Functional outcome of intra-articular tongue type of calcaneus fractures treated with percutaneous technique

Bhavik Y. Dalal, Raghav K. Suthar, Parag Y. Tank, Dipal Rathod, Harshal Damor


Background: Intra-articular calcaneus fracture is relatively rare and morbidity correlates with displacement and relative alignment of fragments. The treatment should address both components to maintain mechanics of foot. Among the available options open reduction and internal fixation is associated with major soft tissue complications and wound healing problems. As an alternative percutaneous fixation offer fewer complications yet good results for less severe calcaneus fractures. Our study aimed to contribute paucity of data available for these rare fractures and help to propose a preferred method of treatment.

Methods: A hospital based study carried out on 20 patients over period of 2 year with closed displaced intra-articular tongue type of calcaneal fracture treated with percutaneous fixation and outcome was evaluated using clinical, radiological criteria and American Orthopaedic Foot & Ankle Society (AOFAS) score. All patients were followed up for minimum 9 months with mean follow up of 13.5 month.

Results: All patients had evidence of union within 2 month follow up. Mean correction in Bohler angle and Gissane angle was 23.2° and 25.4° respectively at final follow up. Mean change in heel height was 3.15 mm and width change was 2.75 mm compare to opposite side. Mean eversion inversion arch was 28° and near normal ankle range of motion. Functional outcome calculated on bases of AOFAS score revealed 18 patients (90%) had good results and 2 patients (10%) had fair results. Mean AOFAS score was 81.25. Complications were reported in three patients, one had signs of peroneal tendinitis and two had persistent pain and heel widening.

Conclusions: We believe percutaneous fixation should be considered as a preferred method for mild to moderately displaced tongue type of intraarticular calcaneus fractures. It potentially allows anatomical fracture reduction with lesser complications and good functional outcome.


Calcaneus fracture, Tongue type, Intra-articular, Percutaneous technique

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Lindsay WRN, Dewar FP. Fractures of the os calcis. Am J Surg. 1958;95:555–76.

Rammelt S, Amlang M, Barthel S, Gavlik JM, Zwipp H. Percutaneous Treatment of Less Severe Intraarticular Calcaneal Fractures, Clin Orthop Relat Res. 2010;468:983–90.

Patel NB, Bhavsar NM, Lil NA. Percutaneous fixation of Calcaneum fractures. GCSMC J Med Sci. 2014;3(1):38-41.

Loucks C, Buckley R.. University of Calgary, Alberta, Canada. Bohler's angle: correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma. 1999;13(8):554-8.

Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies and recent developments. Injury. 2004;35:443–61.

Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot: surgical management of calcaneal fractures. Clinical Orthop Relat Res. 1993;292:128–34.

Rammelt S, Barthel S, Biewener A, Gavlik JM, Zwipp H. Calcaneus fractures: open reduction and internal fixation [in German]. Zbl Chir. 2003;128:517–28.

Fernandez DL, Koella C. Combined percutaneous and ‘‘minimal’’ internal fixation for displaced articular fractures of the calcaneus. Clin Orthop Relat Res. 1993;290:108–16.

Forgon M, Zadravecz G. Closed reduction and percutaneous osteosynthesis: technique and results in 265 calcaneal fractures. In: Tscherne H, Schatzker J, eds. Major Fractures of the Pilon, the Talus and the Calcaneus. Berlin, Germany: Springer Verlag; 1993: 207–213.

Gavlik JM, Rammelt S, Zwipp H. Percutaneous, arthroscopically assisted osteosynthesis of calcaneus fractures. Arch Orthop Trauma Surg. 2002;122:424–8.

Westhues H. Eine neue Behandlungsmethode der Calcaneusfrakturen. Arch Orthop Unfallchir. 1934;35:121.

Westhues H. Eine neue Behandlungsmethode der Calcaneusfrakturen: Zugleich ein Vorschlag zur Behandlung der Talusfrakturen. Zentralbl Chir. 1935;35:995–1002.

Goff CW. Fresh fracture of the os calcis. Arch Surg. 1938;36:744–65.

Gissane W. News notes: Proceedings of the British Orthopedic Association. J Bone Joint Surg Am. 1947;29:254–8.

Essex-Lopresti P. The mechanism, reduction technique and results in fractures of the os-calcis. Clin Orthop. 1993;290:3-16.

Tornetta P III. Percutaneous treatment of calcaneal fractures. Clin Orthop. 2000;375:91-6.

Rammelt S, Amlang M, Barthel S, Zwipp H. Minimally-invasive treatment of calcaneal fractures. Injury. 2004;35(2):55-63.

Cobey JC. Posterior roentgenogram of the foot. Clin Orthop Relat Res. 1976;118:202–7.

Broden B. Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol. 1949;31:85–8.

Bohler L. Behandlung der Fersenbeinbru¨che. Arch Klin Chir. 1929;157:723–32.

Kitaoka H, Alexander I, Adelaar R, Nunley J, Myerson M, Sanders M. Clinical rating systems for the ankle, hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int. 1994;15:349–53.

Bezes H, Massart P, Delvaux D, Fourquet JP. The operative treatment of intraarticular calcaneal fractures: indication, technique and results in 257 cases. Clin Orthop. 1990;290:55-9.

Thordarson DB, Krieger LE. Operative vs. Non operative treatment of intraarticular fractures of calcaneum: A prospective randamized trial. Foot and ankle Int. 1996;17:2-9.

Zeman P, Zeman J, Matejka J, Loudela K, Klinika K. Lomg term results of calcaneal fracture treatment by open reduction and internal fixation using a calcaneal locking compressive plate from an extended lateral approach. Acta Chir Orthop Traumatol Cech. 2008;75960:457-64.

Eastwood DM, Langkamer VG, Atkins RM. Intra-articular fractures of the calcaneum. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. Bristol Royal Infirmary, England. J Bone Joint Surg Br. 1993;75(2):189-95.

Backes M, Schep NWL, Luitse JSK, Goslings C, Schepers T. The effect of postoperative wound infections on functional outcome following intra-articular calcaneal fractures. Arch Orthop Trauma Surg. 2015;135:1045–52.

Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, et al. Mini-Open Sinus Tarsi Approach with Percutaneous Screw Fixation of Displaced Calcaneal Fractures: A Prospective Computed Tomography-Based Study. Foot Ankle In. 2012;33:925-33.

Stulik J, Stehlik J, Rysavy M, Wozniak A. Minimally-invasive treatment of intraarticular fractures of the calcaneum. J Bone Joint Surg [Br]. 2006; 88(12):1634-41.

Arastu M, Sheehan B, Buckley R. Minimally invasive reduction and fixation of displaced calcaneal fractures: surgical technique and radiographic analysis. In Orthopaedics (SICOT). 2014;38:539-45.

Rak V, Ira D, Masek M. Operative treatment of intra articular calcaneal fractures with calcaneal plates and its complications, Indian J Orthop. 2009;43(3):271-80.

Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. Fractures of the calcaneus. Orthop Clin North Am. 2002;33:263-85.

Levine DS, Helfet DL. An introduction to the minimally invasive osteosynthesis of intra-articular calcaneal fractures. Injury. 2001;32:51-4.

Jain S, Jain AK, Kumar I. Outcome of open reduction and internal fixation of intra articular calcaneal fracture fixed with locking calcaneal plate. Chinese J Traumatology. 2013;16:355-60.

Schepers T, Schipper IB, Vogels LM, Ginai AZ. Percutaneous treatment of displaced intra-articular calcaneal fractures. J Orthop Sci. 2007;12:22-7.

Hammond WA, Crist BD. Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: A case series. Injury. 2013;44:1483-5.

Vaupel ZM, Erdogan M. Outcome of displaced intraarticular calcaneal fractures treated using a lateral plate and screw construct: Long term result. AAOS Annual meeting speciality day. San Francisco, CA: 2012: 99-100.