Gissane described percutaneous elevation of depressed intra-articular fractures and this formed the basis of Essex-Lopresti’s classic 1951 paper. He elevated his tongue-type fractures with a percutaneous Gissane spike. Joint-depression fractures were reduced by a limited open approach before being fixed with a spike. Unfortunately he did not separate the fracture types in his results.
There has been increased interest in percutaneous or limited open reduction techniques recently, often with arthroscopic assistance (Tornetta 2000, Gavlik et al 2002, Rammelt 2002). Essex-Lopresti's technique is used to reduce tongue-type fractures. Joint depression fractures are reduced with an elevator introduced through the sinus tarsi or a punch passed through the inferior surface of the bone. Post-reduction stabilisation has been achieved with K-wires (Stulik et al 2006), a unilateral fixator (Magnan et al 2006) or a ring fixator (Paley and Fischgrund, Talarico 2004, McGarvey et al 2006).
DeWall (2010) reported a comparison between the outcomes of 83 calcaneal fractures treated by percutaneous reduction and screw fixation and of 42 fractures treated by conventional ORIF. One surgeon principlly used percutaneous treatment, th other ORIF. Reduction was assessed by plain films and was similar (not always complete) in both groups. Clinical resultsusing the FFI and SF36 were similar, but only a limited subgroup was assessed. There were 6/42 deep infections and 9/42 wound complications in the ORIF group compared with 0/83 and 5/83 in the percutaneous group.
Rammelt (2010) selected 61 Sanders type 2 fractures for percutaneous reduction, using arthroscopic control in 33 type 2A and 2B fractures. Five fractures could not be reduced percutaneously and underwent ORIF. Mean follow-up was 29 months and the results were compared with historic, comparable controls who underwent ORIF. Quality of reduction was comparable. There was one wound dehiscence in the ORIF group and no wound complications in the percutaneous group. The percutaneous group had better subtalar movement and less time off work and the AOFAS hidfoot scores were comparable.
Results appear similar to those of open reduction and internal fixation, possibly with lower rates of serious infection. The technique is demanding, particularly in joint depression or comminuted fractures which seem to do slightly less well. The joint fragments are not always fully reduced, but this may not adversely affect the results.
As yet there are no RCTs comparing open and minimally invasive techniques, so it is difficult to reach a conclusion as to the place of each in management. The current Dutch trial includes percutaneous techniques as one comparator arm; it will probably be published about 2015.