Arthroscopically-Assisted Osteosynthesis of Calcaneal Fractures: Clinical and Radiographic Results of a Prospective Study

PURPOSE OF THE STUDY The aim of this prospective study was to evaluate the clinical and radiographic results in a group of patients with calcaneal fractures treated by means of minimally invasive, arthroscopically-assited osteosynthesis. MATERIAL AND METODS A total of 175 calcaneal fractures in 154 patients were treated surgically at the Trauma Centre of Masaryk Hospital between January 2006 and August 2010. Twenty-six patients were enrolled in this prospective study. They had a total of 30 calcaneal fractures, of which 28 were managed by minimally invasive, arthroscopically-assisted osteosynthesis. The patient's records included demographic data, relevant medical history, fracture type by Sander's classification, associated injuries, time to surgery, length of surgery, post-operative quality of reduction, Bohler's angle before and after surgery, healing complications, hospitalisation time, follow-up period, bone union, functional outcome in Rowe score and hardware removal. The patients underwent minimally invasive osteosynthesis under arthroscopic and radiographic guidance. For this procedure, patients with Sanders type IIa and IIb fractures were predominantly indicated. The group also included patients older than 60 years, smokers, patients addicted to alcohol, a diabetic patient, a dialysed patient and a patient with chronic lower-limb lymphoedema. RESULTS The patient group included 21 men with 25 fractures (83.5%) and five women with five fractures (16.5%). Nine men (42.9%) were heavy smokers; three men (14.3%) and one woman (20 %) were addicted to alcohol. All fractures were closed and, according to the Sanders system, were classified as follows: 16 fractures as type IIa (57.1%); eight fractures as IIb (28.6%); two fractures as IIIab (7.1%) and one IIIac and IIIbc (3.6% respectively). Six patients (23.1%) sustained bilateral fractures of the lower-limb. In the post-operative period, no disturbance of soft tissue healing and no superficial or deep wound infection were observed. The outcome of fracture reduction assessed by CT examination was excellent in 24 fractures (85.6%), satisfactory in one (3.6%) and poor in one fracture (3.6%). The mean Bohler's angle was +7.2 degrees pre-operatively and +35.4 degrees post-operatively. In all patients bone union was achieved within 3 months; hardware was removed in 19 fractures (67.9%). Functional outcomes according to the Rowe score were very good in 18 (69.2%), good in four (15.4%) and satisfactory in four (15.4%) patients. There were no poor results. The mean Rowe score for the whole patient group was 86 points. DISCUSSION The demographic data are in agreement with the recent literature data. However, most studies have not included smokers and people addicted to alcohol, therefore, no comparison can be made. The comparison with studies on ORIF-treated fractures is also difficult, because our study included a higher number of less severe fracture types. The surgical technique is demanding and was, at the beginning, associated with intra-operative errors. The post-operative values of Bohler's angle are comparable to the results of ORIF techniques, but this does not mean that this technique could substitute the use of ORIF in complex fractures. The absence of any soft- or bone-tissue healing problems is a very good result, considering the number of risk factors in our patient group. The good functional outcomes according to the Rowe score can be attributed to a higher proportion of less complex fractures in the group. CONCLUSIONS In our group of patients with predominantly less severe types of calcaneal fractures, the quality of post-operative fracture reduction, as a result of minimally invasive, arthroscopically-assisted osteosynthesis, appeared to be comparable with open techniques. The observed complete bone healing and absence of soft-tissue problems could present a surgical option to treatment nihilism in patients contraindicated for ORIF techniques.