Percutaneous Cannulated Screw Fixation vs. Open Reduction and Plate Fixation for Displaced Intraarticular Calcaneal Fracture: A Two-Center Retrospective Propensity-Matched Analysis.

Percutaneous Cannulated Screw Fixation vs. Open Reduction and Plate Fixation for Displaced Intraarticular Calcaneal Fracture: A Two-Center Retrospective Propensity-Matched Analysis. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Percutaneous Cannulated Screw Fixation vs. Open Reduction and Plate Fixation for Displaced Intraarticular Calcaneal Fracture: A Two-Center Retrospective Propensity-Matched Analysis. Qingbing Jiang, Yifeng Shang, Xiong Liao, Wei Su This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6237941/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose The optimal surgical strategy for the treatment of displaced intra-articular calcaneal fractures remains controversial.The purpose of this retrospective cohort study was to compare the clinical and radiologic outcomes of open reduction and plate fixation (ORPF) via the sinus tarsi approach versus percutaneous cannulated screw fixation (PCSF) in patients with displaced intra-articular calcaneal fractures with follow-up to 2 years. Methods A retrospective analysis was performed on the records of all patients with displaced intra-articular calcaneal fractures (Sanders types II and III) who were admitted to two level I trauma centers between January 2018 and December 2022. Data were analyzed using propensity score matching (PSM) at a 1:1 ratio. The primary outcome was assessed using the AOFAS score for evaluating ankle function. Secondary outcomes included operative time, postoperative VAS, wound complication rates, and hardware removal rates. Radiological outcome assessment was conducted based on X-rays taken preoperatively and 3 months post-injury. Results A total of 143 patients were included in the analysis. We successfully matched 62 patients in the ORPF cohort with 62 patients in the PCSF cohort using PSM. At 24 months, there was no significant difference in the AOFAS scores between the two groups ( P > .05); similarly, there were no significant differences in radiological outcomes at 3 months postoperatively (P > .05). However, the PCSF group had significantly lower operative time (65 ± 35 min vs 95 ± 40 min, P < .01), postoperative VAS score (5 ± 1 vs 8 ± 1.5, P < .05), wound complication rates (3.2% vs 9.6%, P < .01), and hardware removal rates (14.5% vs 0, P < .01) compared to the ORPF group. Conclusion In this study, we found that both surgical procedures resulted in satisfactory ankle function and radiological outcomes. The PCSF group was associated with lower VAS scores, fewer wound complications, a lower reoperation rate, and no cases requiring hardware removal. Intra-articular calcaneal fractures Percutaneous fixation Cannulated screws Open reduction Figures Figure 1 Figure 2 1 Introduction Intra-articular calcaneal fractures are serious injuries that, if inadequately treated, can result in chronic pain, stiffness, and hindfoot deformity[ 1 ]. Most displaced intra-articular calcaneal fractures are typically treated with surgical intervention to achieve superior outcomes[ 2 ]. Various surgical methods for reduction and fixation are available, such as plates, cannulated screws, and intramedullary nails.A classical procedure is open reduction and internal fixation (ORPF) with plates, which is performed through the classic extended L-shaped lateral approach, allowing for comprehensive visualization and restoration of the calcaneal anatomy. However, excessive exposure can often result in soft tissue complications. Many surgeons have adopted less invasive surgical approaches, such as the sinus tarsi approach and multiple percutaneous incisions, to improve outcomes. Alternatively, As a minimally invasive technique, percutaneous cannulated screw fixation (PCSF) offers significant advantages, including reduced postoperative pain, fewer soft tissue complications, and shortened rehabilitation period[ 3 ]. However, it relies on X-ray-assisted indirect reduction, which raises concerns about the quality of reduction and postoperative functional recovery. Objectives The purpose of this study was to investigate the clinical and radiologic outcomes of the PCSF for displaced intra-articular calcaneal fractures and compare these to a comparator cohort of patients managed ORPF through sinus tarsi approach. 2 Materials and methods 2.1 Study Design and Setting This is a retrospective cohort study of consecutive patients admitted to two Level I trauma centers (The First Affiliated Hospital of Guangxi Medical University, Nanning, P.R. China and Changsha Central Hospital, Changsha, P.R. China.) with displaced intra-articular calcaneal fractures from January 2018 to December 2022. The study followed the STROBE guidelines for observational research[ 4 ]. 2.2 Participants Patients over 18 were eligible if they had a fresh displaced intra-articular calcaneal fracture that underwent surgical treatment and could complete outcome questionnaires. Exclusion criteria included open calcaneal fractures, polytrauma, and cognitive impairments (Fig. 1 ). 2.3 Data source The primary outcome questionnaires were administered during routine follow-up visits in the outpatient clinic, with a minimum follow-up period of 24 months. The secondary outcome questionnaires, including the surgical duration and VAS score, were completed on the first postoperative day; the status of incision complications was assessed two weeks postoperatively; the reoperation rate and hardware removal rate were recorded at one year postoperatively. Baseline demographic data, including age, sex, mechanism of injury, smoking status, and the presence of comorbid diabetes, were obtained from the clinical case database. The X-ray and CT data for each patient were discussed in a meeting attended by two foot and ankle specialists, one trauma orthopedic surgeon, and one radiologist. The preoperative imaging of the patients was reviewed to determine the parameters of radiographic deformity and fracture classification.The imaging data at 24 weeks postoperatively were used to assess the radiographic outcomes. The fractures were classified according to the Sanders classification[ 5 ]. Radiographic deformity was assessed using the Böhler’s angle, Gissane’s angle, and posterior facet inclination angle. 2.4 Surgical procedure ORIP group The patient was positioned in the lateral decubitus position, and the fracture site was exposed via a sinus tarsi approach[ 6 ]. The articular surface was reduced under direct visualization, correcting the Gissane’s angle, Böhler’s angle, and the shape of the calcaneus, followed by fixation with a plate (Wego, China) . PCSF group The patient was positioned in the prone position, and the surgery was performed under fluoroscopic guidance using a C-arm. Percutaneous reduction was achieved by inserting a Steinmann pin into the posterior calcaneal block to elevate the posterior articular surface, or by using a self-made calcaneal distractor to correct the Gissane’s angle, Böhler’s angle, and the shape of the calcaneus. Fixation was performed with percutaneous cannulated screws (Wego, China). 2.5 Outcome Measurement The primary outcome measure was the AOFAS score at 24 months. The AOFAS score is a pivotal tool in the evaluation of foot and ankle health, providing a standardized measure for assessing treatment efficacy and outcomes[ 7 ]. The secondary outcome measures included operative time, VAS score postoperatively, wound complications (defined as surgical site infection, necrosis of the skin, or dehiscence), reoperation (defined as implant failure, severe joint pain requiring arthrodesis, deep infection requiring debridement, and other salvage procedures.) rates, and hardware removal. The measurements of radiographic outcomes include Gissane’s angle, Böhler’s angle, and posterior facet inclination angle. 2.6 Statistical Analysis First, normality of the data was assessed using the Shapiro-Wilk test and Q-Q plots. Propensity score matching was performed using a 1:1 greedy nearest neighbour method, incorporating baseline covariates such as age, sex, Sanders classification, initial Böhler’s angle, Gissane’s angle, mechanism of injury, and comorbidities. To test the success of the matching procedure, standardised mean differences were calculated to compare continuous and categorical baseline covariates between the ORPF and PCSF groups. Univariate analysis was conducted to assess differences in baseline covariates between the ORPF and PCSF cohorts, ensuring group equality in the matching process. Statistical differences were examined using chi-squared tests (χ²) for categorical variables and independent samples t-tests for continuous variables. A P value < 0.05 was defined as statistically significant. All analyses were performed with SPSS 29 Statistics (IBM, USA). 2.7 Bias We made efforts to eliminate bias at each stage of the study but were unable to address the potential selection bias associated with treatment allocation. 3 Results 3.1 Participants Between January 2018 and December 2022, 133 patients with displaced intra-articular calcaneal fractures were treated at two level 1 trauma centers and met the inclusion criteria. After a minimum of 2 years of follow-up, with 8 excluded due to loss to follow-up and 1 failure to match. Data were available for 124 patients (93.2%), Of these, 62 underwent open reduction and internal fixation (ORPF), matched 1:1 with 62 from the percutaneous screw fixation (PCSF) group (Fig. 2 ). Propensity score matching revealed no significant differences in baseline characteristics between the cohorts (Table 1 ). Table 1 Baseline characteristics in the matched study cohorts after PSM. Variable ORIF group (n = 62) PCSF group (n = 62) P -value Age, mean (SD) 41.0 (19) 44.6 (15.8) .31 a Gender Male, n (%) 39 (62.9) 36 (58.1) .16 a Female, n (%) 23 (37.1) 26 (41.9) .11 a Mechanism of injury Fall, n (%) 41 (66.1) 45 (72.6) .17 a Traffic accident, n (%) 21 (33.9) 17 (27.4) .19 a Sanders classification Type II, n (%) 29 (46.8) 35 (56.5) .15 a Type III, n (%) 33 (53.2) 27 (43.6) .14 a Radiographic deformity, mean (SD) Gissane’s angle 86.4 (19.3) 88.1 (18) .4 a Böhler’s angle 9.8 (5.5) 10.5 (7.3) .31 a Comorbidities, n (%) Smoking status 21 (33.9) 14 (43.8) .31 b Diabetes 4 (6.5) 6 (9.7) .39 b Peripheral vascular disease 2 (3.2) 1 (1.6) .26 a Independent samples t test. b Pearson χ 2 test. 3.2 Primary Outcome At 24 months, there were no significant differences in AOFAS scores between the two groups. Both techniques yielded satisfactory outcomes (Table 2 ). Table 2 Comparison of primary outcomes, secondary outcomes, and radiographic outcomes. Variable ORPF group PCSF group Difference (95% CI) P -value Primary outcomes AOFAS score, mean (SD) 87.5 88.9 1.4 (0.7–2.1) < .01 Secondary outcomes Operative time (min), mean (SD) 95 (40) 65 (35) 30 (25–35) < .01 VAS postoperatively, mean (SD) 5 (1) 8 (1.5) 3 (2.5–3.5) < .05 Wound complications, n (%) 6 (9.6) 2 (3.2) < .01 Hardware remove, n (%) 9 (14.5) N/A < 0.1 Re-operation, n (%) 2 (3.2) 1 (1.6) .16 Radiographic outcomes Böhler’s angle, mean (SD) 31.5 (7.5) 27.4 (6.8) .21 Gissane’s angle, mean (SD) 130.5.4 (7) 128 (5.5) .29 3.3 Secondary Outcomes The PCSF group had lower operative time, postoperative VAS scores, wound complication rates, and reoperation rates. There were no significant differences in radiographic outcomes between the two groups (Table 2 ). The ORPF group had significantly higher incision complications compared to the PCSF group, including 2 cases of skin edge necrosis, 1 case of flap necrosis requiring transferred flap repair, 2 cases of superficial infections that were cured with antibiotics, and 1 cases of deep infections that required debridement and removal of the implants. In contrast, the PCSF group had only 2 cases of superficial incision infection, which were cured after dressing changes.It is worth noting that the ORPF group had 10 cases that required removal of internal fixation devices due to skin irritation and footwear discomfort, whereas there were no such complications in the PCSF group.There were 2 cases in the ORPF group and 1 case in the PCSF group that required ankle arthrodesis due to severe painful arthritis. 4 Discussion Treatment options for intra-articular calcaneal fractures remain controversial[ 8 ]. Although non-surgical treatment may yield good results, for high-grade fractures, achieving anatomical or near-anatomical reduction through surgery has a positive impact on outcome[ 9 ]. High-quality reduction can enhance long-term outcomes of intra-articular fractures, and correcting intra-articular step-offs is crucial for achieving optimal functional results[ 10 ]. In the past, excellent reduction was typically achieved through extensive exposure and direct visualization, but this approach resulted in more complications[ 11 ].With the in-depth study of calcaneal anatomy and biomechanics, advancements in minimally invasive techniques for calcaneal fractures represent a paradigm shift in surgical intervention methods[ 12 ]. Compared to traditional open surgery, minimally invasive surgery (MIS) involves minimizing soft tissue disruption and allowing for faster recovery. Percutaneous fixation methods, including arthroscopic assistance[ 13 ], computer navigation[ 14 ], and robotic assistance[ 15 ], are at the forefront of MIS for treating calcaneal fractures. These techniques involve smaller incisions, allowing for the insertion of specialized instruments and implants under the guidance of imaging technology[ 16 ]. MIS aims to achieve stable fracture fixation while potentially decreasing complications associated with open surgery. The clinical results of this study are consistent with other research[ 17 – 19 ], showing no significant differences in patient-reported outcome measures (PROMs) when comparing open surgery and minimally invasive surgery for displaced intra-articular calcaneal fractures. Both procedures can effectively reconstruct the traumatic anatomy of the calcaneus, with no significant differences in radiographic outcomes. However, there are some important findings in the observed secondary outcomes of this study. Firstly, the PCSF group had shorter surgical times and lower postoperative VAS scores, which contribute to improved patient satisfaction and facilitate early rehabilitation. Studies have shown that early rehabilitation is beneficial for improving range of motion and outcomes. Secondly, PCSF is more favorable for the calcaneal skin, which originally lacked blood supply. Various methods aim to reduce skin complications, such as selecting optimized incisions, minimally invasive plate osteosynthesis, and improved suturing techniques[ 20 ]. The sinus tarsi approach is a relatively less invasive option that allows direct visualization of the joint surface through a limited incision, and a randomized controlled trial has confirmed its efficacy.[ 21 ]. In comparison, PCSF has the advantage of minimally affecting the pathological and physiological conditions of the local skin, resulting in extremely low rates of soft tissue-related complications. Finally, another notable advantage is that the cannulated screws, being deeply embedded within the bone, do not provoke irritation to the surrounding soft tissues, thereby alleviating concerns about the need to remove the internal fixation due to patient discomfort. However, the PCSF reliance on indirect reduction guided by fluoroscopy poses significant challenges to the surgeon's reduction technique, consequently leading to a steeper learning curve. Strengths The strength of this study resides in the 1:1 propensity score matching, which enables a comparison between two cohorts of patients undergoing different surgical procedures. The inclusion criteria for this study are relatively comprehensive, resulting in a larger sample size compared to other studies. In addition, the loss to follow-up rate is low. Limitations The primary limitation of this study is its retrospective design, which may introduce bias due to the lack of randomization in the allocation process, potentially impacting the study outcomes. Despite propensity score matching, the assignment of patients to treatment groups may still be influenced by selection bias. Other limitations include the follow-up duration, as some patients with post-traumatic arthritis may require arthrodesis after an extended period. Finally, the data were obtained from two centers, and variations in surgical preferences among surgeons may impact the group allocation. Implications This study demonstrates that both ORPF and PCSF techniques can achieve satisfactory clinical outcomes, with PCSF associated with faster postoperative recovery and a lower incidence of complications. Further randomized trials are warranted to elucidate the statistical significance of these findings. 5 Conclusions This study shows that for displaced intra-articular calcaneal fractures of Sanders type II and III, the clinical outcomes of PCSF intervention are statistically similar to those of ORPF, as assessed by patient-reported outcome measures (AOFAS score) and radiographic outcomes. Both surgical techniques can correct calcaneal joint surface displacement and deformity. Importantly, in the PCSF group, the incidence of wound complications and the reoperation rate are significantly lower. Declarations Ethics approval The study was approved by Ethical Committee of our institution. Consent to participate Informed consent was obtained from all patients included in the study. Consent for publication All participants gave their written informed consent to publish the obtained data of the current study. Funding Declaration This research did not receive any external funding. Author Contribution Conception and design: SuAcquisition of data: LiaoAnalysis and interpretation of data: Shang， JiangDrafting of manuscript: JiangCritical revision: Su References L. Zhang, P. Su, J. Li, Complications in the Management of Displaced Intra-articular Calcaneal Fractures: A Systematic Review and Network Meta-Analysis of 2538 Patients, J Foot Ankle Surg 61(6) (2022) 1348-1356. https://doi.org/10.1053/j.jfas.2022.07.001. A. Chirayath, N. Dhaniwala, K. Kawde, A Comprehensive Review on Managing Fracture Calcaneum by Surgical and Non-surgical Modalities, Cureus 16(2) (2024) e54786. https://doi.org/10.7759/cureus.54786. J. Thor, R. Socklingam, C. Kon, Outcomes of Percutaneous Fixation in Intra-articular Calcaneal Fractures, Cureus 16(9) (2024) e68428. https://doi.org/10.7759/cureus.68428. E. von Elm, D.G. Altman, M. Egger, S.J. Pocock, P.C. Gotzsche, J.P. Vandenbroucke, S. 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Osman, Extensible lateral approach versus sinus tarsi approach for sanders type II and III calcaneal fractures osteosynthesis: a randomized controlled trial of 186 fractures, J Orthop Surg Res 20(1) (2025) 8. https://doi.org/10.1186/s13018-024-05345-z. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6237941","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432441459,"identity":"98b7a8e5-4428-489c-8ff3-5ca0d7a854fe","order_by":0,"name":"Qingbing Jiang","email":"","orcid":"","institution":"Guangxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qingbing","middleName":"","lastName":"Jiang","suffix":""},{"id":432441460,"identity":"00024384-d026-4a0e-8258-b2648a22a744","order_by":1,"name":"Yifeng Shang","email":"","orcid":"","institution":"Guangxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yifeng","middleName":"","lastName":"Shang","suffix":""},{"id":432441461,"identity":"31c1d7cc-7d57-4e68-875b-d952d1280b7b","order_by":2,"name":"Xiong Liao","email":"","orcid":"","institution":"University of South China","correspondingAuthor":false,"prefix":"","firstName":"Xiong","middleName":"","lastName":"Liao","suffix":""},{"id":432441462,"identity":"587938e4-35ef-4026-99ff-a2a6e97a3b12","order_by":3,"name":"Wei Su","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsklEQVRIiWNgGAWjYPACCTk29vYDpGkx5uM5k0CaNYnzJBwMiFMqH5H+TJqnwiK9TYIhgeFHxTbCWgzPnDGT5jkjkdsm3XiAsefMbSK0tPewSee2AbXIHEhgZmwjRksz+zPp3H8S6WwSCQbEaZFnbzCTzm2QSCBeiwHPGWPrP8ckDNuAgXyQKL/Iz0h/eHNGTZ28fHv7wQc/Koix5QAS5wAORWi2NBClbBSMglEwCkY0AADtAjamQSG+HAAAAABJRU5ErkJggg==","orcid":"","institution":"Guangxi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Wei","middleName":"","lastName":"Su","suffix":""}],"badges":[],"createdAt":"2025-03-16 13:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6237941/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6237941/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79585984,"identity":"1caae264-410f-410d-bdd3-2fb817e14387","added_by":"auto","created_at":"2025-03-31 12:30:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48344,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient involvement in this study.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6237941/v1/1a9a283139e903bf905bc5e2.jpg"},{"id":79585986,"identity":"663acdae-6def-48bb-83b1-1dfaf439c00a","added_by":"auto","created_at":"2025-03-31 12:30:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":75241,"visible":true,"origin":"","legend":"\u003cp\u003ePCSF and ORIF for displaced intra-articular calcaneal fractures.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6237941/v1/1e552d8d5b108d197de3f619.jpg"},{"id":89304547,"identity":"c9ce4482-5ff8-4c39-b36b-893a0f4ba7ad","added_by":"auto","created_at":"2025-08-18 14:53:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":737431,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6237941/v1/37cc8d8c-9fa9-449c-a33e-be9922407af9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Percutaneous Cannulated Screw Fixation vs. Open Reduction and Plate Fixation for Displaced Intraarticular Calcaneal Fracture: A Two-Center Retrospective Propensity-Matched Analysis.","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eIntra-articular calcaneal fractures are serious injuries that, if inadequately treated, can result in chronic pain, stiffness, and hindfoot deformity[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost displaced intra-articular calcaneal fractures are typically treated with surgical intervention to achieve superior outcomes[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Various surgical methods for reduction and fixation are available, such as plates, cannulated screws, and intramedullary nails.A classical procedure is open reduction and internal fixation (ORPF) with plates, which is performed through the classic extended L-shaped lateral approach, allowing for comprehensive visualization and restoration of the calcaneal anatomy. However, excessive exposure can often result in soft tissue complications. Many surgeons have adopted less invasive surgical approaches, such as the sinus tarsi approach and multiple percutaneous incisions, to improve outcomes. Alternatively, As a minimally invasive technique, percutaneous cannulated screw fixation (PCSF) offers significant advantages, including reduced postoperative pain, fewer soft tissue complications, and shortened rehabilitation period[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, it relies on X-ray-assisted indirect reduction, which raises concerns about the quality of reduction and postoperative functional recovery.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObjectives\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe purpose of this study was to investigate the clinical and radiologic outcomes of the PCSF for displaced intra-articular calcaneal fractures and compare these to a comparator cohort of patients managed ORPF through sinus tarsi approach.\u003c/p\u003e"},{"header":"2 Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design and Setting\u003c/h2\u003e \u003cp\u003eThis is a retrospective cohort study of consecutive patients admitted to two Level I trauma centers (The First Affiliated Hospital of Guangxi Medical University, Nanning, P.R. China and Changsha Central Hospital, Changsha, P.R. China.) with displaced intra-articular calcaneal fractures from January 2018 to December 2022. The study followed the STROBE guidelines for observational research[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants\u003c/h2\u003e \u003cp\u003ePatients over 18 were eligible if they had a fresh displaced intra-articular calcaneal fracture that underwent surgical treatment and could complete outcome questionnaires. Exclusion criteria included open calcaneal fractures, polytrauma, and cognitive impairments (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data source\u003c/h2\u003e \u003cp\u003eThe primary outcome questionnaires were administered during routine follow-up visits in the outpatient clinic, with a minimum follow-up period of 24 months. The secondary outcome questionnaires, including the surgical duration and VAS score, were completed on the first postoperative day; the status of incision complications was assessed two weeks postoperatively; the reoperation rate and hardware removal rate were recorded at one year postoperatively. Baseline demographic data, including age, sex, mechanism of injury, smoking status, and the presence of comorbid diabetes, were obtained from the clinical case database.\u003c/p\u003e \u003cp\u003eThe X-ray and CT data for each patient were discussed in a meeting attended by two foot and ankle specialists, one trauma orthopedic surgeon, and one radiologist. The preoperative imaging of the patients was reviewed to determine the parameters of radiographic deformity and fracture classification.The imaging data at 24 weeks postoperatively were used to assess the radiographic outcomes. The fractures were classified according to the Sanders classification[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Radiographic deformity was assessed using the B\u0026ouml;hler\u0026rsquo;s angle, Gissane\u0026rsquo;s angle, and posterior facet inclination angle.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Surgical procedure\u003c/h2\u003e \u003cp\u003e \u003cem\u003eORIP group\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe patient was positioned in the lateral decubitus position, and the fracture site was exposed via a sinus tarsi approach[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The articular surface was reduced under direct visualization, correcting the Gissane\u0026rsquo;s angle, B\u0026ouml;hler\u0026rsquo;s angle, and the shape of the calcaneus, followed by fixation with a plate (Wego, China) .\u003c/p\u003e \u003cp\u003e \u003cem\u003ePCSF group\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe patient was positioned in the prone position, and the surgery was performed under fluoroscopic guidance using a C-arm. Percutaneous reduction was achieved by inserting a Steinmann pin into the posterior calcaneal block to elevate the posterior articular surface, or by using a self-made calcaneal distractor to correct the Gissane\u0026rsquo;s angle, B\u0026ouml;hler\u0026rsquo;s angle, and the shape of the calcaneus. Fixation was performed with percutaneous cannulated screws (Wego, China).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Outcome Measurement\u003c/h2\u003e \u003cp\u003eThe primary outcome measure was the AOFAS score at 24 months. The AOFAS score is a pivotal tool in the evaluation of foot and ankle health, providing a standardized measure for assessing treatment efficacy and outcomes[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The secondary outcome measures included operative time, VAS score postoperatively, wound complications (defined as surgical site infection, necrosis of the skin, or dehiscence), reoperation (defined as implant failure, severe joint pain requiring arthrodesis, deep infection requiring debridement, and other salvage procedures.) rates, and hardware removal. The measurements of radiographic outcomes include Gissane\u0026rsquo;s angle, B\u0026ouml;hler\u0026rsquo;s angle, and posterior facet inclination angle.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical Analysis\u003c/h2\u003e \u003cp\u003eFirst, normality of the data was assessed using the Shapiro-Wilk test and Q-Q plots. Propensity score matching was performed using a 1:1 greedy nearest neighbour method, incorporating baseline covariates such as age, sex, Sanders classification, initial B\u0026ouml;hler\u0026rsquo;s angle, Gissane\u0026rsquo;s angle, mechanism of injury, and comorbidities. To test the success of the matching procedure, standardised mean differences were calculated to compare continuous and categorical baseline covariates between the ORPF and PCSF groups. Univariate analysis was conducted to assess differences in baseline covariates between the ORPF and PCSF cohorts, ensuring group equality in the matching process. Statistical differences were examined using chi-squared tests (χ\u0026sup2;) for categorical variables and independent samples t-tests for continuous variables. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was defined as statistically significant. All analyses were performed with SPSS 29 Statistics (IBM, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Bias\u003c/h2\u003e \u003cp\u003eWe made efforts to eliminate bias at each stage of the study but were unable to address the potential selection bias associated with treatment allocation.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participants\u003c/h2\u003e \u003cp\u003eBetween January 2018 and December 2022, 133 patients with displaced intra-articular calcaneal fractures were treated at two level 1 trauma centers and met the inclusion criteria. After a minimum of 2 years of follow-up, with 8 excluded due to loss to follow-up and 1 failure to match. Data were available for 124 patients (93.2%), Of these, 62 underwent open reduction and internal fixation (ORPF), matched 1:1 with 62 from the percutaneous screw fixation (PCSF) group (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePropensity score matching revealed no significant differences in baseline characteristics between the cohorts (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics in the matched study cohorts after PSM.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eORIF group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePCSF group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41.0 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.6 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.31\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (62.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (58.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.16\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.11\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMechanism of injury\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (66.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (72.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.17\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraffic accident, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.19\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSanders classification\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType II, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (46.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.15\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType III, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (53.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.14\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRadiographic deformity, mean (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGissane\u0026rsquo;s angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86.4 (19.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.1 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.4\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u0026ouml;hler\u0026rsquo;s angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.8 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.5 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.31\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eComorbidities, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.31\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.39\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral vascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eIndependent samples t test. \u003csup\u003eb\u003c/sup\u003ePearson χ\u003csup\u003e2\u003c/sup\u003e test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Primary Outcome\u003c/h2\u003e \u003cp\u003eAt 24 months, there were no significant differences in AOFAS scores between the two groups. Both techniques yielded satisfactory outcomes (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of primary outcomes, secondary outcomes, and radiographic outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eORPF group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePCSF group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifference (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePrimary outcomes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAOFAS score, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4 (0.7\u0026ndash;2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSecondary outcomes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (25\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS postoperatively, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.5\u0026ndash;3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHardware remove, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-operation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRadiographic outcomes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u0026ouml;hler\u0026rsquo;s angle, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.5 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.4 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGissane\u0026rsquo;s angle, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130.5.4 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Secondary Outcomes\u003c/h2\u003e \u003cp\u003eThe PCSF group had lower operative time, postoperative VAS scores, wound complication rates, and reoperation rates. There were no significant differences in radiographic outcomes between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The ORPF group had significantly higher incision complications compared to the PCSF group, including 2 cases of skin edge necrosis, 1 case of flap necrosis requiring transferred flap repair, 2 cases of superficial infections that were cured with antibiotics, and 1 cases of deep infections that required debridement and removal of the implants. In contrast, the PCSF group had only 2 cases of superficial incision infection, which were cured after dressing changes.It is worth noting that the ORPF group had 10 cases that required removal of internal fixation devices due to skin irritation and footwear discomfort, whereas there were no such complications in the PCSF group.There were 2 cases in the ORPF group and 1 case in the PCSF group that required ankle arthrodesis due to severe painful arthritis.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eTreatment options for intra-articular calcaneal fractures remain controversial[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although non-surgical treatment may yield good results, for high-grade fractures, achieving anatomical or near-anatomical reduction through surgery has a positive impact on outcome[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. High-quality reduction can enhance long-term outcomes of intra-articular fractures, and correcting intra-articular step-offs is crucial for achieving optimal functional results[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the past, excellent reduction was typically achieved through extensive exposure and direct visualization, but this approach resulted in more complications[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].With the in-depth study of calcaneal anatomy and biomechanics, advancements in minimally invasive techniques for calcaneal fractures represent a paradigm shift in surgical intervention methods[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Compared to traditional open surgery, minimally invasive surgery (MIS) involves minimizing soft tissue disruption and allowing for faster recovery. Percutaneous fixation methods, including arthroscopic assistance[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], computer navigation[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and robotic assistance[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], are at the forefront of MIS for treating calcaneal fractures. These techniques involve smaller incisions, allowing for the insertion of specialized instruments and implants under the guidance of imaging technology[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. MIS aims to achieve stable fracture fixation while potentially decreasing complications associated with open surgery.\u003c/p\u003e \u003cp\u003eThe clinical results of this study are consistent with other research[\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], showing no significant differences in patient-reported outcome measures (PROMs) when comparing open surgery and minimally invasive surgery for displaced intra-articular calcaneal fractures. Both procedures can effectively reconstruct the traumatic anatomy of the calcaneus, with no significant differences in radiographic outcomes. However, there are some important findings in the observed secondary outcomes of this study. Firstly, the PCSF group had shorter surgical times and lower postoperative VAS scores, which contribute to improved patient satisfaction and facilitate early rehabilitation. Studies have shown that early rehabilitation is beneficial for improving range of motion and outcomes.\u003c/p\u003e \u003cp\u003eSecondly, PCSF is more favorable for the calcaneal skin, which originally lacked blood supply. Various methods aim to reduce skin complications, such as selecting optimized incisions, minimally invasive plate osteosynthesis, and improved suturing techniques[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The sinus tarsi approach is a relatively less invasive option that allows direct visualization of the joint surface through a limited incision, and a randomized controlled trial has confirmed its efficacy.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In comparison, PCSF has the advantage of minimally affecting the pathological and physiological conditions of the local skin, resulting in extremely low rates of soft tissue-related complications.\u003c/p\u003e \u003cp\u003eFinally, another notable advantage is that the cannulated screws, being deeply embedded within the bone, do not provoke irritation to the surrounding soft tissues, thereby alleviating concerns about the need to remove the internal fixation due to patient discomfort. However, the PCSF reliance on indirect reduction guided by fluoroscopy poses significant challenges to the surgeon's reduction technique, consequently leading to a steeper learning curve.\u003c/p\u003e \u003cp\u003e \u003cem\u003eStrengths\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe strength of this study resides in the 1:1 propensity score matching, which enables a comparison between two cohorts of patients undergoing different surgical procedures. The inclusion criteria for this study are relatively comprehensive, resulting in a larger sample size compared to other studies. In addition, the loss to follow-up rate is low.\u003c/p\u003e \u003cp\u003e \u003cem\u003eLimitations\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe primary limitation of this study is its retrospective design, which may introduce bias due to the lack of randomization in the allocation process, potentially impacting the study outcomes. Despite propensity score matching, the assignment of patients to treatment groups may still be influenced by selection bias. Other limitations include the follow-up duration, as some patients with post-traumatic arthritis may require arthrodesis after an extended period. Finally, the data were obtained from two centers, and variations in surgical preferences among surgeons may impact the group allocation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eImplications\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis study demonstrates that both ORPF and PCSF techniques can achieve satisfactory clinical outcomes, with PCSF associated with faster postoperative recovery and a lower incidence of complications. Further randomized trials are warranted to elucidate the statistical significance of these findings.\u003c/p\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eThis study shows that for displaced intra-articular calcaneal fractures of Sanders type II and III, the clinical outcomes of PCSF intervention are statistically similar to those of ORPF, as assessed by patient-reported outcome measures (AOFAS score) and radiographic outcomes. Both surgical techniques can correct calcaneal joint surface displacement and deformity. Importantly, in the PCSF group, the incidence of wound complications and the reoperation rate are significantly lower.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e The study was approved by Ethical Committee of our institution.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all patients included in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e All participants gave their written informed consent to publish the obtained data of the current study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003cb\u003eFunding Declaration\u003c/b\u003e This research did not receive any external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception and design: SuAcquisition of data: LiaoAnalysis and interpretation of data: Shang， JiangDrafting of manuscript: JiangCritical revision: Su\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eL. Zhang, P. Su, J. Li, Complications in the Management of Displaced Intra-articular Calcaneal Fractures: A Systematic Review and Network Meta-Analysis of 2538 Patients, J Foot Ankle Surg 61(6) (2022) 1348-1356. https://doi.org/10.1053/j.jfas.2022.07.001.\u003c/li\u003e\n\u003cli\u003eA. Chirayath, N. Dhaniwala, K. Kawde, A Comprehensive Review on Managing Fracture Calcaneum by Surgical and Non-surgical Modalities, Cureus 16(2) (2024) e54786. https://doi.org/10.7759/cureus.54786.\u003c/li\u003e\n\u003cli\u003eJ. Thor, R. Socklingam, C. Kon, Outcomes of Percutaneous Fixation in Intra-articular Calcaneal Fractures, Cureus 16(9) (2024) e68428. https://doi.org/10.7759/cureus.68428.\u003c/li\u003e\n\u003cli\u003eE. von Elm, D.G. Altman, M. Egger, S.J. Pocock, P.C. Gotzsche, J.P. Vandenbroucke, S. 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Sanders, Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes, Foot Ankle Int 15(7) (1994) 349-53. https://doi.org/10.1177/107110079401500701.\u003c/li\u003e\n\u003cli\u003eS.R. Lewis, M.W. Pritchard, J.L. Solomon, X.L. Griffin, J. Bruce, Surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures, Cochrane Database Syst Rev 11(11) (2023) CD008628. https://doi.org/10.1002/14651858.CD008628.pub3.\u003c/li\u003e\n\u003cli\u003eR. BUCKLEY, Operative Compared with Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures, (2002).\u003c/li\u003e\n\u003cli\u003eP.V. Giannoudis, C. Tzioupis, A. Papathanassopoulos, O. Obakponovwe, C. Roberts, Articular step-off and risk of post-traumatic osteoarthritis. Evidence today, Injury 41(10) (2010) 986-95. https://doi.org/10.1016/j.injury.2010.08.003.\u003c/li\u003e\n\u003cli\u003eH. Zwipp, S. Rammelt, S. Barthel, Calcaneal fractures--open reduction and internal fixation (ORIF), Injury 35 Suppl 2 (2004) SB46-54. https://doi.org/10.1016/j.injury.2004.07.011.\u003c/li\u003e\n\u003cli\u003eJ. Pang, A. Hussain, M. Yan, K. Kapur, G. Solomou, C. Brassett, C. Pasapula, A.R. Norrish, The cadaveric research model for calcaneus fractures: A scoping review of biomechanical, anatomical, radiographic and fracture fixation studies, Foot (Edinb) 59 (2024) 102085. https://doi.org/10.1016/j.foot.2024.102085.\u003c/li\u003e\n\u003cli\u003eD. Gao, T.M. Wong, C. Fang, F.K. Leung, X. Li, B. Jia, Y. Wang, B. Yu, Arthroscopic-assisted percutaneous fixation of intra-articular calcaneal fractures using an intraoperative distraction device, J Orthop Surg (Hong Kong) 29(1) (2021) 2309499020979095. https://doi.org/10.1177/2309499020979095.\u003c/li\u003e\n\u003cli\u003eJ. Franke, K. Wendl, A.J. Suda, T. Giese, P.A. Grutzner, J. von Recum, Intraoperative three-dimensional imaging in the treatment of calcaneal fractures, J Bone Joint Surg Am 96(9) (2014) e72. https://doi.org/10.2106/JBJS.L.01220.\u003c/li\u003e\n\u003cli\u003eX. Yuan, K. Tan, J. Hu, B. Zhang, H. Zhang, Does robot-assisted percutaneous hollow screw placement combined with tarsal sinus incision reduction in the treatment of calcaneal fracture perform better at a minimum two year follow-up compared with traditional surgical reduction and fixation?, Int Orthop 47(6) (2023) 1575-1581. https://doi.org/10.1007/s00264-023-05752-7.\u003c/li\u003e\n\u003cli\u003eM. Smith, G. Medlock, A.J. Johnstone, Percutaneous screw fixation of unstable ankle fractures in patients with poor soft tissues and significant co-morbidities, Foot Ankle Surg 23(1) (2017) 16-20. https://doi.org/10.1016/j.fas.2015.11.008.\u003c/li\u003e\n\u003cli\u003eM.R. Bahaeddini, A.R. Konjkav, A. Aminian, P. Tabrizian, S.N. Gravand, S. Amiri, M.S. Mirjalily, H. Tayyebi, F.N. 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Verstappen, M. Poeze, M. Edwards, J. Biert, E. Hermans, Treatment of displaced intra-articular calcaneal fractures: A single-center experience study with 20 years follow-up, Injury 53(10) (2022) 3535-3542. https://doi.org/10.1016/j.injury.2022.06.037.\u003c/li\u003e\n\u003cli\u003eA.A. Fadle, A.A. Khalifa, P.M. Shehata, W. El-Adly, A.E. Osman, Extensible lateral approach versus sinus tarsi approach for sanders type II and III calcaneal fractures osteosynthesis: a randomized controlled trial of 186 fractures, J Orthop Surg Res 20(1) (2025) 8. https://doi.org/10.1186/s13018-024-05345-z.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Intra-articular calcaneal fractures, Percutaneous fixation, Cannulated screws, Open reduction","lastPublishedDoi":"10.21203/rs.3.rs-6237941/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6237941/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe optimal surgical strategy for the treatment of displaced intra-articular calcaneal fractures remains controversial.The purpose of this retrospective cohort study was to compare the clinical and radiologic outcomes of open reduction and plate fixation (ORPF) via the sinus tarsi approach versus percutaneous cannulated screw fixation (PCSF) in patients with displaced intra-articular calcaneal fractures with follow-up to 2 years.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was performed on the records of all patients with displaced intra-articular calcaneal fractures (Sanders types II and III) who were admitted to two level I trauma centers between January 2018 and December 2022. Data were analyzed using propensity score matching (PSM) at a 1:1 ratio. The primary outcome was assessed using the AOFAS score for evaluating ankle function. Secondary outcomes included operative time, postoperative VAS, wound complication rates, and hardware removal rates. Radiological outcome assessment was conducted based on X-rays taken preoperatively and 3 months post-injury.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 143 patients were included in the analysis. We successfully matched 62 patients in the ORPF cohort with 62 patients in the PCSF cohort using PSM. At 24 months, there was no significant difference in the AOFAS scores between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05); similarly, there were no significant differences in radiological outcomes at 3 months postoperatively (P\u0026thinsp;\u0026gt;\u0026thinsp;.05). However, the PCSF group had significantly lower operative time (65\u0026thinsp;\u0026plusmn;\u0026thinsp;35 min vs 95\u0026thinsp;\u0026plusmn;\u0026thinsp;40 min, P\u0026thinsp;\u0026lt;\u0026thinsp;.01), postoperative VAS score (5\u0026thinsp;\u0026plusmn;\u0026thinsp;1 vs 8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5, P\u0026thinsp;\u0026lt;\u0026thinsp;.05), wound complication rates (3.2% vs 9.6%, P\u0026thinsp;\u0026lt;\u0026thinsp;.01), and hardware removal rates (14.5% vs 0, P\u0026thinsp;\u0026lt;\u0026thinsp;.01) compared to the ORPF group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn this study, we found that both surgical procedures resulted in satisfactory ankle function and radiological outcomes. The PCSF group was associated with lower VAS scores, fewer wound complications, a lower reoperation rate, and no cases requiring hardware removal.\u003c/p\u003e","manuscriptTitle":"Percutaneous Cannulated Screw Fixation vs. Open Reduction and Plate Fixation for Displaced Intraarticular Calcaneal Fracture: A Two-Center Retrospective Propensity-Matched Analysis.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-31 12:30:03","doi":"10.21203/rs.3.rs-6237941/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6c76ac7-71fe-400d-88d8-6c40ec843780","owner":[],"postedDate":"March 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T14:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-31 12:30:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6237941","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6237941","identity":"rs-6237941","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}