Jacobs Journal of Surgery

Evaluation of Patients Undergoing Minimally Invasive Surgical Treatment for Calcaneus Fractures

*Castro Filho Carlos Daniel Candido
Department Of Orthopedic Surgery, Celso Pierro General And Maternity Hospital, Brazil

*Corresponding Author:
Castro Filho Carlos Daniel Candido
Department Of Orthopedic Surgery, Celso Pierro General And Maternity Hospital, Brazil

Published on: 2017-10-23



Calcaneus Fractures; Minimally Invasive Treatment; Ankle; Sanders Classification; Surgical Treatment of Calcaneus Fractures; AOFAS.


Calcaneus fractures comprise 2% of human body fractures. They usually occur as a result of high-energy trauma, such as falls and car crashes [1]. Fifty percent of cases are associated with other fractures, such as fractures of the tibial shaft, hip, or lumbar spine [2,4]. The tarsus bones are the most affected, with 75% predominance among intra-articular fractures [2].

Poor results are often achieved after treating this kind of fracture as they are complex and it is difficult to reduce and maintain congruence. These fractures can incapacitate patients due to pain and chronic articular stiffness, in addition to hind foot deformities that cause difficulty in wearing conventional shoes [3].

Retrospective studies have shown that conservative treatment is generally used for undisplaced fractures in elderly people and in patients with comorbidities [3,5,7,8]. However, surgical treatment is a better option for displaced fractures in adults up to 70 years old [7, 8].

The preferred repair technique is the extended lateral approach and osteosynthesis with plates and screws [3-5]. Some patients present with soft-tissue complications (8– 32% of cases) [5] and 43.5% require complementary procedures to remove implants [6]. Other authors have published results for less invasive approaches and wire and screw fixation, which result in a lower incidence of soft-tissue complications [1, 2,7,8].

Based on these studies and our personal experience with several types of treatment, we chose a lateral approach and the minimal fixation technique [14], which focuses on the talocalcaneal joint without destroying soft tissue and fixes the joint using only wires and screws, not plates or grafts. This method is minimally invasive. We evaluated the functional results obtained using this technique to treat calcaneus fractures, emphasizing the incidence of soft-tissue complications.

Figure 1. Lateral ankle approach – a minimally invasive technique.




Patients and Methods

This was a retrospective study conducted at the University Hospital of Campinas, São Paulo, Brasil. Twenty-seven patients (20 men and 7 women; mean age, 46.6 years) were diagnosed with calcaneus fractures between 2006 and 2010 and were treated with a minimally invasive surgical technique until 2 weeks after the trauma. Eighteen had right calcaneus fractures, seven had left calcaneus fractures, and two had both calcanei fractured.

Gissane’s and Böhler’s angles were measured and evaluated on pre- and postoperative X-rays and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale questionnaire [16,18] was conducted.

Inclusion criteria were adult patients diagnosed with calcaneus fractures classified as Sanders types II or III [19], who submitted to a minimally invasive surgical treatment by the same surgeon, had at least 2 years of postoperative followup, and wanted to be included in the study.

Exclusion criteria were skeletally immature patients, patients treated with this technique with  years follow-up, and those who did not want to be a part of the study.

Patients were called to the Department of Orthopedics and Traumatology, evaluated according to the inclusion criteria, and invited to participate in the study. Patients who accepted the invitation signed a consent form. They were evaluated at our ambulatory center, and Böhler’s and Gissane’s angles were measured on pre- and postoperative X-rays. We used preoperative computed tomography (CT) to classify the fractures according to Sander’s classification [2, 5, 16]. The patients also answered the AOFAS questionnaire [16,18].

Student’s t-test was used for independent samples and the Mann–Whitney U-test was used for non-parametric data. A p ≤ 0.05 was considered significant.

This study was approved on April 1, 2013, by the Research Ethics Committee of Plataforma Brasil, under number 233.735.


At the end of the evaluation, 25 patients were able to walk without limitations, and two needed crutches. These two patients had bilateral calcanei fractures. All patients had difficulty in walking on irregular surfaces. A 78.5-point average postoperative result was obtained on the AOFAS scale.

The angles and measured values are listed in Table 1. Improvement was observed in 100% of the angles measured during the postoperative evaluation.

Table 1. Evaluation of patients with calcaneus fractures.

The average angles measured postoperatively were 31.8° for Böhler’s, and 102.8° for Gissane’s (reference values: 20–40° Böhler, and about 100° Gissane) [11]. No early or late postoperative complications were observed.

Figure 2. Measurement of Böhler’s (B) and Gissane’s (G) angles. Böhler, 26°; Gissane, 102°


There was a predominance of male patients with an average age of 46.6 years, similar to previous reports [4,14,16,17]. The mechanism of trauma was axial trauma in all cases due to a high fall. Sander’s CT classification was adopted, which evaluates the number of fragments and deviations between the fragments. According to the inclusion criteria, the patients selected for the study were classified as Sanders II and III (fractures in two or three parts with intra-articular deviation). No immobilization was necessary during postoperative care. After the procedure, it was possible to ensure earlier mobility of the ankle, which provided better quality of life for the patients.

Böhler’s and Gissane’s angles were measured on preoperative and postoperative X-rays to evaluate the results, and the data were linked to the answers on the AOFAS questionnaire. The Böhlers’s and Gissane angles of all patients were measured during the postoperative evaluation. Although the measurements were standardized and obtained by experienced professional, few differences were detected between observers; however, rotation during the X-ray exam may have influenced the values obtained, as well as the precision of goniometry used.

We did not observe any soft-tissue complications such as necrosis, tendonitis of peroneal tendons, wound dehiscence, or neurovascular lesions. These complications have reached rates of 27–33% in previous studies [10, 11,17]

Figure 3. Postoperative lateral-view X-ray of the subtalar joint.

Figure 4. Postoperative axial-view X-ray of the screws.

The AOFAS questionnaire is a good way to evaluate strength, function, pain, and calcaneus alignment. In the present study, 7.4% of patients had excellent results, 51.85% had good results, 29.63% had regular results, and 11.10% had poor results. Hence, 59.25% had good or excellent results. Previous studies have reported good or excellent results in 42–62% of cases [7, 12, 13, 15].

Patients who presented with bilateral fractures were surgically treated for only one calcaneus fracture. The other foot of each patient was treated without surgery; because they had Sanders I fracture (extra-articular fractures without deviations).

Previous studies have found that 80% of patients can return to work after surgical treatment of calcaneus fractures under the conventional lateral “L” approach [11,12,15,16]. In the present study, 100% of patients returned to their occupational activities after treatment. Only one patient reported some difficulty in readapting to routine, due to pain because of a bilateral fracture.

Owing to the socioeconomic situation of our patients (mostly laborers) with functions that demand bearing weight and climbing up and down stairs, we consider our return-towork percentage a success. We found discrepant results in the literature when comparing the minimally invasive and the conventional lateral “L” approaches for treating calcaneus fractures, which can be explained by the fact that a minimally invasive technique causes less morbidity to the patient and is less aggressive to soft tissues.

In recent researches we didn’t found studies or technique about arthroscopic and laser surgery for calcaneal fractures.


The use of a minimally invasive technique is a good alternative for treating calcaneus fractures, as it reestablishes the talocalcaneal intra-articular surface, recovers Böhler’s and Gissane’s angles, and provides better soft tissue conditions and quicker mobility for patients.


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