Abstract
The management of displaced intra-articular fractures of the calcaneus remains controversial due to the soft tissue complications associated with the traditional extensile lateral surgical approach. Minimally invasive percutaneous techniques have been developed with the aim of restoring calcaneal shape while reducing wound complications. This review evaluated functional and radiographic outcomes following percutaneous fixation of displaced intra-articular fractures of the calcaneus. A systematic search of MEDLINE and EMBASE databases identified studies that reported functional outcomes or radiographic measurements after percutaneous fixation. Data on patient demographics, fracture classification, operative technique, outcomes, complications, and study quality were extracted. Eight studies comprising 295 patients and 309 fractures met inclusion criteria. All studies included fractures of Sanders type three, seven included fractures of Sanders type two, and two reported fractures of Sanders type four. The average follow-up period across all studies was 29.2 months. Functional outcomes were favourable, with a pooled average score on the American Orthopaedic Foot and Ankle Society hindfoot scale of 85.6 across all studies and an average Maryland foot score of 88.9 across two studies. Radiographic correction was maintained at final follow-up, with improvements in both Böhler and Gissane angles reported in five studies. Five studies were assessed as high quality and three as low quality. Percutaneous fixation of displaced intra-articular fractures of the calcaneus provides reliable functional improvement, satisfactory restoration of radiographic parameters, and a lower rate of wound complications compared with open reduction and internal fixation. Larger, high-quality prospective studies are required to define the optimal minimally invasive method.
Level of clinical evidence: 2
Introduction
Intra-articular calcaneal fractures remain among the most challenging injuries in foot and ankle surgery, often associated with long-term disability if anatomical reduction is not achieved. Traditional extensile lateral approaches allow for direct visualization but are frequently complicated by wound breakdown, infection, and sural nerve injury. Reported complication rates as high as 30% have driven increasing interest in minimally invasive techniques. ,
Percutaneous fixation methods, including screw fixation aided by fluoroscopy, arthroscopy, patient-specific instrumentation, or 3D-assisted planning, aim to restore calcaneal morphology while minimizing soft-tissue trauma. Recent reports suggest that these approaches may achieve satisfactory radiographic restoration of Böhler and Gissane angles, with functional outcomes comparable to those of open techniques, but with lower rates of wound complications. Nevertheless, the available evidence is largely limited to small, heterogeneous cohort studies with variable methodology.
Given the increasing adoption of minimally invasive strategies in clinical practice, a critical appraisal of the reported functional and radiological outcomes is required. This systematic review evaluates the evidence for percutaneous fixation of calcaneal fractures, with a focus on postoperative function, radiographic alignment and complication rates.
Methods
A systematic review was conducted according to PRISMA guidelines. Ovid MEDLINE and EMBASE were searched for peer-reviewed English language papers from the earliest records until 9th July 2025. The search was conducted by a single author (MB), and two authors (MB, FB) independently screened titles and abstracts
Search terms and inclusion criteria
The applied search terms in databases included: “Calcaneus fracture” OR “Calcaneal fracture” OR “Calcaneus” AND “Percutaneous” OR “Closed” OR “Minimally Invasive” OR “Fracture Management” OR “Operative Management”.
Studies measuring functional or radiological outcomes in patients undergoing minimally invasive calcaneal fractures were included. Randomized controlled trials (RCTs) and cohort studies were considered. Non-clinical studies, reviews, case reports, unpublished data and conference reports were excluded. Studies which did not measure functional or radiological outcomes or use patients who did not undergo minimally invasive surgery were excluded.
Data extraction
One author (MB) extracted the data. Relevant data (Authors, the date and type of the study, the number and demographics of the patients, fracture type, surgical approach and functional or radiological outcomes) was collected. ( Table 1 )
Table 1
Study characteristics data.
|
Author
Year Study design |
Patients | Sanders Classification | M:F | Age (years) | Surgical approach | Reduction technique | Fixation method |
Mean Follow-Up
(Months) |
Complications |
|---|---|---|---|---|---|---|---|---|---|
|
Kong et al.
2025 Retrospective |
32 |
S2: 12
S3: 20 |
28:4 | 54.3 | Percutaneous | Percutaneous prying and repositioning | 1–3 cannulated screws | ≥12 months | 1 wound complication |
|
Dai et al., 2024
Retrospective |
52 |
S2: 23
S3: 29 |
34:18 | 51.7 | Percutaneous ± arthroscopy | Percutaneous prying and repositioning under arthroscopic visualization | 3 cannulated screws | 23.7 | |
|
Wang., et al 2023
Retrospective |
15 | S2&3: proportion no reported | 12:3 | 45.2 | Robot assisted percutaneous ± tarsal sinus approach | Percutaneous prying and repositioning | Robot-assisted cannulated screws | 0 | |
|
Song et al.
2023 Prospective |
19 |
S2: 11
S3: 8 |
12:7 | 41.3 | Percutaneous with 3D-printed cast jig | Percutaneous prying and repositioning using Schanz pins | 5 cannulated screws | 0 | |
|
Wang et al 2021
Retrospective |
30 |
S2: 22
S3: 8 |
24:6 | 46.2 | Percutaneous | Percutaneous prying and repositioning | 3–4 headless compression screws | 24.8 months | 2 cases of loosening |
|
Wang et al 2020
Retrospective |
19pts (20ft) |
S3: 7
S4: 13 |
11:8 | 37.9 | Percutaneous with patient specific instrument (PSI) | Percutaneous prying and repositioning using Schanz pins or kwires using PSI | 1–2 cortical screws + 2–3 cannulated screws | 0 | |
|
Weng et al 2020
Retrospective |
78 |
S2: 60
S3: 18 |
45:33 | 39.0 | Percutaneous | Percutaneous prying and repositioning | 1–2 cannulated screws | 8.7 years (104.4 months) |
3 wound complications
1 subtalar arthrodesis |
|
Schepers et al.
2008 Retrospective |
50 |
S2: 23
S3: 17 S4: 17 |
n/a | 46 | Percutaneous | Percutaneous prying and repositioning | 2–3 cannulated screws | 35 months (2.9 years) | 9 wound complications |
*S2: Sanders II fracture, S3: Sanders III fracture, S4: Sanders IV fracture
Study quality assessment
All papers were assessed for methodological quality using the Newcastle-Ottawa Scale (NOS). This tool assesses three domains: selection of study groups, comparability between groups, and determination of the outcome of interest, across a total of eight items. The maximum score attainable is nine stars. Based on the NOS, each study was evaluated using a scoring system, quantified by the number of stars awarded. When a study included relevant information that was associated with methodological quality of the NOS tool, one star was awarded. Studies assigned 7 to 9, 4 to 6, and 0 to 3 stars were identified as high- quality, moderate- quality, and low-quality, respectively.
Results
Study characteristics
The initial search yielded 2588 publications. No additional studies were subsequently added after searching the grey literature. After screening the article titles and abstracts, 12 studies were included for review ( Fig. ). Following a full-text evaluation, a further 4 studies were excluded, leaving 8 studies that met the inclusion criteria. The included papers comprised a total of 8 studies, including 295 patients and 309 calcanei. Of these, 7 were retrospective and 1 was prospective. The mean patient age was 45.2 (S.D. 5.78) years, with a male predominance (77.6% male, 22.4% female, among studies reporting gender). The mean follow-up duration was 29.2 (S.D. 31.6 months) ( Table 1 ).
2020 Prisma flow diagram showing the systematic selection of records.
Performed operations
The included studies employed a range of minimally invasive surgical technique alterations for calcaneal fracture fixation. Subtalar arthroscopy-assisted fixation was reported by Dai et al. (2024), who used a medial distraction device and percutaneous prying reduction under arthroscopic guidance. 3D-guided or PSI-assisted screw fixation was used in two studies: Wang et al. (2020) employed a patient-specific instrumentation (PSI) jig, while Wang et al. (2023) utilized robot-assisted 3D planning for screw placement and lastly Song et al. (2023) applied a 3D jig-assisted technique, employing a 3D-printed cast to guide percutaneous screw placement. ,,
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