Screw-Only Fixation Found to Be Safe and Effective for Intra-Articular Calcaneal Fractures

Screw-only fixation has become a reliable option for treating intra-articular calcaneal fractures. It provides stable fixation with fewer soft-tissue complications compared to plating. Clinical studies show that when reduction quality is achieved, screw fixation yields comparable radiological and functional outcomes to plate fixation. For selected fracture types, particularly Sanders II–III, this approach offers a balance between stability and minimal invasiveness.

Overview of Intra-Articular Calcaneal Fractures

The calcaneus is a complex bone that supports the body’s weight and influences gait mechanics. When its articular surface is disrupted, restoring alignment and joint congruity becomes essential to prevent long-term disability.

Anatomical and Biomechanical Considerations

The calcaneus plays a central role in hindfoot biomechanics, transmitting forces from the leg to the foot during walking. Intra-articular fractures typically involve the posterior facet of the subtalar joint, creating incongruity that alters load distribution. Proper restoration of this surface is vital to regain motion and prevent post-traumatic arthritis.

Classification and Clinical Relevance

The Sanders classification remains the most widely used system for intra-articular calcaneal fractures, categorizing injuries based on CT imaging. The number and displacement of fracture lines determine whether screw-only or plate fixation is appropriate. Complex patterns often require more rigid constructs, while simpler ones can be managed percutaneously.

Principles of Surgical Fixation in Calcaneal Fractures

Surgical management aims not only at restoring bone shape but also at preserving surrounding soft tissues. The approach must balance mechanical stability with biological preservation.

Goals of Internal Fixation

Internal fixation seeks to restore the calcaneal height, width, and alignment while maintaining subtalar joint congruity. Stable fixation allows early movement of the ankle and subtalar joints, reducing stiffness. Limiting soft-tissue disruption remains critical because wound complications can compromise outcomes.

Common Surgical Approaches

The extensile lateral approach provides wide visualization of the posterior facet but carries risks such as wound necrosis or infection. Minimally invasive techniques using small incisions reduce these risks while achieving satisfactory reduction under fluoroscopy. The surgeon’s choice depends on fracture complexity and patient factors like skin condition or comorbidities.

Screw-Only Fixation: Technique and Rationale

Screw-only fixation has gained popularity as imaging technology and surgical precision have advanced. It offers a less invasive alternative for specific fracture configurations.

Surgical Technique Overview

This method involves percutaneous or limited open reduction followed by insertion of cannulated screws under fluoroscopic guidance. Screws are placed strategically to compress fracture fragments and restore joint surfaces accurately. Each trajectory is planned preoperatively to achieve optimal compression without violating adjacent joints.

Biomechanical Advantages of Screw Fixation

Screw constructs provide adequate stability for selected patterns with minimal hardware prominence. They preserve periosteal blood supply better than plates, supporting faster healing. Smaller incisions mean lower tension on skin flaps, which reduces wound complications—a key advantage in patients with fragile soft tissues.

Calcaneal Plate Fixation: Technique and Considerations

Despite advances in minimally invasive surgery, plate fixation still holds value in managing complex or comminuted fractures where fragment control is challenging.

Design and Application of Calcaneal Plates

Calcaneal plates are anatomically contoured to match bone geometry, helping restore normal shape after collapse. Locking plate technology improves purchase in osteoporotic bone by converting shear forces into compressive ones at the screw-bone interface. Accurate placement prevents irritation of peroneal tendons or impingement near the subtalar joint.

Limitations and Complications Associated with Plating

Plating requires larger incisions that may compromise local vascularity, leading to delayed healing or infection. Studies have reported higher rates of wound dehiscence compared with screw-only methods. Hardware prominence occasionally necessitates removal once union is achieved.

Comparative Evaluation: Screw vs Plate Fixation Outcomes

Comparative studies have shown that both methods can yield similar radiological correction when performed precisely, but their complication profiles differ significantly.

Radiological and Functional Outcomes

Restoration of Böhler’s angle—a key radiographic indicator—has been found comparable between screw-only and plate fixation in controlled series. Functional scoring systems such as AOFAS or Maryland Foot Score often reveal no significant difference when anatomical reduction is achieved. Early mobilization tends to favor screw constructs due to less postoperative swelling.

Complication Profiles and Revision Rates

Screw-only fixation shows fewer wound problems because it avoids large flaps typical of lateral plating approaches. However, plating may provide greater rigidity in severely comminuted cases requiring delayed loading protocols. Revision rates generally depend more on initial reduction accuracy than on implant type itself.

Patient Selection and Indications for Each Method

Selecting the appropriate technique hinges on fracture pattern, patient biology, and surgeon expertise rather than one-size-fits-all principles.

Criteria Favoring Screw Fixation

Screw-only fixation suits simple displaced intra-articular fractures (Sanders II–III). It benefits patients with poor skin quality or those at high risk for infection due to diabetes or smoking history. This approach also supports quicker rehabilitation through minimally invasive recovery pathways.

Scenarios Where Plating Remains Preferable

Plate fixation remains indicated for severely comminuted fractures (Sanders IV) where multiple fragments need rigid stabilization. It allows precise reconstruction when fragment orientation cannot be maintained percutaneously. Patients with healthy soft-tissue envelopes tolerate lateral exposure better in these cases.

Future Directions in Calcaneal Fracture Management

Technological progress continues to refine how surgeons treat calcaneal injuries, aiming for improved function with fewer complications.

Emerging Techniques and Materials

Innovations include bioabsorbable screws that eliminate hardware removal procedures and low-profile plates designed to minimize irritation around tendons. Three-dimensional printing now enables custom implants tailored to unique fracture morphologies, enhancing fit and stability during reconstruction.

Long-Term Perspectives on Functional Recovery

Future research focuses on individualized care strategies considering bone density, activity level, and comorbidities rather than uniform protocols. Long-term trials comparing subtalar joint preservation between screw-only and plated constructs are underway across multiple centers worldwide.

FAQ

Q1: What type of calcaneal fractures are best treated with screw-only fixation?
A: Simple displaced intra-articular fractures classified as Sanders II–III respond well to screw-only fixation due to sufficient stability with minimal incision size.

Q2: Does screw-only fixation allow early weight-bearing?
A: Early partial mobilization is possible once radiographic healing begins since this method preserves soft tissue integrity better than plating.

Q3: Are there higher risks of loss of reduction with screws compared to plates?
A: Not necessarily; when reduction is accurate under fluoroscopic control, screw constructs maintain alignment effectively in non-comminuted patterns.

Q4: Why do some surgeons still prefer plate fixation?
A: Plate systems provide rigid stabilization necessary for highly comminuted or osteoporotic fractures where fragment control is difficult using screws alone.

Q5: What new materials are being explored for future calcaneal implants?
A: Research includes bioabsorbable composites and 3D-printed titanium structures designed for patient-specific geometry while reducing hardware-related complications.