Better management of Sanders Ⅱ and Ⅲ calcaneus fractures via a tailored distractor-assisted percutaneous approach versus sinus tarsi approach: a comparative cohort study with 2-year follow-up.

Abstract

The surgical strategy of displaced intra-articular calcaneal fractures (DIACFs) remains technically challenging. While sinus tarsi approach (STA) is widely applied for DIACFs, increasing concerns regarding the wound-related sequelae drive surgeons to target and advance minimally invasive surgery (MIS). This study aims to introduce a tailored distractor-assisted MIS and compares its medium-term outcomes with conventional STA approach reduction and fixation in patients with Sanders Ⅱ and Ⅲ calcaneus fractures. From Jan 2021 to Jun 2023, 133 cases (133 feet) diagnosed as DIACFs are prospectively randomized to receive either the tailored distractor-assisted MIS (MIS-arm) or conventional STA (STA-arm) reduction and fixation in the city trauma center. A 2-year follow-up is scheduled to record surgical outcomes. The medical records and radiological measurements during the follow-up are retrospectively retrieved and compared between the two treatment-arms for curative effect evaluation. At the last follow-up, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hind foot score and Visual Analog Scale (VAS) score are used to evaluate the functional rehabilitation. The basic demographic characteristics and clinical presentations were comparable among the MIS-arm (67 feet) and the STA-arm (66 feet). Perioperatively, the MIS-arm vs STA-arm showed significant advantages in the interval between injury to operation, the operation time, and the hospital stay (average 1.3 vs 3.8 days, P < .05; 40.1 vs 65.4 min, P < .05; 4.9 vs 8.5 days, P < .05; respectively). Notably, the MIS-arm vs STA-arm was less likely to develop wound infection (0 % vs 6.1 %, P < .05). For postoperative radiological measurements, the MIS-arm achieved significant improvement from pre-operation with regards to calcaneal height, width, Bohler's angle, and Gissane angle (p < 0.05, respectively) as the STA-arm done and there were no differences between those two-arms in any above radiological indices (p > 0.05, respectively). At the last follow-up, the functional outcomes including AOFAS and the VAS were comparable between the two cohorts (81.4 ± 7.6 vs 79.5 ± 8.8, t = -2.20, P > .05; 1.3 ± 1.5 vs 2.30 ± 0.9, t = -4.33, P > .05; respectively). During the 2-year follow-up, no failure of reduction were observed. Further subgroup analysis confirmed no technical preference regarding MIS among Sanders type II and III. The tailored distractor-assisted MIS actually worked out as conventional STA strategy did in radiological and functional outcomes for Sanders Ⅱ and Ⅲ calcaneus fractures. Lower rate of incision-related complications showed advantages of the tailored distractor-assisted MIS over STA. Further cohort study is required to clarify its clinical significance vs other MIS techniques.