a single-incision sinus tarsi approach.33
Wound complication rates were consistent with other
published studies of minimally invasive approaches and
lower compared with published results of the extensile lateral approach. In our study, 6.2% of patients experienced a
superficial infection and 3.1% had a deep infection. We had
no cases of osteomyelitis. A recent meta-analysis comparing the extensile lateral approach to a sinus tarsi approach
found an overall wound complication rate for the extensile
lateral approach of 24.9%, with 71% of those classified as
minor wound complications and 29% classified as major
wound complications.26 For the sinus tarsi approach,
Nosewicz et al report a 4.9% rate of wound healing complications, all classified as minor.26 Kline et al found a wound
complication rate of 6.1% for minimally invasive
approaches, none of which required operative intervention,
and 29.1% for the extensile lateral approach, 9% of which
required operative intervention.23 In a systematic review of
the sinus tarsi approach, Schepers reported a wound complication rate of 0% to 15.4%, with a superficial infection
rate of 4.1% and a deep infection rate of 0.7%.31 Weber et al
published a comparison of the extensile lateral approach
versus a minimally invasive sinus tarsi approach and
reported zero wound complications in the minimally invasive group with only 1 patient (4.2%) reporting a plantar
nerve lesion.42 In our study, there were only 2 secondary
surgeries for hardware removal (6.2%) compared with 20%

Foot & Ankle International - September 2019

Table of Contents for the Digital Edition of Foot & Ankle International - September 2019