The guiding significance of calcaneal tuberosity integrity in the surgical treatment of calcaneal fractures: a retrospective case–control study

BACKGROUND: The optimal surgical approach for displaced intra-articular calcaneal fractures remains contentious. While minimally invasive surgery (MIS) reduces soft-tissue complications, its application in complex fractures is debated. Ligamentotaxis, a cornerstone of MIS, requires an intact calcaneal tuberosity as a fulcrum. This study evaluates the utility of preoperative tuberosity integrity assessment in guiding surgical approach selection. METHODS: In this retrospective case-control study, 118 patients (2019-2022) were allocated to two treatment algorithms due to an institutional protocol evolution. Group A (Sanders-guided, n = 51) received MIS for Sanders type II/III and ELA for type IV. Group B (tuberosity-guided, n = 67) received MIS if the tuberosity was intact or an extended lateral approach (ELA) if comminuted. Outcomes included operative metrics, radiographic reduction (Böhler's angle, facet step-off), functional scores (AOFAS, Maryland Foot Score), VAS pain scores, and complications. RESULTS: No significant differences were observed in radiographic or functional outcomes between the two groups. However, the tuberosity-guided approach suggested a potential reduction in operative time for fractures with comminuted tuberosity (93.5 ± 6.1 min vs. 103.2 ± 4.7 min, p = 0.017, a preliminary finding due to the small sample size). Analysis of the entire cohort (n = 118) revealed that the wound complication rate was notably higher when comminuted tuberosity fractures were treated with STA (2/2, 100%) compared to ELA (1/9, 11.1%, p = 0.011). Furthermore, among all STA cases, patients with comminuted tuberosity had a markedly higher observed complication rate than those with intact tuberosity (100% vs. 9.5%, p < 0.001). CONCLUSION: Preoperative assessment of calcaneal tuberosity integrity offers a potentially valuable adjunct to the Sanders classification for selecting the surgical approach in displaced intra-articular calcaneal fractures. It achieves comparable clinical outcomes. Given the exploratory nature of subgroup analyses based on a limited number of comminuted fractures, the findings regarding enhanced operative efficiency and complication profiles are preliminary and require validation in larger, prospective cohorts.