Calcaneal fracture

Indication

Displaced intra-articular calcaneal fractures (Sanders II–IV) are the primary surgical indication. The decision point divides surgeons between open reduction with plate fixation via an extensile lateral or sinus tarsi incision, percutaneous or arthroscopically assisted reduction with screw or wire fixation, and primary subtalar arthrodesis for the most severe joint destruction (typically Sanders IV).

The techniques

• Extensile lateral approach (ELA): Full lateral exposure of the calcaneus through a long L-shaped or straight incision, allowing direct visualization and plate fixation of all fracture fragments.
• Sinus tarsi approach (STA): A 3–5 cm oblique incision over the sinus tarsi, providing limited exposure for reduction and fixation with a plate or screws while preserving the lateral soft-tissue envelope.
• Percutaneous / balloon / arthroscopic-assisted: Closed or limited-open reduction using a distractor, Schanz pins, or arthroscopic guidance, followed by percutaneous cannulated screws, K-wires, or fine-wire circular fixation without a formal extensile incision.
• Primary subtalar arthrodesis (PSA): Immediate fusion of the subtalar joint with bone graft and compression screws or a plate, bypassing attempted articular reconstruction; usually reserved for Sanders IV fractures or severe comminution.

What the evidence says

Meta-analyses consistently show STA yields fewer wound complications than ELA (RR 2.82, 95% CI 2.00–3.98 for ELA vs STA) [1]; an earlier meta-analysis reported an odds ratio of 0.16 (95% CI 0.06–0.41) for wound healing complications favouring STA [2]. Radiographic restoration of Böhler’s and Gissane’s angles does not differ significantly between STA and ELA in pooled data, although heterogeneity is high (I² up to 98%) [3]. A network meta-analysis of six approaches found no single approach superior across all outcomes [4]. For percutaneous/arthroscopic techniques, a systematic review of 152 patients reported AOFAS scores 72–94 and only one superficial infection, but evidence level was too low for pooling [5]. An RCT of distractor-assisted arthroscopic fixation versus open plating (n=60) showed shorter operative time, less blood loss, and comparable AOFAS scores at one year [6]. Another RCT comparing percutaneous prodding/K-wire via STA versus ORIF for Sanders III (n=51) found fewer wound complications and equivalent radiographic and functional outcomes [7]. Primary subtalar arthrodesis for Sanders IV fractures (9 studies, 192 fractures) achieved fusion rates 94–100% at mean 4 months, mean AOFAS 71, and VAS 3.3 [8]. A separate review comparing PSA with osteosynthesis for Sanders IV (9 studies, 142 patients) found no clear difference in AOFAS scores but noted methodological limitations [9]. Operative versus nonoperative meta-analysis (7 RCTs, 824 patients) showed no functional difference but higher complication rates with surgery (25% vs 17%) [10].

What members see

What is your observed wound-complication rate with STA versus ELA in smokers or diabetics, and does it match the pooled 5.9% mean POWC for STA [11]? For percutaneous/arthroscopic cases, how often do you convert to open plating intra-operatively, and what triggers that decision? In Sanders IV fractures, do you offer primary fusion upfront or only after failed ORIF, and what functional scores do you record at two years?

Cost and access

Sources do not provide direct cost comparisons. Factors driving cost differences include implant price (locking plates vs cannulated screws vs external fixator frames), operative time (ELA longer than STA or percutaneous), hospital stay (shorter with minimally invasive approaches [6]), and the potential for a second procedure for hardware removal or late subtalar fusion after ORIF.

Open questions

• Does primary subtalar arthrodesis for Sanders IV provide better long-term function than ORIF with planned late fusion if needed?
• What is the learning curve for arthroscopic-assisted percutaneous fixation, and does it affect reduction quality in high-energy fractures?
• Are there specific fracture patterns (e.g., tongue-type, medial wall comminution) where one approach is clearly superior?
• How do patient-reported outcomes (PROMIS, FAOS) compare across techniques at 5–10 years?
• Does robotic or navigation assistance meaningfully reduce radiation exposure or improve screw placement in percutaneous fixation?

References

11 of 21 papers retrieved for this room are cited above. The search was limited to systematic reviews, meta-analyses and randomised trials in humans, English, 2016 onwards. Query and full result set: research/raw/calcaneal-fracture.json.

1. 1Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature. Injury 2024 · PMID 38729077 Meta-Analysis, Review
2. 2Meta-analysis of two surgical approaches for calcaneal fractures: sinus tarsi versus extensile lateral approach. ANZ J Surg 2017 · PMID 28122417 Meta-Analysis, Review
3. 3Extensile lateral versus sinus tarsi approach for calcaneal fractures: A meta-analysis. Medicine (Baltimore) 2021 · PMID 34397810 Meta-Analysis, Systematic Review
4. 4Efficacy and Postoperative Complication Rates of Different Surgical Approaches for Calcaneal Fractures: A Network Meta-analysis. Altern Ther Health Med 2024 · PMID 37971444
5. 5Percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures: Systematic review and surgical technique. Foot Ankle Surg 2020 · PMID 31320206 Systematic Review
6. 6Clinical efficacy of distractor combined with arthroscopy-assisted minimally invasive screw fixation for calcaneal fractures. J Orthop Surg Res 2025 · PMID 40713805 Randomized Controlled Trial
7. 7Percutaneous Prodding Reduction and K-Wire Fixation Via Sinus Tarsi Approach Versus ORIF for Sanders Type III Calcaneal Fractures: A Prospective Case-Controlled Trial. J Foot Ankle Surg 2022 · PMID 34253433 Randomized Controlled Trial
8. 8Primary subtalar arthrodesis in displaced intra-articular calcaneal fracture: a systematic review. Musculoskelet Surg 2026 · PMID 40375052 Systematic Review
9. 9Osteosynthesis or primary arthrodesis for displaced intra-articular calcaneus fractures Sanders type IV - A systematic review. Foot Ankle Surg 2022 · PMID 33893034 Systematic Review
10. 10Operative Versus Nonoperative Treatment for Displaced Intra-Articular Calcaneal Fractures: A Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg 2016 · PMID 27150233 Meta-Analysis, Review
11. 11Geographical Differences in Wound Complication Rates Following the Sinus Tarsi Approach in Displaced Intra-articular Calcaneal Fractures: A Systematic Review of the Literature. Clin Orthop Surg 2024 · PMID 38304215 Systematic Review

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