ORIGINAL ARTICLE

Percutaneous Reduction and Fixation of Displaced Intra-Articular Calcaneus Fractures

Matthew DeWall, MD, Christopher E. Henderson, MD, Todd O. McKinley, MD, Thomas Phelps, BA, Lori Dolan, PhD, and J. L. Marsh, MD
calcaneus fractures minimizes complications and achieves and maintains extra-articular reductions as well as the standard extensile open reduction and internal xation. Further study of this technique is warranted. This should include assessment of articular reduction and longer follow-up of a larger number of patients. Key Words: calcaneus fracture, percutaneous, xation (J Orthop Trauma 2010;24:466476)

Objectives: The purpose of this study is to assess the initial results

of percutaneously reducing and xing calcaneus fractures compared with a concurrent control group that was openly reduced and internally xed through an extensile lateral approach.

Design: Retrospective cohort study, consecutive series. Setting: Level I trauma center. Patients/Participants: One hundred twenty patients with 125 intra-articular calcaneus fractures were selected as a consecutive series with treatment method randomized by surgeon and time of presentation. Intervention: Patients treated with open reduction and internal
xation (OR group) had an extended lateral approach and fractures were xed with plates and screws. Patients treated with percutaneous reduction (PR group) had small incisions with indirect fragment manipulation, and the reduction achieved was secured with screws alone.

INTRODUCTION
The optimal treatment of displaced intra-articular fractures of the calcaneus (DIACF) is controversial. Recent studies have suggested superior results with surgical reduction and xation, at least in certain subgroups of patients.1,2 The most common approach has been to reduce and internally x the fracture with a combination of plates and screws through an extended lateral approach. Unfortunately with this approach, wound complications, including deep and supercial infections and wound sloughs, have been reported to occur in 1.8% to 27% of patients.112 Reducing and xing select fractures percutaneously has been recommended, particularly for those classied as tonguetype fractures in the Essex-Lopresti classication system, or Type 2C by the Sanders system, and excellent results have been reported.1319 In an attempt to optimize patient outcome by combining the benets of operative treatment with a reduced rate of wound complications, a method of percutaneously reducing and xing calcaneus fractures through small incisions has been developed by one of the authors, who has used this method for all intra-articular fracture types since 1999. This article reports the results for this initial series of patients with DIACF that were reduced and internally xed percutaneously. For a control group, the outcomes were compared with a concurrent group of patients treated by a lateral extensile approach and xed with plates and screws. Questions addressed by this retrospective cohort study include: 1) Was the rate of postoperative wound complications reduced by this method of percutaneous reduction and xation? 2) Were the fractures reduced and the reductions maintained to a similar degree using the percutaneous method? 3) Do patient outcomes at a minimum of 2 years after injury, measured by examination of hindfoot motion and on standardized health status questionnaires, differ between the two treatment groups?
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Main Outcome Measurement: Clinical and radiographic

assessment.

Results: There were 41 patients with 42 fractures in the OR group

and 79 patients with 83 fractures in the PR group. There were no signicant differences in sex, age, open fractures, fracture classication, or initial Bohlers angle between the two groups. Bohlers angle was improved after surgery by an average of 22.4 in the OR group and 25.3 in the PR group (P = 0.31). The average loss of reduction at healing (minimum 4 months postoperatively) was not signicantly different between the two groups. Deep infection occurred in six of 42 of the OR group and zero of 83 of the PR group (P = 0.002). The incidence of minor wound complications was nine of 42 in the OR group and ve of 83 in the PR group (P = 0.03). The need for late subtalar fusions (two of 26 and three of 41 with full 2-year follow-up) and implant removal (ve of 42 and 10 of 83) was not signicantly different.

Conclusions: The results of this study suggest that in comparison to open reduction, this method of percutaneously reducing and xing
Accepted for publication November 25, 2009. From the Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA. This work was funded by the following grant: NIH 5 P50 AR055533. No benets were received. Reprints: J. L. Marsh, MD, Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA 52242 (e-mail: j-marsh@uiowa.edu). Copyright 2010 by Lippincott Williams & Wilkins

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METHODS
Between January 2000 and May 2007, 120 patients with 125 DIACF were treated operatively by one of two surgeons at a single institution. One surgeon treated patients with standard extensile open reduction and internal xation (ORIF) through a lateral incision and the fractures were internally xed with plates and screws, whereas the second surgeon reduced fractures percutaneously and xed them with screws alone. Patients were assigned to surgeon and therefore treatment group by week of presentation and by referral.

Surgical Technique
The fractures in the percutaneous group (PR) were reduced by manipulating the fracture fragments through multiple small stab incisions. The patient was placed in the lateral position on a radiolucent table. The C-arm uoroscope was brought in from the foot of the bed. In joint depression fractures, the tuberosity fragment was manipulated with a large corkscrew applied from the posterolateral corner of the heel across the tuberosity. This was used for manual traction and to control alignment during maneuvers to reduce the fracture. The position of the tuberosity was evaluated by lateral and Harris uoroscopic views obtained by moving the C-arm with the heel in a stable lateral position. The goals were to restore Bohlers angle and heel length and width. When the tuberosity was repositioned, it was provisionally xed to the sustentaculum by multiple Kirschner wires. The articular fragment or fragments were then manipulated through small lateral incisions using elevators or curved hemostats. The reduction was judged on the same views but in addition, multiple Brodens views of the posterior facet were obtained.20 The reduced fragments were provisionally xed with Kirschner wires. In tongue patterns, similar techniques were used but the large facet fragment was reduced rst. Instead of a cork screw, this fragment was manipulated with two parallel Steinmann pins placed from posterior along the length of the facet fragment. The reduction was judged uoroscopically and stabilized with Kirschner wires in a similar way. The fractures were xed by replacing Kirschner wires with 3.5- and 4.0-mm screws placed percutaneously through small incisions guided by uoroscopy. Cannulated screws were not used because, in the surgeons opinion, there is a much better sense of entering the sustentaculum with a 2.5-mm drill bit. Generally screws were directed from the tuberosity, posterolateral to the sustentaculum, anteromedial and were 60 to 75 mm in length and were fully threaded. Screws directed across the posterior facet from lateral to medial were 35 to 45 mm in length and were partially threaded. All screws were directed into the sustentaculum (Fig. 1). The fractures in the open reduction group (OR) were treated with an extensile lateral approach described by Gould, Zwipp, Sanders, Benirschke, and others.5,2123 The reduction was evaluated by uoroscopy and was also directly visualized. The fracture was xed with a combination of screws and either one third tubular or dedicated multihole calcaneal plates. The postoperative protocol for the two groups was similar. All patients were placed into either removable splints or short leg casts. Patients were kept nonweightbearing for 8 to
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10 weeks postoperatively. They then began progressive weightbearing and were transitioned to normal footwear. After approval was obtained from the Institutional Review Board, the patients were identied by review of hospital records and trauma service databases. Existing chart information was analyzed for patient demographics, incidence of complications, and details of treatment. Charts were reviewed from the time of injury to the most recent follow-up. Wound complications dened as deep infections were those requiring operative debridement and/or intravenous anti biotics. Wound complications dened as supercial required dressing changes, additional clinic visits, and/or oral antibiotic therapy. The patients who had painful hardware removed were noted. Patients who had a minimum of 2-year follow-up were assessed for whether they had or had not required a subtalar fusion. The fractures were classied according to the EssexLopresti and Sanders classications on injury radiographs and computed tomography (CT) scans.13,21 The lateral and Harris view radiographs at the time of injury, postoperatively, and at least 4 months after injury were used to assess the degree to which the fractures were reduced and whether the reduction initially achieved was maintained. The radiographs were blinded by a study participant who was not involved in either patient care or measuring the radiographs. The instrumentation and implants were removed from the images using Adobe Photoshop (Adobe Systems, Singapore) so that no characteristics were present to identify the method that was used to x the fracture. The critical radiographic landmarks used to measure the calcaneus were left unaltered (Fig. 2). After a training session in which all investigators assessed sample radiographs to decide how to measure them, the actual measurements for the study were performed by two investigators not directly involved with the care of patients in either group. A subset of radiographs was measured by both investigators to ensure that there was interobserver agreement, and then most radiographs were assessed by one of the investigators. All patients had Bohlers angle and calcaneal length measured on the lateral view and lateral tuberosity translation on the Harris view at all three time points. An eligible subgroup of patients with a minimum of 2 years of follow-up from injury was invited to participate in the clinical follow-up portion of the study. Patients agreeing to participate were evaluated at a clinic visit with repeat radiographs, subtalar motion was measured by the McMasters method, and ankle motion was measured. Those patients evaluated in clinic as well as those unable to return but wishing to participate by mail were also evaluated with standardized health status questionnaires, including SF-36 and the Foot Function Index.24,25 Data were analyzed using either the t test for independent variables or the Fisher exact test and reported using P = 0.05 to indicate signicant differences.

RESULTS
There were 41 patients with 42 fractures in the OR group and 79 patients with 83 fractures in the PR group. The difference in numbers between the two groups can be explained by referred patients from outside institutions with
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FIGURE 1. (A, B) Preoperative radiographs of a 52 year old female with a joint depression intra-articular calcaneus fracture demonstrating attening of Bohlers angle. (C, D) Preoperative CT scan demonstrating Sanders IIIAB pattern. (E, F) Post operative radiographs following percutaneous xation demonstrating correction of Bohlers angle to 29 degrees. (G, H) Radiographs at eight months status post surgery demonstrating preservation of Bohler s angle at 28 degrees.

one surgeon receiving more referrals for calcaneus fractures. The two surgeons nearly always chose their preferred treatment methods; however, there were nine patients who crossed over. The surgeon favoring the percutaneous technique used a standard extensile approach in one patient and there were eight patients treated with percutaneous methods by the surgeon using principally standard ORIF. The patients and the fractures in the two groups were not signicantly different including sex (greater than 80% male in both groups, P = 0.14), age at the time of injury (average age 41 years OR and 40 years PR, P = 0.91), open fractures (P = 0.12), fracture classication according to Essex-Lopresti (P = 0.16), and Sanders classication (P = 0.71). The average time to surgery from the day of injury was 13.6 days for the OR group and 9.3 days for the PR group. The fractures in the OR group were classied as 32 joint depression type and 10 tongue type. There were 19 Sanders Type 2, 15 Sanders Type 3, one Sanders Type 4, and seven lacked available injury CT scans for the Sanders classication. In the PR group, there were 61 joint depression and 22 tongue-type fractures. There were 32 Sanders Type 2, 27 Sanders Type 3, ve Sanders Type 4, and 19 without available injury CT scans for the Sanders classication (Table 1). The surgeon using percutaneous techniques would typically not operate on a patient without a preoperative CT scan. However, many CT scans were returned to outside institutions and despite efforts, they were not able to be retrieved to assign a Sanders classication for this study. The average time of follow-up for chart and

radiographic review was 24.7 months (range, 268 months) for the OR group and 21.9 months (range, 267 months) for the PR group. One hundred twenty fractures (41 OR and 79 PR) had sufcient radiographs available to be included in the portion of the study that compared the ability to obtain and maintain fracture reduction between the two groups. Initial Bohlers angle averaged 0.0 in the OR group (range, 30 to 29) and 3.3 in the PR (range, 60 to 30). This difference was not signicant (P = 0.34). Postoperative Bohlers angle was improved over that measured on the injury radiograph by an average of 22.4 in the OR group and 25.3 in the PR group (P = 0.31). The average loss of reduction at the time of fracture healing (minimum 4 months postoperatively) was 4.0 in the OR group and 2.1 in the PR group (P = 0.10). The width of the calcaneus as assessed on the Harris view was reduced postoperatively by an average of 3.9 mm in the OR and 3.5 mm in the PR group, and this reduction was maintained to a similar degree in both groups (P = 0.46 and P = 0.92). No signicant improvement in calcaneus length as measured on the lateral view was obtained by reduction in either group (Table 2). Fractures were stratied by Sanders classication and comparisons were again made for degree of correction of Bohlers angle and reduction of width on Harris view. There were no signicant differences in preoperative, postoperative, and healed Bohlers angle measurements or change in Harris width between the PR or OR group for Sanders II, III, or IV
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FIGURE 2. (A, B) Radiographs of an ORIF case before and after blinding the method of xation using Adobe Photoshop to remove all identifying hardware. The key features of the calcaneus used to measure Bohlers angle are not obscured.

fractures. Postoperative Bohlers angle was improved over that measured on the injury radiograph by an average of 22.1 in the Sanders II OR group and 22.0 in the Sanders II PR group (P = 0.99). Postoperative Bohlers angle was improved over that measured on the injury radiograph by an average of 24.3 in the Sanders III OR group and 31.6 in Sanders III PR group (P = 0.94). No useful comparison could be made for Sanders Type IV fractures given only one Sanders IV treated in the OR group. However, in the PR group (ve fractures), the average Bohlers angle on injury radiograph was 8.5 and the average postoperative Bohlers angle was 17.8 for a correction of 26.3. The average loss of reduction at the time of fracture healing (minimum 4 months postoperatively) was 1.8. The average reduction in width on the Harris view was 4 mm. The rates of wound complications were signicantly different between the two treatment groups. Deep infection occurred in six of 42 (14.3%) of the OR group and zero of 83 of the PR group (P = 0.002). The incidence of minor wound complications was nine of 42 (21.4%) in the OR group and ve of 83 (6.0%) in the PR group (P = 0.03). One of the deep

TABLE 1. Demographics*
ORIF Age (mean) Gender Open fractures Sanders II Sanders III Sanders IV Tongue Joint depression Number of fractures 41 years 88% male 2 19 15 1 10 32 42 PR 40 years 80% male 0 32 27 5 22 61 83 P 0.91 0.13 0.12 0.71 0.71 0.71 0.16 0.16

*The patients not included for Sanders classication had no preoperative computed tomography scan. ORIF, open reduction and internal xation; PR, percutaneous reduction.

infection cases was an open fracture; no infections resulted in amputation. The need for implant removal was determined for all patients through the time of their last follow-up visit (range, 4 months to 5 years). Removal was undertaken for painful, prominent implants in ve of 42 (11.9%) fractures treated with OR and 10 of 83 (12.0%) fractures in the PR group. These rates were not signicantly different (P = 0.23). Those fractures that had a minimum of 2 years clinical follow-up recorded in their chart were assessed for having received a subtalar fusion. There were 26 fractures (60.5%) in the OR group and 41 fractures (49.4%) in the PR group that qualied. Of these, two fractures in the OR group and three fractures in the PR group had a subtalar fusion for daily pain-limiting activity. This was not a signicant difference (P = 0.36). A total of 51 patients (20 ORIF and 31 PR) with 53 fractures were invited to participate in the clinical follow-up portion of this study at a minimum of 2 years after injury (range, 2466 months; average 40.4 months). Of these, 22 (seven ORIF and 15 PR) patients agreed to return to our institution for repeat clinical examination with an average follow-up time of 40.6 months, and ve additional patients (PR group) would not return but agreed to participate by completing standardized health status questionnaires by mail. The average SF-36 mental score in the OR group was 47.5, whereas in the PR group, it was 48.6 (P = 0.86). SF-36 physical score averaged 39.6 in the OR group and 47.1 in the PR group, also not a signicant difference (P = 0.09). Foot Function Index scores averaged 70.7 for those patients in the OR group and 66.6 for the PR group (P = 0.67). The subscores of the Foot Function Index including pain (P = 0.27) and disability (P = 0.85) scores were also not signicantly different between the two groups. Subtalar motion in the injured foot averaged 12.1 in the OR group (50.7% of uninjured) and 10.5 in the PR group (42.6% of uninjured). This was not a signicant difference (P = 0.49). Ankle motion was also not found to be signicantly
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TABLE 2. Demographics
ORIF (average) Bohlers injury Bohlers postoperatively D Bohlers Bohlershealed D Bohlers at healing Reduction of calcaneus width on Harris view Change in width at healing Change in calcaneal length Deep infection Minor wound complication Subtalar fusion Hardware removal 0.0 22.4 22.4 18.4 4.0 3.9 mm 0.5 mm 1.3 mm 6/42 9/42 2/26 5/42 PR (average) 3.3 22.0 25.3 19.9 2.1 3.5 mm 0.5 mm 0.1 mm 0/83 5/83 3/41 10/83 P 0.34 0.70 0.31 0.55 0.10 0.46 0.92 0.16 0.002 0.03 0.36 0.23

ORIF, open reduction and internal xation; PR, percutaneous reduction.

different with an average arc of motion of 47.6 in OR group and 53.6 in the PR group (P = 0.34).

DISCUSSION
Since the early 1990s, the extended lateral approach for ORIF has been the most commonly used operative technique, but percutaneous techniques seem to be becoming more popular particularly for tongue-type fractures classied as Sanders 2C.1419 Tornetta used the Essex-Lopresti reduction for Sanders 2C fractures combined with internal xation with screws.18 Levine and Helfet described a minimally invasive percutaneous technique but used it only for 5% to 10% of calcaneal fractures.19 Arthroscopically assisted percutaneous xation,14 the use of an external distraction device,16 and a limited posterior incision, modied Gallie approach15 have all been recently described. Techniques using either a ring xator or calcaneal minixator have also been reported.26,27 Stulik et al and Walde et al reported low rates of 1.7% and 3.3%, respectively, deep infections after limited approach techniques and percutaneous Kirschner wire xation.28,29 Sangeorzan et al described using a push screw for indirect reduction of severe joint depression calcaneal fractures to reconstitute length and height as a temporary salvage maneuver.30 The patients in the current study treated with a percutaneous technique were not selected. With the exception of one patient, the method was applied by one surgeon to all cases that he treated operatively, including joint depression fractures and more comminuted Sanders Type 3 and 4 fractures. To assess the results of this percutaneous technique, we were fortunate to have a group of patients treated with a standard extended lateral approach at the same institution to serve as a control. The strengths of the control group and comparative study design were several and included concurrent treatment, similar follow-up, similar assessments made by the same independent observer, and radiographs measured by an observer blinded to the treatment groups. The control group did, however, have limitations. Patients were not randomly assigned to the two treatments and there were a small number of crossover patients between groups. We attempted to control

for this by assessing for differences between patients or between the fractures in the two groups at baseline and found no signicant differences. There were only two surgeons involved and the results are only directly applicable to their practices during the time of this study. There was a signicantly higher rate of deep infection in those patients treated with standard extensile ORIF. The six patients in this group who developed infection included one patient treated with ORIF by the surgeon favoring the percutaneous treatment. The decision to treat this patient with extensile ORIF was dictated by a prolonged time from injury to surgery and anticipated difculty mobilizing fragments with percutaneous means. There were no patients in the PR group who had a deep infection. When combined with the greater rate of supercial wound problems in the OR group, these data suggest that this technique of limited-approach percutaneous reduction is less damaging to the soft tissues with less risks for severe infections and that this represents an important advantage of this less invasive approach to reduce calcaneus fractures. One of the most important questions addressed by this study was, can an adequate reduction be obtained and maintained using percutaneous reduction techniques with the fracture xed with screws alone? In comparison to the control group treated with an extensile open approach and plating, the answer would seem to be yes, at least for the assessments of reduction made in this study. These included heel width on the Harris view and Bohlers angle on the lateral view. Buckley et al has demonstrated that Bohlers angle is predictive of outcome. In his study, the operative group treated with an extended lateral approach had a mean increase in Bohlers angle of +16.5.31 Shuler et al found that the range of increase in Bohlers angle after an extended lateral approach was +13.7 to 31.0.10 The average increase in Bohlers angle of 22.4 in the OR group and 25.3 in the PR group in the current study were similar to these previous reports. Both of our groups had a small loss of Bohlers angle at healing with an average decrease of 4.0 in the OR group and 2.1 in the PR group. This is also similar to other reports in the literature. In a study of calcaneal fractures 3 months after ORIF, Buckley reported a mean decrease in Bohlers angle compared with the initial reduction of 7 in a group with adjunctive bone graft and 6 in a group without bone graft.32 Unfortunately, with the radiographs available, there was no satisfactory method in this study to measure the quality of the articular reductions. Postoperative CT scans were not routinely obtained and it was not possible to accurately measure residual articular displacements on plain radiographs. The ability to accurately reduce the articular surface might have been better in the OR group because the reduction was directly visualized with this approach. If this is true, longer follow-up of a larger number of patients may show a difference in posttraumatic arthritis between the two groups. The inability to compare the two groups with respect to articular reduction is an important limitation of the current study. This limitation can only be addressed through prospective assessment of standardized postoperative CT scans to measure reduction in two similar groups of patients treated with the alternate techniques. Even more important would be longer follow-up
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of a larger number of patients to assess for differences in clinical outcome or arthrosis. One of the suggested benets of percutaneous xation over open reduction is the ability to maintain subtalar motion. This is thought to be the result of the excessive scarring within the sinus tarsi that results with open reduction. In our series, however, subtalar motion was not signicantly different between the two techniques in the patients who were followed up. If an equivalent reduction was obtained, motion should be better in the percutaneous group given the limited approach. However, this did not appear to be the case in our series. The limited motion may be a result of a less satisfactory articular reduction, which could limit motion; however, the lack of CT scans hindered our ability to assess this parameter. Although the senior author (JLM) feels the percutaneous approach can be applied to all fractures, it is possible that it is best for those less comminuted articular surfaces and for articular fractures with large tongue-type facet fragments as described by other authors.17,18 Although our Sanders Type 4 fractures were successfully treated percutaneously, there were only a small number of these severe injuries and it is likely that these fractures with more comminuted articular surfaces are more accurately reduced and may have better outcomes with the extended lateral approach. Importantly, reducing calcaneal fractures using percutaneous techniques is best performed within 10 days of injury, before fragments become immobile as a result of fracture consolidation. When delays to surgery are longer, fractures should be reduced through open approaches. Patient outcomes at 2 years minimum follow-up measured by clinical examination and health status questionnaires revealed that the patients in the two groups did not signicantly differ. Unfortunately, as a result of the numbers of patients agreeable to participate in the clinical follow-up portion of our study, it was not powered to detect meaningful differences. The current requirements of our Institutional Review Board require initial patient contact to be by mail. Patients were asked in a letter with a yes or no check box if they would be willing to participate. If they declined, there could be no further contact with them. In addition, the data from some patients who did return for clinical follow-up could not be used secondary to consent irregularities. These problems decreased the number of patients available and therefore the value of the follow-up portion of our study. There were other weaknesses of this preliminary study that make the results difcult to transfer to other patients and surgeons. The patients were retrospectively reviewed and the information on infections was based on chart reviews. A signicant proportion of patients were either lost to follow-up or refused to participate in further clinical follow-up decreasing the value of the clinical outcome measures. The comparisons made apply only to the two surgeons and the specic techniques they used in these patients. The surgeon using the percutaneous technique treated more fractures and had been in practice for more years than the surgeon using the open technique and this surgeon developed the percutaneous technique. This method of percutaneously reducing and xing calcaneus fractures is technically demanding and requires a thorough understanding of calcaneal anatomy and extensive
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use of intraoperative uoroscopy. It was developed after years of experience with the extended lateral open approach. A signicant learning curve must be anticipated. The advantage of decreased wound complications combined with an equivalent ability to obtain and maintain the overall reduction of the height and width of the heel indicate that this technique has merit. Future studies that include CT scanning of the articular reduction and longer follow-up will allow the authors to determine which fracture types ultimately benet the most from this technique. REFERENCES
1. Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intraarticular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84:17331744. 2. Thordarson DB, Krieger LE. Operative vs non-operative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int. 1996;17:29. 3. Al-Mudhaffar M, Prasad CV, Modi A. Wound complications following operative xation of calcaneal fractures. Injury. 2000;31:461464. 4. Assous M, Bharma MS. Should os calcis fractures in smokers be xed? A review of 40 patients. Injury. 2001;32:631632. 5. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot: surgical management of calcaneal fractures. Clin Orthop Relat Res. 1993;292:128134. 6. Benierschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18:16. 7. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures analysis of 190 fractures. J Orthop Trauma. 1999;13:369372. 8. Geel CW, Flemister AS Jr. Standardized treatment of intra-articular calcaneal fractures using an oblique lateral incision and no bone graft. J Trauma. 2001;50:10831089. 9. Harvey EJ, Grujic L, Early JS, et al. Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int. 2001;22:868873. 10. Shuler FD, Conti SF, Gruen GS, et al. Wound-healing risk factors after open reduction and internal xation of calcaneal fractures. Orthop Clin North Am. 2001;32:187192. 11. Stephenson JR. Surgical treatment of displaced intraarticular fractures of the calcaneus. A combined lateral and medial approach. Clin Orthop Relat Res. 1993;290:6875. 12. Stromsoe K, Mork E, Hem ES. Open reduction and internal xation in 46 displaced intraarticular calcaneal fractures. Injury. 1998;29:313316. 13. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39:395419. 14. Gavlik JM, Rammelt S, Zwipp H. Percutaneous, arthroscopically-assisted osteosynthesis of calcaneus fractures. Arch Orthop Trauma Surg. 2002; 122:424428. 15. Park IH, Song KW, Shin SI, et al. Displaced intra-articular calcaneal fracture treated surgically with limited posterior incision. Foot Ankle Int. 2000;21:195205. 16. Schepers T, Schipper IB, Vogels LM, et al. Percutaneous treatment of displaced intra-articular calcaneal fractures. J Orthop Sci. 2007;12:2227. 17. Tornetta P 3rd. The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma. 1998;12:469473. 18. Tornetta P 3rd. Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res. 2000;375:9196. 19. Levine DS, Helfet DL. An introduction to the minimally invasive osteosynthesis of intra-articular calcaneal fractures. Injury. 2001;32(Suppl 1): SA51SA54. 20. Broden B. Roentgen examination of subtaloid joint in fractures of calcaneus. Acta Radiol. 1949;31:8591. 21. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 1993; 290:8795. 22. Gould N. Lateral approach to the os calcis. Foot Ankle. 1984;4:218220.

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23. Zwipp H, Tscherne H, Thermann H, et al. Osteosynthesis of displaced intraarticular fractures of the calcaneus. Results in 123 cases. Clin Orthop Relat Res. 1993;290:7686. 24. Ware JE. Sherbourne CD. The MOS 36 item short-form health survey (SF-36). Med Care. 1992;30:473483. 25. Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Indexa measure of foot pain and disability. J Clin Epidemiol. 1991;44:561570. 26. Talarico LM, Vito GR, Zyryanov SY. Management of displaced calcaneal fractures by using external ring xation, minimally invasive open reduction, and early weightbearing. J Foot Ankle Surg. 2004;43: 4350. 27. Magnan B, Bortolazzi R, Marangon A, et al. External xation for displaced intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006;88:14741479.

28. Walde TA, Sauer B, Degrief J, et al. Closed reduction and percutaneous Kirschner wire xation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 210 years. Arch Orthop Trauma Surg. 2008;128:585591. 29. Stulik J, Stehlik J, Rysavy M, et al. Minimally-invasive treatment of intraarticular fractures of the calcaneum. J Bone Joint Surg Br. 2006;88:16341641. 30. Schildhauer TA, Sangeorzan BJ. Push screw for indirect reduction of severe joint depression-type calcaneal fractures. J Orthop Trauma. 2002; 6:422424. 31. Loucks C, Buckley R. Bohlers angle: correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma. 1999;13:554558. 32. Longino D, Buckley R. Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful? J Orthop Trauma. 2001;15: 280286.

Invited Commentaries
Roy Sanders, MD Tampa, Florida
While the previous paper offers the reader an opportunity to evaluate a large series of calcaneal fractures treated with percutaneous techniques, it should be clear that this is a somewhat controversial topic. As such, the Editorial Board felt it worthwhile to request the commentaries of several leaders in the eld, to offer their opinions regarding this treatment method. As Editor-in-Chief, I felt that this would offer the reader further insight into the thought process surrounding management of these difcult fractures. Below you will nd the commentaries of ve key opinion leaders followed by a rebuttal from the authors. We hope this discussion will stimulate further renement of present treatment methods.

Stephen K. Benirsrchke, MD Harborview Medical Center, University of Washington, Seattle, WA

The appropriate treatment of displaced calcaneal fractures has been a topic of much controversy in the last three decades. General consensus among most orthopaedic surgeons has, however, converged in recent years on a protocol that restores anatomic morphology, anchors that reduction with xation, and requires the patient to be nonweightbearing for 6 to 12 weeks. My colleagues and I have advocated this approach throughout this period, and I would regret a return to the era of uncertainty that this article might instigate. From the onset, I want to explicitly state that an open reduction is not necessarily an anatomic reduction of grossly displaced fragments. An anatomic reduction of a displaced calcaneal fracture returns not just Bohlers angle (a measure of the position of the posterior facet) to its preinjury value, but also addresses the anterior process by re-establishing the proper relationship among the three articular (anterior, middle, and posterior) facets that guide the motion of the talus on the calcaneus and support the cuboid. Reduction of the anterior process distal to the critical angle of Gissane is essential in restoring lateral column length. The anterior process involving the calcaneocuboid joint is responsible for buttressing the cuboid, thereby preventing lateral column shortening and the sequelae associated with it (including lateral peritalar subluxation, posterior tibial tendon insufciency, and progression to a at foot). Although a purely tongue-type fractureone that has a single, horizontal fracture planemay be amenable to percutaneous reduction, maintenance of reduction is very difcult to achieve. More complicated fracture patterns require an open approach and even with an open approach, anatomic reduction is difcult to achieve and maintain. Having access to the fracture fragments allows them to be manipulated into an anatomic position, which is easiest when the anterior process is reduced rst, followed by the posterior facet and nally the tuberosity.1,2 Unfortunately, both the percutaneous and open reduction and internal xation protocols described in the article do not obtain either re-establishment of Bohlers angle or of the morphology of the anterior process. Consequently, it is not surprising that the outcome of the two treatment protocols is similarneither obtained an anatomic reduction. This can be easily demonstrated using the data provided in Table 2 of the article. In the study, posttreatment Bohlers angle averaged 22 with the mean healed angle equal to 18 to 20. (No ranges or standard deviations for Bohlers angle were given.) My colleagues and I have measured the Bohlers angle of 184 uninjured calcanei and obtained a mean of 32.8 with a range of 18 to 46.4 and a standard deviation of 5 (unpublished data).3 Bohlers angle varies tremendously among individuals but little between the left and right foot of an individual. As a result of this variability among people, it is imperative to obtain contralateral views of the uninjured side (if possible) to guide the reduction of displaced calcaneal fractures. The mean posttreatment Bohlers angle of the current study is outside the 95% condence interval of the mean angle
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in our uninjured sample and the posttreatment Bohlers angle is statistically unlikely to be anatomic (t = 29.3, P , 0.0001). Additionally, observation of Figure 1EF and Figure 2A (posttreatment views) show a markedly shortened and displaced anterior process, even in the presence of (for this population) a relatively large Bohlers angle (29). The radiograph (Fig. 2A) demonstrates persistent displacement of the lateral part of the anterior process. This anterolateral portion has not been brought out to length and realigned with the medial sustentacular fragment of the calcaneus (which is the constant fragment). In an anatomically reduced calcaneus, the middle facet is visible on the lateral radiograph and is not obscured by a superiorly displaced anterior process. It seems clear that percutaneous manipulation can restore some height to the calcaneus and it seems likely to me that some reduction is better than conservative treatment. If an open procedure is used, it is untenable to not obtain an anatomic reduction, which can only be guaranteed, in my experience, by comparison to the uninjured calcaneus. For this reason, bilateral, displaced calcaneal fractures are particularly difcult to treat. I expect that the long-term sequelae

associated with a malaligned talocalcaneal interface and a shortened lateral column will adversely impact the quality of life of the patient. Because many calcaneal fractures occur in relatively young patients, this leaves them vulnerable to decades of disability. Although I grant that a prospective, randomized clinical trial comparing the outcome of conservative, improved and anatomic reductions would be scientically interesting, I believe that it would not be in the individual patients best interest. I remain convinced that displaced calcaneal fractures should be treated .similar to any other fracture in a weightbearing jointwith anatomic reduction, stable internal xation, atramautic surgical technique, and early mobilization.1 REFERENCES
1. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18:16. 2. Letournel E. Open reduction and internal xation of calcaneus fractures. In: Spiegel P, ed. Topics in Orthopaedic Trauma. Baltimore: University Park Press; 1984:173192. 3. Summers H, Kramer PA, Benirschke SK. Pediatric calcaneal fractures. Orthop Rev. 2009;1:3033.

Michael P Clare, MD . Florida Orthopaedic Institute, Tampa, FL

The authors are to be commended for a well-designed, scientically sound preliminary study. This article reports the results of a retrospective cohort study comparing percutaneous reduction and xation versus open reduction and internal xation for displaced intra-articular calcaneal fractures. Fractures in the percutaneous reduction group were managed through small stab incisions using threaded pins, periosteal elevators, direct and indirect reduction techniques, and screw xation. Fractures in the open reduction group were treated through an extensile lateral approach, direct reduction techniques, and traditional plate and screw xation. Patients were randomized by surgeon and time of presentation; one surgeon almost exclusively used percutaneous reduction and xation, whereas the other surgeon primarily used open reduction and internal xation techniques. The main variables assessed in this study included wound complication rates, quality of the extra-articular reduction and maintenance of the reduction, hindfoot range of motion, and two health status questionnaires. The authors reported a signicantly lower deep infection and wound complication rate in the percutaneous reduction group compared with the open reduction group. Correlation with patient comorbidities or tobacco use, factors that can certainly inuence wound healing, was not included in the statistical analysis. I have used percutaneous reduction and xation techniques in selected cases, primarily related to signicant patient comorbidities. There was no signicant difference in radiographic results between the two groups, indicating that at least with respect to radiographic parameters used in this study (improvement in Bohlers angle, loss of reduction at healing, narrowing of calcaneal width, and improvement in calcaneal length), the percutaneous reduction techniques restored extra-articular alignment to a similar degree as that achieved with open reduction. Unfortunately, postoperative computed tomography scans were not obtained, which precluded assessment of intra-articular alignment and therefore any comparison of articular congruity between the two groups. Although there was no difference in the rate of conversion to late subtalar arthrodesis between the two groups, longer follow-up is required before denitive conclusions can be drawn. There was surprisingly no difference in subtalar range of motion between the two groups, which, as alluded to in the article, could be the result of greater articular incongruity in the percutaneous reduction group or perhaps some subtle differences in postoperative protocol between the two surgeons. It must again be emphasized that surgical management of calcaneal fractures is technically demanding with a steep learning curve and requires a thorough understanding of calcaneal pathoanatomy and use of intraoperative uoroscopy. One must therefore develop prociency with open techniques before attempting percutaneous reduction and xation.

Stefan Rammelt, MD, PhD Trauma & Reconstructive Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
The article covers an important topic that is subject to continuous debate. The authors are to be commended
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for presenting a study on two different approaches to displaced intra-articular calcaneal fractures: open reduction through an
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extended lateral approach and percutaneous reduction (PR) through multiple stab incisions by two surgeons in a comparable setting. The main result of the study was a signicantly lower rate of postoperative infections in the PR group, which is clinically important given the dreaded consequences that may arise from those. There were no statistically signicant differences between the groups with respect to postoperative Bohlers angle, loss of reduction, the need for hardware removal, secondary subtalar fusion, and outcome as measured with validated instruments like the SF-36 and Foot Function Index as well as subtalar motion in those patients who returned for a repeat examination or were willing to return a questionnaire. Unfortunately, this was the case in only 27 of 120 patients. It is concluded that PR is less damaging to the soft tissues than open reduction, a conclusion to which most readers would agree, but does this really bring us forward? The authors themselves honorably interpret their results with great caution and list major limitations like the retrospective design, signicant loss to follow-up, lack of a power analysis, different levels of surgeon experience, and, most importantly, the lack of measuring the quality of articular reduction. There is evidence from numerous studies that not only reduction of the outer shape of the calcaneus, but especially anatomic reconstruction of the subtalar joint is predictive of outcome when treating displaced intra-articular calcaneal fractures.17 Conversely, the worst functional results are to be expected when open approaches and internal xation are not accompanied by anatomic reduction.5,8,9 Still, many studies solely focus on approaches and technical details to prevent soft tissue problems without adequately addressing anatomic joint reduction.10,11 It is therefore my sincere belief that less invasive treatment methods, which are most helpful in reducing soft tissue complications, should not be applied uniformly to all patients at the cost of less than optimal joint reduction. There are several methods to satisfactorily measure the quality of joint reduction intraoperatively like subtalar arthroscopy and three-dimensional uoroscopy that can be applied together with open or percutaneous reduction to achieve an optimal result.12,13 Furthermore, there are several fracture patterns for which anatomic articular reduction is impossible with closed methods. The authors of the present study concede that the outcome is not different between the two study groups, which might be attributable to less than optimal joint reduction in the PR group. Considering the amount of scarring that results from extensile approaches, one would at least have expected that subtalar motion would be better in the PR group, like has been shown in a similar study with selected fracture patterns and arthroscopic control of joint reduction.14 There are several other factors that have to be considered when choosing the individual treatment for every patient with displaced intra-articular calcaneal fracture like time from injury,

additional injuries, primary irreparable joint damage, functional demand, compliance, comorbidities, and so on. I therefore agree with the authors last statement, that further studies with adequate assessment of articular reduction and longer follow-up are needed to determine which patients will benet most from percutaneous reduction techniques. Given the great variability in fracture patterns, no single method will be useful for all patients and there should be more criteria for treatment selection than surgeon experience and preference. We should strive to combine the advantages of different open and less invasive approaches with adequate control of joint reduction to obtain optimal results for our patients. This requires a thorough preoperative analysis of the individual fracture pattern and other patient characteristics as well as a satisfactory method of assessing anatomic joint reduction if operative treatment of any form is chosen. REFERENCES
1. Janzen DL, Connell DG, Munk PL, et al. Intraarticular fractures of the calcaneus: value of CT ndings in determining prognosis. AJR Am J Roentgenol. 1992;158:12711274. 2. Zwipp H, Tscherne H, Thermann H, et al. Osteosynthesis of displaced intraarticular fractures of the calcaneus: results in 123 cases. Clin Orthop Relat Res. 1993;290:7686. 3. Paley D, Hall H. Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors. J Bone Joint Surg Am. 1993;75: 342354. 4. Boack DH, Wichelhaus A, Mittlmeier T, et al. Therapy of dislocated calcaneus joint fracture with the AO calcaneus plate [in German]. Chirurg. 1998;69:12141223. 5. Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84:17331744. 6. Rammelt S, Barthel S, Biewener A, et al. Calcaneus fractures: open reduction and internal xation [in German]. Zbl Chir. 2003;128:517528. 7. Kurozumi T, Jinno Y, Sato T, et al. Open reduction for intra-articular calcaneal fractures: evaluation using computed tomography. Foot Ankle Int. 2003;24:942948. 8. Paul M, Peter R, Hoffmeyer P. Fractures of the calcaneum. A review of 70 patients. J Bone Joint Surg Br. 2004;86:11421145. 9. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82:225250. 10. Magnan B, Bortolazzi R, Marangon A, et al. External xation for displaced intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006;88:14741479. 11. Walde TA, Sauer B, Degreif J, et al. Closed reduction and percutaneous Kirschner wire xation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2 10 years. Arch Orthop Trauma Surg. 2008;128:585591. 12. Rammelt S, Gavlik JM, Barthel S, et al. Value of subtalar arthroscopy in the management of intra articular calcaneus fractures. Foot Ankle Int. 2002;23: 609619. 13. Geerling J, Kendoff D, Citak M, et al. Intraoperative 3D imaging in calcaneal fracture careclinical implications and decision making. J Trauma. 2009;66:768773. 14. Rammelt S, Amlang M, Barthel S, et al. Percutaneous treatment of less severe intraarticular calcaneal fractures. Clin Orthop Relat Res. 2010;468: 983990.

Bruce Sangeorzan, MD University of Washington, Seattle, WA

The concept of comparative effectiveness research in medicine is not only important because the government and payers want it to be, it is important because medical care, like any other commodity, has a cost at which it can no longer
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be provided.13 That is why the American Recovery and Reinvestment Act of 2009 created the Federal Coordinating Council for Comparative Research. Orthopedics, particularly that involving injuries to healthy young people, is central in this argument because the function, the risk, and the physical and emotional and nancial cost are played out over a long segment of life. For that reason, comparing treatments that have different risks and costs using the same outcome measures is critical in determining how we will treat patients in the future. It is in this context that the manuscript in this months Journal should be a stimulus for discussion. It compares one treatment with presumably higher costs and higher risks with another with a lower risk and cost prole to determine if their outcomes are measurably different. In this issue of the Journal of Orthopaedic Trauma, the authors have provided us with a retrospective review of patients with intra-articular fractures of the calcaneus who were treated by two different surgeons using different techniques of open reduction internal xation over a 7-year period. The volume was moderate with 1.3 patients per month. The groups were not randomized. Patients were either admitted to or referred to the surgeons who chose the technique. The surgeon did not always choose his or her primary technique (nine patients crossed over) and it is not clear if the patients were analyzed by intent to treat or by actual treatment group. The outcome measures, although validated, have shortcomings that limit the conclusions. The SF-36 is a widely used health status measure that is subject to changes in any part of ones emotional or physical life. It is not very responsive to incremental changes in function that an orthopaedic patient might experience. The Foot Function Index (FFI) is a measure used to assess the foot validated in a population with rheumatoid arthritis. Its ceiling is very low for healthy patients. It would not likely demonstrate the difference between activities of daily living and higher functional activity. Beyond the intrinsic limitations of the outcome measures, less than one fourth of the patients

participated in the outcome assessment. The attempt at blinding the x-rays (Fig. 2) is not very effective. It is clear to many of the readers that there are no screw heads visible and therefore the treatment was open reduction and internal xation with a plate. Despite these methodologic imperfections, there is value and knowledge here. This is a real-world study carried out by clinicians. All clinicians know that the real world does not t neatly into scientic studies. The skill of surgeons varies, the intensity and biology of the injuries vary, and patient satisfaction is often highly inuence by the patients outlook. No study is perfect. The two groups are relatively balanced in terms of sex, age, and initial Bohlers angle. Although we do not know that the intensity of injury was the same, there is no reason to suspect that it was not. Many of the methodologic aws are things that clinically active physicians can understand. A noncontrolled study like this may reasonably reect real-world care in a nonacademic setting in which treating physicians have variable skill, training, and interest. So although there is risk in drawing too strong a conclusion from this retrospective, uncontrolled study, it can reasonably be concluded that there is enough clinical equipoise that a prospective randomized trial would not be unethical. Furthermore, it suggests that we need to look hard at whatever treatments we select to be sure that there is value to the patients. It is critically important that clinicians with face-to-face patient contact are running comparative effectiveness research. This well-written study, although methodologically imperfect, is a building block toward a more comprehensive trial. REFERENCES
1. Agel J, Beskin JL, Brage M, et al. Reliability of the Foot Function Index: a report of the AOFAS Outcomes Committee. Foot Ankle Int. 2005;26: 962967. 2. Akhter MN, Levinson RA. Comparative effectiveness research and the future practice of medicine. J Natl Med Assoc. 2009;101:13011302. 3. Aston G. Comparative effectiveness. Why does it matter to you? Hosp Health Netw. 2009;83:2225, 31.

Hans Zwipp, MD Universitatsklinikum Dresden, Dresden, Germany

This article is informative because it addresses questions that have been unanswered for some time, namely, does percutaneous reduction of intra-articular calcaneal fractures minimize the rate of deep infections as compared with open reduction and internal xation (ORIF)? The answer appears to be yes, it does. This was proven with high signicance (P = 0.002) by the authors, observing six of 42 patients in the ORIF group and zero of 83 in the closed reduction and internal xation (CRIF) group with objective signs of deep infections. Unfortunately, whether the six infected cases in the ORIF group healed or not was never stated; neither were the data related to number of revision surgeries and ultimate outcomes in these cases ever mentioned. With respect to the SF-36 and
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the foot function index, both groups showed no signicant differences. Bohlers angle, calcaneal length and width, loss of reduction, and even the rates of subtalar fusion were not signicantly different. There are some important advantages seen in this study, namely 1) each group of differently treated calcaneal fractures was operated on only by one surgeon; 2) patients age, sex, and fracture type according to Sanders classication have been considered as comparable (although the number of calcaneal fractures in the CRIF group was twice as high as in the ORIF group); and 3) the independent radiographic evaluation by technical blinding of the two treatment groups was very important.
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Disadvantages of this article, however, included: 1) fewer numbers in the ORIF group and still less than 100 in the CRIF group; 2) a lack of a prospective randomized study design; 3) a lack of postoperative Brodens view or computed tomography scanning as well as at the time of follow-up; 4) a short follow-up time, on average, 24.7 months (range, 268 months) for the ORIF group and 21.9 months (range, 266 months ) for the CRIF group; and 5) no intraoperative radiologic control of Brodens view and no intraoperative arthroscopy to judge anatomic reconstruction of the posterior facet. The discussion of the results by the authors is very selfcritical and honest, eg, the authors point out the limitations of this study including the fact that it is retrospective, not randomized, and without a computed tomography control postoperatively or at the time of follow-up. It is very honest to note that the expected and nonstatistically seen difference in subtalar motion at follow-up could be the result of

a nonanatomic joint reconstruction in the CRIF group. This sounds reasonable because other authors1 have reported that there is much better subtalar motion in cases performed with minimally invasive techniques and not by ORIF. Although it appears that percutaneous xation may minimize postoperative infections and maintain subtalar motion, without expectation of anatomic joint reduction, I believe that the subtalar joint will deteriorate rapidly and require premature fusion. Because the authors recognize that for further studies, a computed tomography control postoperatively and at time of follow-up would be mandatory to answer these questions, I look forward to a larger series with these data clearly evident. REFERENCE
1. Rammelt S, Gavlik JM, Barthel S, et al. Value of subtalar arthroscopy in the management of intra articular calcaneus fractures. Foot Ankle Int. 2002;23: 609619.

Author Response to Commentary

J. L. Marsh, MD
Our article and the commentaries indicate that the optimal technique to reduce and internally x displaced intraarticular calcaneal fractures is controversial. In my practice, I have nearly exclusively used percutaneous techniques for many years and some of these patients are the subjects in one of the arms of the study. In one of the commentaries, Dr. Benirschke is clear that he feels in his hands all patients are best treated with open reduction and internal xation through an extended lateral approach. In their commentaries, Drs. Rammelt, Zwipp, and Clare indicate that they prefer a selective approach choosing between these techniques based on patient and fracture characteristics. Most surgeons would probably agree with a selective approach, but the best technique for a given patient remains controversial. The current study, others in the literature, and common sense all indicate that limited or percutaneous approaches have fewer wound complications than the extended lateral approach. Because some of these complications have signicant consequences, this is an important advantage. Although not shown in this study, the commentaries suggest that percutaneous approaches may result in better subtalar motion. On the other hand, extensile lateral approaches in which the fracture fragments and the joint are directly visualized probably lead to better reductions at least for the more complex fractures. I would not argue that all of my percutaneously treated calcaneal fractures are perfectly reduced. Therefore, in choosing between these techniques, a surgeon must balance the decreased risk for complications with percutaneous techniques against more perfect reductions for some fractures with extensile open approaches. This balance must be assessed based not only on the characteristics of the fracture and the patient, but also as the commentaries make clear, the surgeons experience and preferences play a role. In his commentary, Dr. Sangeorzan calls for additional high-quality prospective clinical research to allow these choices to be increasingly guided by evidence rather than opinion and preferences. The ability to improve and maintain the improved position of calcaneal fracture fragments with percutaneous approaches with a very low complication rate means these techniques are here to stay, at least for some patients. With future advances such as wider availability of and better intraoperative three-dimensional imaging, subtalar arthroscopy, limited sinus tarsi approaches, and better instruments and manipulation techniques, the reduction quality gap between the two techniques will narrow and this will increase the number of patients that would benet from percutaneous techniques.

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