Calcaneus Fractures

Calcaneal fractures comprise 2% of all fractures. They are the most common fractures in the tarsal bones, accounting for 60% of all the tarsal fractures. Most calcaneal fractures (60%) occur in patients who are still in their wage-earning age (30 to 50 years old). Approximately 75% of these are displaced and intra-articular fractures (DIACFs).

Majority of displaced intra-articular calcaneal fractures involves the posterior facet, which is the major weight-bearing surface of the sub-talar joint. These fractures typically result from high-energy trauma; however can also result after low energy injuries, especially in females above the age of 60 years. Primary mechanism involves traumatic axial loading following a fall from height or motor-vehicle accidents.

Patients usually present with a painful, swollen and bruised heel and the arch of the foot. Significant swelling may lead to blistering of the skin. Approximately 15% of all calcaneal fractures have an associated open wound and 5%-10% involve both heels.

The economic impact of calcaneal fractures to the patients and the society is considerable and is a consequence of extended hospital stay, cost of treatment, residual pain, time to mobilization and delayed return to work.

Some studies have reported that a considerable number of patients may not be able to resume their work even after one year of sustaining the injury. The patients may remain symptomatic for one to two years and secondary arthrodesis may be needed in up to 16% of the non-operatively treated patients.

Factors associated with a poor outcome include age over 50, obesity, manual labour, workers compensation, smokers, bilateral fractures, multiple trauma, vasculopathies and male gender.

Classification

Sanders classification: Based on the number of intra-articular fracture lines and their location on semicoronal CT images. This classification is useful not only in understanding typical fracture patterns but also in predicting the outcome.

Type 1: all intra-articular fractures with less than 2 mm displacement, regardless of the number of fracture lines/fragments present

 

Type 2a: one primary fracture line that courses through the lateral aspect of the posterior facet; often accompanied by one or more accessory fracture lines that do not involve the posterior facet

 

Type 2b: one primary fracture line that courses through the central aspect of the posterior facet; often accompanied by one or more accessory fracture lines that do not involve the posterior facet

 

Type 2c: one primary fracture line that courses through the medial aspect of the posterior facet and is accompanied by a transverse fracture through the body of the calcaneus; often accompanied by one or more accessory fracture lines that do not involve the posterior articular facet

 

Type 3ab: two primary fracture lines, one coursing through the lateral aspect of the posterior facet and the second through the central aspect; usually presents with depression of the central fragment

 

Type 3ac: two primary fracture lines, one coursing through the lateral aspect of the posterior facet and the second through the medial aspect; usually presents with depression of the central fragment.

 

Type 3bc: two primary fracture lines, one coursing through the central aspect of the posterior facet and the second through the medial aspect; usually presents with depression of the central fragment;

 

Type 4: three or more primary fracture lines with greater than 2 mm of articular displacement, and severely comminuted.

Essex-Lopresti classification

Tongue-type fractures: Primary fracture line runs obliquely through the posterior facet forming two fragments, the secondary fracture line runs in one of two planes  the axial plane beneath the facet exiting posteriorly. 

Joint depression fractures: Superolateral fragment and posterior facet remain attached to the tuberosity posteriorly behind the posterior facet.

Sanders classification of displaced intra-articular calcaneal fractures (Courtesy of Dr. Matt Skalski, Radiopaedia.org)

Treatment

Conservative vs Surgical Treatment

The optimal management of displaced intra-articular calcaneal fractures remains debatable. Controversies and variable opinion exist among the foot and ankle surgeons regarding the choice of operative or non-operative treatment. Some authors report that the restoration of intra-articular anatomy is essential to restore the normal gait biomechanics, early return to work and minimize the need for subsequent subtalar arthrodesis.

Historically, DIACFs were treated non-operatively with a combination of rest, elevation, ice and immobilization with plaster cast, followed by physiotherapy and gradual mobilization. However, this often required delayed reconstruction of the mal-united fracture or a subtalar arthrodesis, leaving the patient with a painful and stiff foot, which delayed or permanently prevented their return to work and other pre-injury activities.

The results of a prospective RCT from Canada comparing operative versus non-operative treatment of DIACFs suggested that without stratification of the groups, the functional results were equivalent in both the groups. However, after unmasking the data by removal of the patients who were receiving workers' compensation, the outcomes were significantly better in some groups of surgically treated patients.

UK Heel Trial

The results of an RCT from the UK (Heel trial) concluded that operative treatment compared with non-operative showed no symptomatic or functional advantage after two years in patients with typical displaced intra-articular fractures of the calcaneus, and the risk of complications was higher after surgery. Twenty-two tertiary referral hospitals (27 specialist surgeons) participated with final inclusion of 151 patients with DIACFs. These patients were randomly allocated to operative (n=73) or non-operative (n=78) treatment groups. 95% follow-up was achieved for the primary outcome  and a complete set of secondary out comes were available for 75% of participants.

However, the UK heel trial was heavily criticized by Pearce et al. During the study period, 2006 patients presented with calcaneal fractures, of which 502 were deemed eligible for recruitment into the trial. Many of these were excluded quite reasonably (undisplaced fractures), but also excluded were patients that clearly needed surgery (open or severely displaced fractures). An important point to note is that only 30% of eligible patients consented to be included in the trial, with the majority of those who declined doing so because they had a preference for either operative or non-operative treatment. The follow-up period was only 2 years. This is important in view of that fact that there is evidence that it may take two years for the symptoms from these fractures to stabilize and that the patients may even continue to improve for up to six years.

In an excellent response to the Heel trial, Parker and Winson reported there are longer-term studies to report a relative risk reduction in radiographic subtalar arthritis of 41% with surgery and a statistically significant correlation between the best results and surgery at ten years follow-up.

It is worth mentioning here that there is evidence in literature that patients do better, with fewer complications, from subtalar arthrodesis for post-traumatic arthritis after an initial open reduction and internal fixation of a calcaneal fracture than they do with subtalar arthrodesis for arthritis following mal-union of a non-operatively treated fracture.

Another recently published multicentre RCT from Sweden showed that patient-reported clinical, functional and quality of life outcomes were better after operative treatment at 8 to 12 years follow-up.

Surgical Treatment

The aim of surgical treatment is to restore anatomical reduction of the articular surface, the subtalar joint and normal width of the calcaneus, and to maintain this reduction with stable fixation.

Several open surgical techniques such as medical, lateral, combined lateral and medial, and posterior approaches have been described, of which the extensile lateral approach is widely practiced as the most commonly used approach.

Indications for surgery include displaced tongue-type fractures, Sanders type 2 and 3 fractures, posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity, anterior process fracture with >25% involvement of calcaneocuboid joint and displaced sustentaculum fractures.

ORIF Through Extensile Lateral Approach

The extensile lateral approach has been considered to provide better exposure of the anatomy of the fractures and helps to obtain better reduction, however it does carry significantly higher risk of wound related complications (11.7% to 35%) despite the use of meticulous surgical technique.

Howard et al., retrospectively reviewed 226 displaced intra-articular calcaneus fractures treated through an extensile lateral approach and found an overall wound complication rate of 25% (57/226 fractures).

Folk et al. identified diabetes, smoking and open fractures as independent risk factors for wound complications. In their series, 48 of 190 fractures developed wound complications (25%), and 40 of these required further operative intervention (21%).

Backes et al., in their retrospective study on 191 patients, reported 25% (47/191 fractures) incidence of wound related complications following open reduction and internal fixation using the extensile lateral approach.

De Groot et al., in a retrospective study, reported a 32% wound complication rate following the fixation of DIACFs via the extensile lateral approach with a median follow-up of 6.5 years. An interesting finding in their study was that short-term wound complications did not influence the mid- to long-term clinical or functional outcome.

Jain and colleagues reported 14.2% wound complication rate in 28 patients treated with the extensile lateral approach in a retrospective study.

Schepers et al. reported a lower complication rate using a special single layer suturing technique for wound closure following the extensile lateral approach for displaced intra-articular calcaneal fractures. In their retrospective study on 53 patients with a mean follow-up of 6 years, the overall wound related complication rate was 7.5% using this particular meticulous technique. They also described an inverse relationship of wound related complications with surgeons’ experience in the management of calcaneal fractures.

 

Zwipp et al. reported an 11% wound complication rate in 102 patients with displaced intra-articular calcaneal fractures who were treated with open reduction and internal fixation using the extensile lateral approach.

Zeman et al., in a retrospective study, have shown a 20.7% wound complication rate after fixation of displaced intra-articular calcaneal fractures via the extensile lateral approach in 46 patients.

Harvey et al., in a retrospective review, reported an 11% wound complication rate (24 of 218) for these fractures treated via the extensile lateral approach.

Minimally Invasive Reduction and Percutaneous Fixation

Minimally invasive techniques have yielded promising results, with a decreased rate of deep infection and wound related complications. However, controversy exists regarding the appropriate indications for open versus percutaneous fixation techniques and the long-term outcomes with respect to mobility, function, patient satisfaction, degree of arthrosis, and the need for additional revision surgery or implant removal.

These techniques include percutaneous reduction and internal fixation, arthroscopically-assisted fixation, and minimal incision techniques via medial, modified lateral (the sinus tarsi approach), posterior, or combined approaches.

Careful study of preoperative CT scan is vital before attempting minimally invasive reduction, as it helps the operating surgeon to understand the fracture anatomy and dimensions of the displaced fragments. Theses technique are mainly recommended for Sanders type 2 and 3 fractures.

Smerek et al., in a cadaveric biomechanical study, found that percutaneous screw fixation for Sanders type 2b fractures provided strength similar to that of perimeter plating.

Cao et al. reported the early results of percutaneous fixation of 33 displaced intra-articular calcaneal fractures and found 6% (2/33 fractures) incidence of superficial wound infections with a mean follow-up of 12 months.

Hammond and Crist reported the results of the minimally invasive reduction and percutaneous fixation for displaced intra-articular calcaneal fractures in high-risk patients including smokers, diabetics and alcohol and drug users (17 fractures). There were no wound related issues or infections found in these patients, however the mean follow-up was only 3 months.

Xia et al., in a prospective study, found no wound related complication in 38 fractures treated with minimally invasive technique.

Meraj and colleagues, in their prospective study, found no wound related problems in 25 displaced intra-articular calcaneal fractures treated with minimally invasive technique with a mean follow-up duration of 12 months.

Abdelgaid reported 60 fractures that had been reduced with minimally invasive technique and fixed percutaneously with no wound complications at a mean follow-up of 29 months.

Woon et al., in a prospective study, described the outcomes of 22 displaced intra-articular fractures, with a mean follow-up of 33 months. No wound complications or infections were reported, however 1 seroma and 1 prominent screw head were reported.

 

Tomesen and colleagues, in their retrospective study, reported the outcomes of 39 fractures and found 5% incidence of superficial infection and 7% deep infection.

Rammelt et al. reported the outcomes of 61 patients treated with minimally invasive reduction and percutaneous fixation of Sanders type 2a and 2b fractures with a mean follow-up of 24 months and found no wound complications.

Walde et al. retrospectively reviewed 92 fractures treated with minimally invasive technique and found an overall rate of 9.8% of wound related complications.

Schepers et al. retrospectively reviewed 61 fractures that were treated with minimally invasive technique and found 11% superficial and 3% deep infections with a mean follow-up of 35 months.

Stulik et al. reviewed the results of 287 fractures treated with minimally invasive reduction and percutaneous fixation over a period of 10 years and found 7% rate of superficial infection (20/287 fractures) and 1.7% deep infection (5/287 fractures).

Ebraheim and Elgafy presented their results of 106 fractures and reported an overall incidence of 9 cases of infection (8.5%); 4 patients (3.8%) developed superficial wound infections, 4 patients (3.8%) developed pin tract infections, and 1 patients (0.9%) developed osteomyelitis.

 

References

  • Griffin D, Parsons N, Shaw E, et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ 2014;349:4483.

  • Radnay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? J Bone Joint Surg [Am]2009;91-A:541–546.

  • Court-Brown CM, Schmied M, Schutte BG. Factors affecting infection after calcaneal fracture fixation. Injury 2009;40:1313–1315.

  • Scammell BE. Calcaneal fractures. BMJ 2014;349:4779.

  • Yeo J-H, Cho H-J, Lee K-B. Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach. BMC Musculoskeletal Disorders. 2015;16:63.

  • Jiang, N., et al., Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. Int Orthop, 2012. 36(8): p. 1615-22.

  • Pearce, C.J., K.L. Wong, and J.D. Calder, Calcaneal fractures: selection bias is key. Bone Joint J, 2015. 97-B(7): p. 880-2.

  • Abdelgaid, S. M. (2012). Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures. Foot Ankle Surg, 18(3), 164-179. doi: 10.1016/j.fas.2011.07.005

  • Agren, P. H., Mukka, S., Tullberg, T., Wretenberg, P., & Sayed-Noor, A. S. (2014). Factors affecting long-term treatment results of displaced intraarticular calcaneal fractures: a post hoc analysis of a prospective, randomized, controlled multicenter trial. J Orthop Trauma, 28(10), 564-568. doi: 10.1097/BOT.0000000000000149

  • Arastu, M., Sheehan, B., & Buckley, R. (2014). Minimally invasive reduction and fixation of displaced calcaneal fractures: surgical technique and radiographic analysis. Int Orthop, 38(3), 539-545. doi: 10.1007/s00264-013-2235-4

  • Assous, M., & Bhamra, M. S. (2001). Should Os calcis fractures in smokers be fixed? A review of 40 patients. Injury, 32(8), 631-632.

  • Backes, M., Schepers, T., Beerekamp, M. S., Luitse, J. S., Goslings, J. C., & Schep, N. W. (2014). Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach. Int Orthop, 38(4), 767-773. doi: 10.1007/s00264-013-2181-1

  • Benirschke, S. K., & Kramer, P. A. (2004). Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma, 18(1), 1-6.

  • Buckley, R., Tough, S., McCormack, R., Pate, G., Leighton, R., Petrie, D., & Galpin, R. (2002). Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am, 84-A(10), 1733-1744.

  • Cao, L., Weng, W., Song, S., Mao, N., Li, H., Cai, Y., . . . Su, J. (2015). Surgical treatment of calcaneal fractures of sanders type II and III by a minimally invasive technique using a locking plate. J Foot Ankle Surg, 54(1), 76-81. doi: 10.1053/j.jfas.2014.09.003

  • Chen, L., Zhang, G., Hong, J., Lu, X., & Yuan, W. (2011). Comparison of percutaneous screw fixation and calcium sulfate cement grafting versus open treatment of displaced intra-articular calcaneal fractures. Foot Ankle Int, 32(10), 979-985.

  • Crosby, L. A., & Fitzgibbons, T. C. (1996). Open reduction and internal fixation of type II intra-articular calcaneus fractures. Foot Ankle Int, 17(5), 253-258.

  • De Boer, A. S., Van Lieshout, E. M., Den Hartog, D., Weerts, B., Verhofstad, M. H., & Schepers, T. (2014). Functional Outcome and Patient Satisfaction after Displaced Intra-articular Calcaneal Fractures: A Comparison Among Open, Percutaneous, and Nonoperative Treatment. J Foot Ankle Surg. doi: 10.1053/j.jfas.2014.04.014

  • De Groot, R., Frima, A. J., Schepers, T., & Roerdink, W. H. (2013). Complications following the extended lateral approach for calcaneal fractures do not influence mid- to long-term outcome. Injury, 44(11), 1596-1600. doi: 10.1016/j.injury.2013.06.014

  • DeWall, M., Henderson, C. E., McKinley, T. O., Phelps, T., Dolan, L., & Marsh, J. L. (2010). Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma, 24(8), 466-472. doi: 10.1097/BOT.0b013e3181defd74

  • Ding, L., He, Z., Xiao, H., Chai, L., & Xue, F. (2013). Risk factors for postoperative wound complications of calcaneal fractures following plate fixation. Foot Ankle Int, 34(9), 1238-1244. doi: 10.1177/1071100713484718

  • Ebraheim, N. A., Elgafy, H., Sabry, F. F., Freih, M., & Abou-Chakra, I. S. (2000). Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. Foot Ankle Int, 21(2), 105-113.

  • Folk, J. W., Starr, A. J., & Early, J. S. (1999). Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma, 13(5), 369-372.

  • Gougoulias, N., Khanna, A., McBride, D. J., & Maffulli, N. (2009). Management of calcaneal fractures: systematic review of randomized trials. Br Med Bull, 92, 153-167. doi: 10.1093/bmb/ldp030

  • Hammond, A. W., & Crist, B. D. (2013). Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: a case series. Injury, 44(11), 1483-1485. doi: 10.1016/j.injury.2013.01.033

  • Harvey, E. J., Grujic, L., Early, J. S., Benirschke, S. K., & Sangeorzan, B. J. (2001). Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int, 22(11), 868-873.

  • Howard, J. L., Buckley, R., McCormack, R., Pate, G., Leighton, R., Petrie, D., & Galpin, R. (2003). Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma, 17(4), 241-249.

  • Ibrahim, T., Rowsell, M., Rennie, W., Brown, A. R., Taylor, G. J., & Gregg, P. J. (2007). Displaced intra-articular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury, 38(7), 848-855. doi: 10.1016/j.injury.2007.01.003

  • Jain, S., Jain, A. K., & Kumar, I. (2013). Outcome of open reduction and internal fixation of intraarticular calcaneal fracture fixed with locking calcaneal plate. Chin J Traumatol, 16(6), 355-360.

  • Jiang, N., Lin, Q. R., Diao, X. C., Wu, L., & Yu, B. (2012). Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. Int Orthop, 36(8), 1615-1622.

  • Kline, A. J., Anderson, R. B., Davis, W. H., Jones, C. P., & Cohen, B. E. (2013). Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. Foot Ankle Int, 34(6), 773-780. doi: 10.1177/1071100713477607

  • Kumar, V. S., Marimuthu, K., Subramani, S., Sharma, V., Bera, J., & Kotwal, P. (2014). Prospective randomized trial comparing open reduction and internal fixation with minimally invasive reduction and percutaneous fixation in managing displaced intra-articular calcaneal fractures. Int Orthop, 38, 2505-2512. doi: 10.1007/s00264-014-2501-0

  • Meraj, A., Zahid, M., & Ahmad, S. (2012). Management of intraarticular calcaneal fractures by minimally invasive sinus tarsi approach-early results. Malays Orthop J, 6(1), 13-17. doi: 10.5704/MOJ.1203.007

  • Rammelt, S., Amlang, M., Barthel, S., Gavlik, J. M., & Zwipp, H. (2010). Percutaneous treatment of less severe intraarticular calcaneal fractures. Clin Orthop Relat Res, 468(4), 983-990. doi: 10.1007/s11999-009-0964-x

  • Rammelt, S., & Zwipp, H. (2004). Calcaneus fractures: facts, controversies and recent developments. Injury, 35(5), 443-461. doi: 10.1016/j.injury.2003.10.006

  • Sanders, R. (2000). Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am, 82(2), 225-250.

  • Sanders, R., Fortin, P., DiPasquale, T., & Walling, A. (1993). Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res(290), 87-95.

  • Schepers, T. (2011). The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop, 35(5), 697-703. doi: 10.1007/s00264-011-1223-9

  • Schepers, T., Den Hartog, D., Vogels, L. M., & Van Lieshout, E. M. (2013). Extended lateral approach for intra-articular calcaneal fractures: an inverse relationship between surgeon experience and wound complications. J Foot Ankle Surg, 52(2), 167-171. doi: 10.1053/j.jfas.2012.11.009

  • Siebe De Boer, A., Van Lieshout, E. M. M., Hartog, D. D., Weerts, B., Verhofstad, M. H. J., & Schepers, T. (2014). Functional Outcome and Patient Satisfaction after Displaced Intra-articular Calcaneal Fractures: A Comparison Among Open, Percutaneous, and Nonoperative Treatment. The Journal of Foot and Ankle Surgery, 1(8).

  • Smerek, J. P., Kadakia, A., Belkoff, S. M., Knight, T. A., Myerson, M. S., & Jeng, C. L. (2008). Percutaneous screw configuration versus perimeter plating of calcaneus fractures: a cadaver study. Foot Ankle Int, 29(9), 931-935. doi: 10.3113/FAI.2008.0931

  • Stulik, J., Stehlik, J., Rysavy, M., & Wozniak, A. (2006). Minimally-invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg Br, 88(12), 1634-1641. doi: 10.1302/0301-620X.88B12.17379

  • Tennent, T. D., Calder, P. R., Salisbury, R. D., Allen, P. W., & Eastwood, D. M. (2001). The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol. Injury, 32(6), 491-496.

  • Tomesen, T., Biert, J., & Frolke, J. P. (2011). Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am, 93(10), 920-928. doi: 10.2106/JBJS.H.01834

  • Tornetta, P., 3rd. (2000). Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res(375), 91-96.

  • Walde, T. A., Sauer, B., Degreif, J., & Walde, H. J. (2008). Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2-10 years. Arch Orthop Trauma Surg, 128(6), 585-591. doi: 10.1007/s00402-008-0590-1

  • Wallin, K. J., Cozzetto, D., Russell, L., Hallare, D. A., & Lee, D. K. (2014). Evidence-based rationale for percutaneous fixation technique of displaced intra-articular calcaneal fractures: a systematic review of clinical outcomes. J Foot Ankle Surg, 53(6), 740-743. doi: 10.1053/j.jfas.2014.03.018

  • Weber, M., Lehmann, O., Sagesser, D., & Krause, F. (2008). Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum. J Bone Joint Surg Br, 90(12), 1608-1616. doi: 10.1302/0301-620X.90B12.20638

  • Woon, C. Y., Chong, K. W., Yeo, W., Eng-Meng Yeo, N., & Wong, M. K. (2011). Subtalar arthroscopy and flurosocopy in percutaneous fixation of intra-articular calcaneal fractures: the best of both worlds. J Trauma, 71(4), 917-925. doi: 10.1097/TA.0b013e318202f1d0

  • Wu, Z., Su, Y., Chen, W., Zhang, Q., Liu, Y., Li, M., . . . Zhang, Y. (2012). Functional outcome of displaced intra-articular calcaneal fractures: a comparison between open reduction/internal fixation and a minimally invasive approach featured an anatomical plate and compression bolts. J Trauma Acute Care Surg, 73(3), 743-751. doi: 10.1097/TA.0b013e318253b5f1

  • Xia, S., Lu, Y., Wang, H., Wu, Z., & Wang, Z. (2014). Open reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fractures - a randomized controlled trial. Int J Surg, 12(5), 475-480. doi: 10.1016/j.ijsu.2014.03.001

  • Xia, S., Wang, X., Lu, Y., Wang, H., Wu, Z., & Wang, Z. (2013). A minimally invasive sinus tarsi approach with percutaneous plate and screw fixation for intra-articular calcaneal fractures. Int J Surg, 11(10), 1087-1091. doi: 10.1016/j.ijsu.2013.09.017

  • Zeman, P., Zeman, J., Matejka, J., & Koudela, K. (2008). [Long-term results of calcaneal fracture treatment by open reduction and internal fixation using a calcaneal locking compression plate from an extended lateral approach]. Acta Chir Orthop Traumatol Cech, 75(6), 457-464.

  • Zwipp, H., Rammelt, S., Amlang, M., Pompach, M., & Dürr, C. (2013). Operative treatment of displaced intra-articular calcaneal fractures. Oper Orthop Traumatol, 25(6), 554-568. doi: 10.1007/s00064-013-0246-3.

Last Updated: Jan 2018

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Date First Published - March 4, 2018

Date Last Updated - Jan 12, 2019