Medial wall/arthroscopy/posterior facet (MAP) strategy for displaced intra-articular calcaneal fractures: evaluation of a novel minimally invasive protocol in a retrospective comparative cohort.

BACKGROUND

Displaced intra-articular calcaneal fractures (DIACFs) pose substantial challenges due to their complex three-dimensional deformity and the high risk of soft tissue complications. Minimally invasive percutaneous methods and subtalar arthroscopy have emerged to mitigate soft tissue injury, but their limited exposure often hinders reliable reduction of the medial wall. To address these limitations, we developed a novel MAP strategy (Medial wall/Arthroscopy/Posterior facet) that prioritizes a medial-to-lateral sequence to achieve effective and stable reduction.

METHODS

This retrospective analysis included 180 cases of unilateral DIACFs treated between 2022 and 2024. Patients were classified into three groups based on the surgical treatment as follows: arthroscopy-assisted percutaneous screw fixation (MAP, 40 cases), percutaneous screw fixation (PF, 49 cases), and open reduction and internal fixation (ORIF, 91 cases). Outcomes were assessed at 12 months postoperatively, including complications, radiographs, and functional scores using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot score, visual analog scale (VAS) and Maryland Foot Score.

RESULTS

The MAP group exhibited the longest surgical duration (80.0 [70.0, 90.0] min) but had the shortest hospital stay (5.0 [4.0, 6.0] days). The ORIF group experienced a longer preoperative delay (6.0 [6.0, 7.0] days) and had a significantly higher overall complication rate compared to the MAP and PF groups (31.9% vs. 15.0% and 14.3%, p = 0.027). At the 12-month postoperative follow-up, the MAP group demonstrated significantly greater AOFAS scores (84.50 [78.25, 86.00]) compared to the PF group (80.00 [75.00, 84.00], p = 0.029) and the ORIF group (81.00 [74.00, 86.00], p = 0.021). The VAS pain score in the MAP group (2.00 [1.25, 3.00]) was significantly lower than that in the ORIF group (3.00 [2.00, 3.00], p = 0.009). Regarding radiographic assessments, all three groups demonstrated satisfactory postoperative restoration in Böhler's angle, calcaneal height, and calcaneal width compared to preoperative baselines, with no significant intergroup differences observed.

CONCLUSION

In this retrospective cohort study, the MAP strategy was associated with favourable short-term functional outcomes and a low rate of soft-tissue complications in DIACFs.