Clinical Comparison of Extensile Lateral Approach and Sinus Tarsi Approach Combined with Medial Distraction Technique for Intra‐Articular Calcaneal Fractures

Abstract

Objective

To study and compare the clinical outcomes of open reduction and internal fixation via extensile L‐shape incision and limited open reduction via the sinus tarsi approach using the medial distraction technique for intra‐articular calcaneal fractures.

Methods

We performed a retrospective review of 65 intra‐articular calcaneal fractures treated operatively between March 2012 and February 2015. Patients were divided into two groups: 28 were in the sinus tarsi approach group and 37 were in the extensile lateral approach group. All patients were asked to return for a research visit that included radiography and clinical evaluation. The postoperative function was evaluated using the ankle and hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) and the visual analogue scale (VAS).

Results

No significant difference was found in demographics between the two groups. The corrected value of the calcaneal varus angle between the two groups is statistically significant (P < 0.05). The overall wound complication rate was 3.6% in the minimally invasive group versus 13.5% in the extensile group. Four patients in the extensile lateral approach group had developed hindfoot varus deformity at last follow‐up. At the last follow‐up, the average AOFAS ankle and the hindfoot score of the minimal group was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7, while that of the extensile lateral approach group was 83.2 ± 5.6 and 2.3 ± 1.0, respectively.

Conclusion

Limited open reduction via the sinus tarsi approach for intra‐articular calcaneal fractures could reduce the incidence of wound complications effectively, and the medial distraction technique is helpful for correcting the calcaneus varus deformity.

Introduction

Due to the irregularly shaped architecture of the calcaneus, intra‐articular calcaneal fractures have long been considered among the articular fractures that are most difficult to treat. The treatment for intra‐articular calcaneal fractures is a hot topic in the field of foot and ankle surgery1. In many cases, patients could not return to their previous jobs within 3 years after the injury, and some even remained dysfunctional for more than 5 years. Since last century, experts have studied the pathology and the anatomy of calcaneus for a better understanding of intra‐articular calcaneal fractures. However, there are still many patients who are not satisfied with treatment options and outcomes, and determining how best to deal with these fractures remains controversial.

In recent years, the traditional extensile lateral approach has been recognized as the gold standard method for treatment of intra‐articular calcaneal fractures2, 3, 4. The approach provides excellent exposure and facilitates direct reduction of the posterior facet fragment and lateral wall, and also makes it easier to protect the sural nerve. However, the high incidence of wound complications continues to be a concern for orthopedic surgeons. Superficial wound edge necrosis has been found in up to 14% of patients undergoing open reduction and internal fixation via the extensile lateral approach5. Therefore, many surgeons recommend conservative treatment for intra‐articular calcaneal fractures. However, with plaster immobilization for a long period of time, patients will suffer from arthritis in the subtalar joint and have difficulty walking due to pain. Patients should not be treated non‐operatively unless the fractures are nondisplaced or have less than 2 mm of displacement6, 7, 8. The goal of operative treatment is to achieve the best possible reduction of the articular surfaces, to restore the subtalar joint and normal width of the calcaneus, and to maintain this reduction with stable internal fixation7, 9. With improvements in surgical techniques and implants, the extensile lateral approach has been widely used over the past 20 years and a laterally‐based plate is commonly accepted to provide the rigid fixation, but postoperative complications have remained9.

To balance minimizing risks of complications against obtaining the best reduction possible, various minimally invasive techniques have been reported, including a small incision technique, percutaneous fixation, and arthroscopically assisted fixation10, 11. These techniques aim to minimize soft tissue trauma and reduce the risk of complications, and allow good reduction.

The sinus tarsi approach is now widely used for the treatment of intra‐articular calcaneal fractures10, 12, 13, 14, 15. Strong fixation of the fractures is obtained with cannulated screws or a mini‐plate. However, intra‐articular calcaneal fractures are often caused by high‐energy trauma, which leads to depressed posterior facet, lateral wall expansion and hindfoot varus deformity. Treatment via the sinus tarsi approach may result in inadequate fracture reduction. The approach provides exposure of the posterior facet with good visualization, but it is more difficult to correct the hindfoot alignment than when using the extensile lateral approach. The posterior tuberosity has to be reduced percutaneously. There will be some dysfunction, such as varus deformity or subtalar stiffness, if the alignment is corrected unsatisfactorily. Varus malunion has been another common complication besides wound infection and necrosis. Surgeons have paid more attention to the correction of the hindfoot alignment rather than reduction of the depressed posterior facet only. Previous studies have also shown that postoperative varus and short deformities are mainly caused by a poor reduction and fixation5, 9. It is essential for patients with fractures to achieve functional recovery. Common surgical instrument options for the correction include reduction clamps and Steinmann pins. Surgeons have found that sometimes correcting the alignment of the calcaneus using either option is insufficient for reduction of fractures. Therefore, we chose to employ the sinus tarsi approach combined with the medial distraction technique, which aims at correcting the varus deformity for intra‐articular calcaneal fractures to provide anatomical reduction. The technique aimed to restore the height and the width of the calcaneus, correcting the hindfoot alignment operatively and preventing the occurrence of varus deformity.

Several studies have compared the outcomes and complications of the extensile lateral approach and the sinus tarsi approach10, 11, 16. However, to the best of our knowledge, there are no published studies on this technique for intra‐articular calcaneal fractures. The purpose of the present study was to compare the clinical outcomes of open reduction internal fixation via extensile L‐shaped incision and limited open reduction via the sinus tarsi approach using the medial distraction technique for intra‐articular calcaneal fractures.

Materials and Methods

Inclusion and Exclusion Criteria

Inclusion criteria for this study were: (i) intra‐articular fractures classified as Sanders type II or III with hindfoot varus deformity; (ii) closed and fresh fractures; and (iii) fractures that underwent operative treatment via the extensile lateral approach or the sinus tarsi approach combined with the medial distraction technique. The exclusion criteria for all these patients in our trial were as follows: (i) open calcaneal fractures with or without other fractures and comminuted calcaneal tuberosity fractures; (ii) diabetes or other peripheral vascular diseases; (iii) long‐term smoking status or remained smoking during the perioperative period; and (iv) less than 12 months follow‐up.

Patients

We performed a retrospective review of all calcaneal fractures treated operatively between March 2012 and February 2015. The fractures were categorized according to the Sanders classification. Preoperative evaluation of the calcaneal fractures was done using lateral and axial radiographs and computed tomography (CT) scans.

A total of 83 patients met the criteria: 65 patients were willing to participate in our research and 18 patients were lost to follow‐up. Finally, all of these 65 patients were enrolled in the study; 49 of these patients were male and 16 were female. There were 37 right‐side and 28 left‐side cases. The average age of all cases was 43.7 years old. A total of 47 cases were due to a fall from a height, and 18 were secondary to a motor vehicle accident.

All cases were divided into two groups: a sinus tarsi approach group (28 patients) and an extensile lateral approach group (37 patients). According to the Sanders classification, 17 cases of type II and 11 of type III were included in the sinus tarsi group, and 15 of type II and 22 of type III were included in extensile lateral approach group. No significant difference was observed between the two groups (Table 1). The extremities of all patients were elevated and ice was applied in an effort to minimize swelling and avoid blisters. The interval between trauma and surgical intervention was recorded.

Table 1.

Demographic data of patients in both groups

Groups	Age (years)	Gender	Injury pattern		Sanders classification
			Fall from height	Accident	II	III
Extensile lateral approach group	43.8 (26–64)	9F/28M (24.3%F)	24	13	15	22
Sinus tarsi approach group	43.6 (21–65)	7F/21M (25.0%F)	23	5	17	11
P‐value	0.181	0.950	0.107		0.123

F, female; M, male

All operative procedures were undertaken by surgeons who had performed foot and ankle surgery for at least 10 years. All of the data were measured and analyzed by another surgeon who did not participate in the operations.

Operative Procedure

Sinus Tarsi Approach

Surgery was performed under general or spinal anesthesia and the patient was placed in a lateral position with a tourniquet at the thigh. An approximate 2–3‐cm incision was made along a line from the tip of the fibula to the base of the fourth metatarsal (Fig. 1). Attention should be paid to protect the sural nerve and the peroneal tendons. The calcaneofibular ligament was dissected and split sharply, which allowed exposure of the sinus tarsi and the anterolateral wall, and then the fragments of the subtalar joint were cleared. Two 2.5‐mm Kirschner wires were placed into the calcaneal tuberosity and the head of the talus from medial to lateral, respectively, correcting the varus deformity using a tibia distraction device (Johnson & Johnson, USA) and restoring the length of the calcaneus under the X‐ray. Then the posterior facet fragments were reduced with the combination of direct visualization and C‐arm fluoroscopic guidance. Once the fractures were reduced, a temporary Kirschner wire fixation was used to hold the fragments in place. Generally, one screw was directed from lateral to medial, fixing the depressed posterior facet on the medial cortical bone. Two fully threaded cannulated screws were then placed percutaneously from the posterior aspect of the calcaneal tuberosity into the anterior aspect of the calcaneus. If there was not enough support for the posterior facet, we changed to using a micro plate and screw fixation; Acumed plates were used in 2 patients in this group. Fluoroscopy was used for the entire procedure. Once rigid fixation was achieved, the wound was closed with interrupted sutures. There was no need for drains and plaster fixations (Fig. 2).

Figure 1.

Diagrammatic depiction of sinus tarsi approach.

Figure 2.

A 63‐year‐old woman fell from height that caused an intra‐articular fracture of the left calcaneus. (A, B) Preoperative radiographs of lateral and axial views of the intra‐articular calcaneal fracture. (C) Preoperative computed tomography (CT) showing a Sanders type II intra‐articular calcaneal fracture. (D, E) Operative photograph showing the sinus tarsi approach combined with the medial distraction technique. (F, G) Half‐year follow‐up radiographs and (H) half‐year follow‐up CT scan showing that a good reduction was obtained.

Extensile Lateral Approach

The standard extended lateral approach with L‐shaped incision was made in this group, which originated vertically from 5 cm over lateral malleolus or the midpoint between the fibula and Achilles tendon and ended on the base of the fifth metatarsal (Fig. 3). The incision is made directly to the bone at the corner to create a full‐thickness flap. Attention must be paid to protect the sural nerve and peroneal tendons as well. Once the lateral wall of the calcaneus and the subtalar joints were exposed, the full‐thickness flap was held in place with three or four 2.0‐mm Kirschner wires. The fragments and free tissue in the joint space were then cleared up. One 3.5‐mm Steinmann pin was placed into the calcaneal tuberosity to correct the varus deformity and achieve anatomical reduction under C‐arm fluoroscopy, restoring the length and width of the calcaneus. Lateral plates designed for the calcaneus were generally used for fixation, the drains were inserted into the anterior and posterior incision, and then the wound was closed with interrupted sutures followed by compression bandaging (Fig. 4).

Figure 3.

Diagrammatic depiction of extensile lateral approach.

Figure 4.

A 41‐year‐old man fell from height that caused an intra‐articular fracture of the left calcaneus. (A, B) Preoperative radiographs of lateral view and axial view of intra‐articular calcaneal fracture. (C) Preoperative computed tomography (CT) scan showing Sanders type II intra‐articular calcaneal fracture. (D) Operative photograph showing the location of the extensile lateral approach. (E) Photograph showing open reduction and internal fixation with conventional plate via L‐shaped lateral approach. (F) Postoperative CT scan showing that the surface of the subtalar joint was smooth. (G, H) Half‐year follow‐up radiographs showing that good reduction was obtained.

Postoperative Management

Postoperatively, the affected limbs of all patients were elevated to minimize swelling. Passive motion without weight bearing was begun approximately 24 h after the surgery and isometric exercise for lower limb muscle after 48 h. Antibiotics were proactively used once. Drainage was removed when the liquid inside was less than 10 mL/day, keeping the incision dry and changing dressing every 2 days until sutures were removed approximately 2 or 3 weeks after surgery. The wound healing was observed and early wound complications were recorded. Full weight bearing was initiated after 3 months.

Evaluation Methods

Radiographs were taken postoperatively to measure the calcaneal anatomical parameters, including the Böhler angle, the Gissane angle, and the calcaneal varus angle, and CT scans were taken to assess whether anatomical reduction was achieved. In general, patients were told to return to the office for a research visit, which included a clinical examination and radiographic examination 1, 3, 6, and 12 months after surgery. The postoperative function was evaluated using the ankle and hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS)17.

Statistical Analyses

Measurement data were analyzed using SPSS 20.0 software (SPSS, IL, USA) and expressed as mean ± standard deviation. Data comparison in the same group was analyzed by paired t‐test, while data comparison in different groups was performed using the independent sample t‐test. Comparison of wound complications in two groups was analyzed by Fisher's exact test. A P‐value <0.05 was considered statistically significant.

Results

General Results

A total of 65 patients were followed up in our study; the average period of follow‐up was 14.3 months in the minimal invasive group and 14.9 months in the extensile lateral approach group. Average time delay from injury to surgery in the sinus tarsi approach group was 4.9 days and that of the extensile group was 7.2 days (P = 0.208). The operative time of the sinus tarsi approach group (77.3 ± 7.4 min) was a little shorter than that of the extensile incision group (83.1 ± 8.4 min); this difference was not statistically significant (P > 0.05). The average seroma volume of drainage after surgery via extensile L‐shape incision was 184.3 mL.

Clinical Results

All patients gained bone union till the last follow‐up; the fractures were healed at approximately 10 weeks. At last follow‐up, the average AOFAS ankle and hindfoot score of the sinus tarsi approach group was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7, while the extensile lateral approach group was 83.2 ± 5.3 and 2.3 ± 1.0 respectively, there were no significant differences (P > 0.05, Table 2).

Table 2.

Clinical outcome and functional scores at final follow‐up (mean ± SD)

Groups	Waiting time (days)	Operative time (min)	Wound complication (cases)	AOFAS	VAS
Sinus tarsi approach group	4.9 ± 1.0	77.3 ± 7.4	1	88.4 ± 6.6	1.9 ± 0.7
Extensile lateral approach group	7.2 ± 1.5	83.1 ± 8.4	5	83.2 ± 5.3	2.3 ± 1.0
t‐value	7.079	2.931	–	3.508	1.659
P‐value	0.208	0.219	0.05	0.296	0.212

Radiologic Results

An axial view radiograph of the calcaneus was routinely taken, but if it was too difficult for patients to take it in a standing position, we used a measurement technique to represent the angle between the posterior facet and the long axis of calcaneus, using the lateral malleolus and longitudinal bone trabeculae of the posterior calcaneal tubercle as references to obtain the calcaneal varus angle18(Fig. 5). The results showed that there were obvious changes in the Böhler angle, the Gissane angle, and the calcaneal varus angle, compared with preoperative values (Tables 3, 4), which were statistically significant, while the corrected values of the Böhler angle and the Gissane angle were not statistically significant (P > 0.05), but that of the calcaneal varus angle between the two groups was statistically significant (t = 10.353, P = 0.037; Table 5).

Figure 5.

X‐ray calcaneus axial view showing line a representing the articular surface of the posterior calcaneal facet. Line b was drawn parallel along the longitudinal bone trabeculae of the posterior calcaneal tubercle and represents the anatomical calcaneal long axis. Angle α is obtained.

Table 3.

Radiographic parameter of sinus tarsi approach group (mean ± SD, degrees)

Period	Böhler angle	Gissane angle	Calcaneal varus angle
Preoperative	16.7 ± 3.8	95.7 ± 9.5	12.7 ± 2.5
Postoperative	27.2 ± 2.7	125.4 ± 4.1	1.5 ± 0.7
t‐value	13.750	20.520	23.528
P‐value	<0.001	<0.001	<0.001

Table 4.

Radiographic parameters of extensile lateral approach group (mean ± SD, degrees)

Period	Böhler angle	Gissane angle	Calcaneal varus angle
Preoperative	16.1 ± 3.5	94.2 ± 8.6	12.4 ± 3.0
Postoperative	26.5 ± 2.7	126.2 ± 5.0	3.9 ± 2.6
t‐value	14.487	24.421	18.732
P‐value	<0.001	<0.001	<0.001

Table 5.

Radiographic parameters of the corrected value of each angle (mean ± SD, degrees)

Groups	Böhler angle	Gissane angle	Calcaneal varus angle
Sinus tarsi approach group	10.5 ± 4.0	29.7 ± 7.7	11.2 ± 2.5
Extensile lateral approach group	10.4 ± 4.4	32.1 ± 8.0	5.6 ± 1.8
t‐value	0.076	1.211	10.353
P‐value	0.570	0.788	0.037

Complications

Only 1 patient had superficial infection in the minimally invasive group. Three patients developed partial skin flap necrosis and 2 had superficial infections in the extensile lateral approach group, which were resolved by changing dressing. Three patients in the sinus tarsi approach group and 7 in the extensile lateral approach group suffered from different degrees of subtalar joint stiffness at last follow‐up. Another 2 patients in the extensile lateral approach group complained about the discomfort of the internal fixation; both had an additional operation to remove the internal fixation at 12 months postoperatively. Another 4 patients in the extensile lateral approach group had developed hindfoot varus deformity at last follow‐up, none of whom have undergone a revision surgery so far.

Discussion

The optimal management of displaced intra‐articular calcaneal fractures remains controversial. Early in the last century, surgeons raised doubts constantly about whether it was necessary to treat calcaneal fractures operatively5. With the advent of CT scanning and the introduction of antibiotics, surgeons have been able to obtain better outcomes with operative intervention. Nowadays, the lateral extensile approach is considered the gold standard approach for displaced intra‐articular calcaneal fractures, which provides great visualization of fractures and enough space to place the plate; however, postoperative complications include incision infection, skin flap necrosis, and osteomyelitis16, 19, 20, 21, which bother surgeons. To minimize soft tissue trauma, surgeons have developed alternative approaches, such as percutaneous, arthroscopically‐assisted, and small incision techniques. In particular, the minimally invasive sinus tarsi approach has been widely recognized in the past a decade13, 14, 22. Using this approach, not only are the surfaces of the subtalar joint and the calcaneocuboid joint exposed, but also damage to soft tissue is reduced, with a low incidence of postoperative complications. However, operative indication excludes severe comminuted calcaneal fractures because anatomic reduction and stable fixation must be achieved for these fractures.

Mechanism of Fractures

Calcaneus is the largest tarsal bone of the foot, and an important structure of the medial and lateral longitudinal arches, and maintains the stability of the foot23. Intra‐articular calcaneal fractures account for approximately 75% of calcaneal fractures, most of which are caused by high‐energy injuries such as injuries from falling from height and traffic injuries24. The stress acting on the calcaneus usually produces an original fracture line, which divides the bone into two big parts: the anteromedial fragment and the posterolateral fragment. The former includes the anterior and middle facets, the sustentaculum tali, and a part of the posterior facet, and, thanks to the connection of interosseous and deltoid ligaments, the position of this part is relatively stable. The latter consists of the calcaneal tuberosity, the lateral wall and part of the posterior facet. This part is linked with the Achilles tendon. The tension of the Achilles tendon causes the calcaneus to move into the varus position and common pathological changes such as the apophysis of the external wall, and shortening and widening of the calcaneus25.

Advantages

To treat the intra‐articular calcaneal fractures, whether through a traditional approach or a minimally‐invasive approach, it is vital to restore the articular surfaces, and the correction of the alignment cannot be ignored, either26. Calcaneal varusmal union is often caused by improper alignment correction, leading to the ingression of the gravity of the lateral column's center, which makes the fifth metatarsal carry more weight and causes persistent pain. To correct the varus deformity, one Steinmann pin is usually placed into the calcaneal tuberosity with assistants pulling to restore the fractures. This method is suitable for the “L” shape incision that can fully expose the lateral wall of the calcaneus, but for the limited sinus tarsi incision, there tends to be insufficient reduction. In addition, it is difficult to maintain the position effectively with tractive reduction, and the reduction will be lost after internal fixation, which leads to reduction again, extending the time of surgery and increasing the risk of wound healing. At this point, the stable medial distraction device is particularly important. We chose to use the medial distraction technique when we treated intra‐articular calcaneal fractures via sinus tarsi approach; the advantage of this technique is that it can distract the medial column gradually, and maximumly provide calcaneal anatomical reduction with fluoroscopic guidance. Not only does it correct the alignment and restore length and width, it also helps to expose the posterior calcaneal facet, to some extent makes up for the deficiencies of sinus tarsi approach, exposure of which is insufficient, and provides appropriate conditions for reduction. Due to the effect of continuous traction of the tibia distraction device, the position of fixation will not be lost. At the same time, this technique also shortens the operative time effectively, relieves the tourniquet reaction, and reduces the risk of surgical wound complications.

In general, the sinus tarsi approach combined with the medial distraction technique can only apply to Sanders type II and III calcaneal fractures, while for Sanders type IV and severe crushing fractures we use the extensile lateral approach which could offer stabilization of fractures by internal fixation plates. In our study, all fractures were type II and type III; there was no looseness or shift of internal fixation, with good effects in the sinus tarsi approach group at last follow‐up. However, 4 patients developed hindfoot varus deformity in the extensile lateral approach group, and the corrected value of the calcaneal varus angle is statistically significant, which means that medial distraction technique is truly helpful. Considering the early complications, there was only 1 patient who had superficial infection in the minimally invasive group, while partial skin flap necrosis and superficial infection occurred in 5 cases in the traditional group, with a complication rate of 13.5%. The result lay in that the routine approach disrupted the blood supply to the lateral flap of calcaneus, which led to the high incidence of complications. In 2013, Kline et al. reported a retrospective review of 112 intra‐articular calcaneal fractures which were treated using the extensile lateral approach and the minimally invasive sinus tarsi approach; the rate of wound complication was 29.1% and 6.1%, respectively, and 25.8% of the patients needed secondary surgeries10. Our study showed that there were a total of 10 patients who had subtalar joint stiffness with no pain; the result of either group was better than that reported in Kline's study. In 2014, Abdelazeem et al. presented their results for 33 intra‐articular calcaneal fractures treated with screw fixation using the sinus tarsi approach; the mean AOFAS score was 91.7, with excellent‐to‐good results obtained in 93% of cases, which was similar to our results27. However, 1 patient had a postoperative superficial wound infection and another patient had a transient period of sural nerve dysthesia, which we deduced may have been caused by the difference in the operative time. We used the medial distraction technique to correct alignment in the minimally invasive group, and the mean operative time was 77.3 min. However, the mean operative time of Abdelazeem's reporting was 90 min. The longer the operative time was, the higher the rate of wound infection would be. The mean time delay from injury to surgery of the sinus tarsi approach group was 4.9 days; surgeons once reported that the wound complication rate increased when using the invasive approach, delaying definitive fixation of closed intra‐articular calcaneal fractures. The incidence rate of postoperative complications was positively associated with the waiting time28.

Technical Points

When treating the intra‐articular calcaneal fractures using the sinus tarsi approach with the assistance of the medial distraction technique, we should pay attention to the following points. First, it is essential to take a CT scan before reduction of complex Sanders type III fractures, because the minimally invasive incision cannot expose fracture lines completely. Second, we recommend restoring the medial column to correct the varus deformity first, placing two 2.5‐mm Kirschner wires into the calcaneal tuberosity and the head of the talus vertically, and observing the change of angle between the two wires to correct the axial line of the calcaneus. Third, we tried our best to make the medial bony cortex continuous or even valgus slightly with fluoroscopic guidance, and to lock the distraction device to prevent loss of the reduction; it was reported that the valgus inclination stabilizes the foot during gait25. Fourth, excessive pressure would result in shortening of the calcaneus when fixating with two vertical screws. Fifth, because the strength of the cannulated screw is inferior to the plate, it should be considered cautiously in regards to weight‐bearing exercise and the healing of fractures. In this study patients started ankle joint function exercises after 4 weeks, and full weight bearing after 10 weeks. Sixth, early weight bearing is forbidden to avoid the loss of the Böhler angle and the Gissane angle, and the collapse of the articular surface. All the operations in this study were performed by experienced surgeons, and mastering this technique was challenging.

Limitations

During surgery, there may be some potential risks when implanting the wire into calcaneal tuberosity and talus. Even though we avoid the tarsal tunnel and other important structures, the procedure still causes soft tissue trauma, which to some extent increases the rate of postoperative incision infection, and it is possible to injure the bone of osteoporosis patients. Furthermore, this was a retrospective study, the cases were limited, and follow‐up periods also tended to be short, which led to bias of data. In addition, we could not analyze the long‐term curative effect on the patients, which remains to be further studied prospectively and randomly.

Conclusions

In conclusion, the sinus tarsi approach combined with the medial distraction technique is a reliable treatment for Sanders type II and III calcaneal fractures. This method exposes the surfaces of subtalar joint adequately and recovers the Böhler angle and the Gissane angle well. In addition, it correctly aligns the calcaneus, and reduces the incidence of wound complications.