Percutaneous arthroscopic calcaneal osteosynthesis (PACO) for significantly displaced intra-articular calcaneal fractures

P.S. Pastides, L. Milnes, P. Rosenfeld

Introduction: Open reduction and internal fixation of displaced intra-articular calcaneal fractures is susceptible to a high incidence of wound complications. Displaced fractures create abnormal contact characteristics at the subtalar joint, resulting in poor functional outcome and arthritis. We present the functional outcomes of 32 fractures (Sanders 2 and 3) at an average follow up of two years.

Methods: Over a 57 month period, 32 fractures (29 patients) underwent this technique in a London level 1 trauma centre. Open fractures were excluded. The previously described technique with sinus tarsi portals was used. Pre and post-operative radiographs and functional outcomes were assessed.

Results: Our patient cohort consisted of 20 male (23 fractures) and 9 female patients. Classification via the Sanders system revealed 37% 2A, 9% 2B, 41% 3AB, 9% 3AC and 3%3BC. Mean follow up period was 24,2 months (range 5-57). All patients were operated on within 7 days of injury. Average inpatient stay was 1.9 days. 1 patient sustained a port site infection which was managed conservatively, while screws were removed from 2 patients. We had no cases of deep infections. The Bohler’s angle increased from 10 to 29 degrees post operatively. Mean modified AOFAS scores (maximum score 60) was 40.3 (11-60), average VAS was 29.8mm and CFS was 78.1. Importantly the majority of patients returned to their pre injury employment.

Conclusion: PACO is a demanding technique with an associated learning curve. However, our series shows that it is a safe and reproducible technique for significantly displaced intra-articular fractures. Post operative results are very encouraging with high levels of patient satisfaction and return to pre injury employment and activities. In addition it is a more cost effective treatment option as it is associated with minimal wound complications and a reduced hospital stay.