Minimally Invasive Reverse Traction Using Kirschner Wire Retractor for Sanders II and III Calcaneal Fractures: Clinical Outcomes and Advantages

Minimally Invasive Reverse Traction Using Kirschner Wire Retractor for Sanders II and III Calcaneal Fractures: Clinical Outcomes and Advantages | 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 Minimally Invasive Reverse Traction Using Kirschner Wire Retractor for Sanders II and III Calcaneal Fractures: Clinical Outcomes and Advantages Futian Zhang, Longxin An, Weiqiang Zhang, Wenjing Zhang, Zilong Deng, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8805019/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 This retrospective study evaluated the clinical efficacy of a minimally invasive technique involving reverse traction reduction using a Kirschner wire distractor combined with cannulated screw fixation for treating Sanders type II and III calcaneal fractures. A total of 66 patients were analyzed, with 33 treated using the novel minimally invasive method and 33 treated with conventional open reduction and internal fixation using plates. Compared to the control group, the minimally invasive group showed significantly reduced intraoperative blood loss, operative time, hospital stay, and treatment costs, though it required more intraoperative fluoroscopy. Fracture healing time was comparable between groups. At 3 months postoperatively, radiographic outcomes including Böhler and Gissane angles improved significantly in both groups without significant differences between them. The minimally invasive group experienced lower postoperative pain scores and fewer complications. At final follow-up, this group also demonstrated higher AOFAS ankle–hindfoot scores and a greater rate of excellent and good outcomes. These findings suggest that the described minimally invasive approach is a safe and effective alternative to traditional open surgery, offering advantages in surgical trauma, recovery time, and complication rates, although the increased need for fluoroscopy warrants consideration. Calcaneal fracture Minimally invasive treatment Reverse traction Kirschner wire distractor Screw fixation Figures Figure 1 Figure 2 Figure 3 Introduction As the largest tarsal bone in the human foot, the calcaneus plays a fundamental role in weight-bearing and locomotion due to its unique anatomical and physiological structure. It is essential for daily activities and athletic function. Calcaneal fractures, however, commonly result from axial loading injuries, such as falls from a height, where the talus impacts the calcaneus. Notably, approximately 75% of these fractures are intra-articular, and conservative treatment is associated with a higher risk of complications such as nonunion, post-traumatic arthritis, and joint deformity 1 . Surgical treatment via the traditional lateral "L"-shaped approach has been linked to a significant incidence of postoperative complications, making the management of calcaneal fractures a longstanding challenge in orthopedic surgery 2 . Conventional open reduction and internal fixation (ORIF) techniques often require large incisions, pose a high risk of soft tissue injury, and carry a substantial risk of wound complications, all of which result in increased patient morbidity and prolonged recovery. With continuous advancements in medical technology, the concept of minimally invasive surgery (MIS) has gained widespread acceptance in orthopedics. Minimally invasive techniques for calcaneal fracture management aim to reduce incision size and soft tissue damage, thereby promoting faster recovery and minimizing complications 3 , 4 . These procedures often involve refined techniques such as traction, prying, and clamping, combined with precise surgical instruments, which help to overcome many of the limitations of traditional approaches and provide improved clinical outcomes and patient quality of life. Since January 2024, our department has employed a novel minimally invasive technique for the treatment of Sanders type II and III calcaneal fractures, utilizing a Kirschner wire distractor for reverse traction, closed reduction, and cannulated screw fixation. In this study, we present a comparative analysis of the clinical outcomes between this new technique and conventional closed reduction with cannulated screw fixation. Materials and Methods 1. General Information Between January 2024 and December 2024, a total of 40 patients with calcaneal fractures were treated in our department. After excluding elderly patients (≥ 65 years), those with concomitant fractures, pathological or old fractures, and open fractures, 33 patients met the inclusion criteria. Additionally, from January 2023 to December 2023, 70 patients with calcaneal fractures were admitted to our department; following the same exclusion criteria, 33 patients were randomly selected to serve as the control group. This study was approved by the Institutional Ethics Committee, and informed consent was obtained from all patients. The patients were divided into two groups: the observation group (n = 33), treated with reverse traction using a Kirschner wire distractor combined with closed reduction and cannulated screw fixation; and the control group (n = 33), treated with traditional open reduction and internal fixation using a lateral plate. There were no statistically significant differences between the two groups in terms of sex, age, Sanders classification, side of injury, or mechanism of injury (P > 0.05) (Table 1 ). Table 1 Comparison of Baseline Clinical Characteristics Between the Two Groups Variable Observation Group (n = 33) Control Group (n = 33) t-value p-value Sex 0.25 0.15 Male 31 27 Female 2 6 Age (years) 48.15 ± 9.94 45.42 ± 10.04 1.11 0.27 Fracture Type 0.06 0.80 Sanders Type II 19 20 Sanders Type III 14 13 Injured Side 0.25 0.61 Left 14 12 Right 19 21 Cause of Injury 0.09 0.76 Fall from height 25 26 Traffic accident 8 7 2. Perioperative Management All patients received prophylactic intravenous cefuroxime sodium 30 minutes prior to surgery, with dosage and administration according to the manufacturer’s instructions. On the second postoperative day, patients began isometric muscle contraction exercises. Joint mobility and weight-bearing activities were initiated based on the progress of fracture healing. Rivaroxaban was administered for thromboprophylaxis. Patients underwent routine follow-up every two weeks after surgery. 3. Surgical Technique Anesthesia and Positioning All procedures were performed under combined spinal-epidural anesthesia. Patients in the observation group were positioned prone. The surgical technique followed the principle of “traction, prying, and clamping” to achieve reduction. Observation Group: Minimally Invasive Fixation with Kirschner Wire Distractor, Reverse Traction, and Cannulated Screws In the observation group, a minimally invasive technique combining closed reduction and percutaneous fixation was employed. A 2.0 mm Kirschner wire (K-wire) was transversely inserted into the tibial Chaput tubercle, and another into the posterior tuberosity of the calcaneus. These wires were aligned as parallel as possible and connected bilaterally to a specialized K-wire distractor. The wire ends were bent to prevent slippage. Reverse traction was applied under fluoroscopic guidance to restore calcaneal height ("traction" step). Under Broden views (20°, 30°, and 40°), a 4.0 mm K-wire was inserted from the plantar aspect of the calcaneus to create a channel. Through this, a 2.0 mm K-wire was used to elevate the collapsed posterior articular surface under fluoroscopic monitoring in multiple planes ("prying" step). Once axial fluoroscopy confirmed lateral wall widening, a ~ 1 cm lateral incision was made just above the Achilles tendon insertion. Blunt dissection along the medial calcaneal surface exposed the sustentaculum tali. A custom-designed reduction clamp was inserted percutaneously to compress and reduce the lateral wall ("clamping" step). Reduction quality was confirmed by fluoroscopy, assessing restoration of the Böhler and Gissane angles. In cases with comminution of the posterior tuberosity, additional 4.0 mm K-wires were used for further elevation. Preoperative CT imaging guided individualized reduction strategies based on fracture morphology. Following satisfactory reduction, percutaneous guidewires were inserted ~ 2 cm below the lateral malleolus, posterior to the peroneal tendons, to guide cannulated screw placement. A 4.0 mm cannulated screw was first inserted to compress the subtalar joint surface, followed by additional 5.0 mm screws along the fracture lines. Longitudinal fixation was achieved by inserting screws from the calcaneal tuberosity toward the anterior process. For posterior tuberosity fragments, an additional screw was inserted through the Achilles tendon incision. Final C-arm fluoroscopy confirmed satisfactory reduction and hardware placement. The Achilles tendon incision was closed, while the percutaneous screw sites were left unsutured and covered with sterile gauze. Technical Notes: 1) Avoid suturing small incisions for cannulated screws to prevent soft tissue necrosis. Place the screw for joint surface fixation posterior to the peroneal tendons to prevent sural nerve injury. 3) Perform intraoperative fluoroscopy in axial, lateral, and Broden views to assess reduction. Screw placement should consider fracture line distribution to restore calcaneal support and prevent secondary collapse. Fixation across the subtalar joint with a sustentacular screw ensures articular stability. 5) In difficult reductions, a sinus tarsi approach may be used for direct visualization and reduction. 6) Accurate C-arm positioning and foot positioning before draping are essential for standard imaging. Control Group (Open Reduction and Plate Fixation): A traditional L-shaped lateral approach was used. A single-layer dissection exposed the calcaneus to the periosteum. Two 2.0 mm K-wires were placed anterior and posterior to the subtalar joint for exposure. After restoring the Böhler and Gissane angles, temporary K-wire fixation was performed. Satisfactory reduction was confirmed with fluoroscopy. Fixation was completed using a calcaneal plate and cancellous screws. A drain was placed, and the incision was closed in a single layer and dressed with sterile gauze. 4. Outcome Measures 4. Outcome Measures The following parameters were recorded: length of hospital stay, hospitalization cost, operative time, number of intraoperative fluoroscopy exposures, and postoperative pain visual analogue scale (VAS) scores. Pre- and postoperative measurements of Böhler and Gissane angles were compared within and between groups. Ankle and hindfoot function were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score 5 , with outcomes categorized as excellent (90–100), good (75–89), fair (50–74), and poor (< 50). 5. Statistical Analysis Data processing and analysis were performed using R v4.4.1, along with Zstats v1.0 ( http://www.zstats.net).Continuou s variables were expressed as mean ± standard deviation (X̄ ± s) and compared using independent sample t-tests. Comparisons included hospital stay, cost, operative time, number of fluoroscopies, fracture healing time, postoperative VAS scores, changes in Böhler and Gissane angles, and AOFAS scores. A P-value < 0.05 was considered statistically significant. Results 1. Surgical Outcomes The surgical parameters of the two groups, including operative time (minutes), intraoperative blood loss (mL), and total incision length (cm), are presented in Table 2 . All procedures were performed by the same surgical team. The observation group showed significantly better outcomes than the control group in terms of shorter operative time, reduced blood loss, and smaller total incision length (P < 0.05). However, the number of intraoperative fluoroscopy exposures was significantly higher in the observation group compared to the control group (P < 0.05). Table 2 Comparison of Surgical Parameters Between the Two Groups Parameter Observation Group (n = 33) Control Group (n = 33) t-value p-value Operative time (min) 105.42 ± 23.89 133.52 ± 43.76 -3.24 0.02 Intraoperative blood loss (mL) 48.79 ± 7.81 102.27 ± 18.46 -15.33 < 0.01 Total incision length (cm) 1.49 ± 0.17 15.34 ± 0.66 -117.46 < 0.01 Number of fluoroscopies 81.48 ± 22.25 10.58 ± 2.21 18.21 < 0.01 2. Clinical Data Hospitalization-related parameters, including length of hospital stay and total hospitalization costs, were compared between the two groups. The observation group demonstrated significantly shorter hospital stays and lower overall hospitalization expenses compared to the control group (P < 0.05), as shown in Table 3 . Table 3 Comparison of Hospitalization Parameters Between the Two Groups Parameter Observation Group (n = 33) Control Group (n = 33) t-value p-value Length of hospital stay (days) 6.79 ± 2.47 11.09 ± 3.66 -5.60 < 0.01 Total hospitalization cost (¥) 15,172.18 ± 6,222.93 26,071.21 ± 11,721.30 -4.71 < 0.01 3. Radiographic Outcomes Preoperative and postoperative Gissane and Böhler angles were compared between the two groups. Paired-sample t-tests were used to evaluate the effectiveness of the surgical interventions. Both groups showed statistically significant improvements in Gissane and Böhler angles postoperatively compared to preoperative values (P 0.05). However, both parameters demonstrated significant improvements postoperatively in each group compared to their respective preoperative values, indicating the effectiveness of surgical intervention (P 0.05), suggesting that both surgical approaches are effective in restoring the anatomical structure of the calcaneus. Table 4 Comparison of Radiographic Parameters Between the Two Groups Parameter Group Preoperative (°) Postoperative (°) t-value p-value Gissane angle Observation group 83.76 ± 3.69 132.18 ± 2.94 –65.91 < 0.01 Control group 81.39 ± 3.40 132.00 ± 2.96 –69.75 < 0.01 (t, p) 2.71, 0.09 0.25, 0.80 Böhler angle Observation group 15.79 ± 1.96 30.81 ± 3.13 –26.15 < 0.01 Control group 15.30 ± 2.05 32.79 ± 2.42 –35.09 < 0.01 (t, p) 0.98, 0.33 –2.86, 0.06 4. Follow-up Data All patients in both groups completed effective follow-up. Repeated measures analysis of variance (ANOVA) was performed to analyze changes in VAS scores (Table 5 ). Mauchly’s test of sphericity indicated that the sphericity assumption was met (W = 0.841, P = 0.55), allowing the use of standard repeated measures ANOVA. There were statistically significant differences in VAS scores between the two groups (P < 0.01), across different time points (P < 0.01), and a significant interaction effect between group and time (P < 0.01). As time progressed, VAS scores decreased significantly in both groups (P < 0.01), with a more rapid decline observed in the observation group compared to the control group (Fig. 1 A). Table 5 Comparison of VAS Pain Scores Between the Two Groups Time Point Observation Group (mean ± SD) Control Group (SD) F-value p-value Postoperative Day 1 3.81 ± 0.10 6.15 ± 0.10 486.28 < 0.01 Postoperative Day 3 2.27 ± 0.12 4.58 ± 0.12 183.00 < 0.01 Postoperative Day 7 1.55 ± 0.12 2.30 ± 0.12 19.46 < 0.01 Postoperative Day 14 0.61 ± 0.10 1.06 ± 0.10 11.04 0.01 Source of Variation F-value p-value Between Groups 180.08 < 0.01 Over Time 917.87 < 0.01 Interaction (Group × Time) 118.83 < 0.01 Regarding ankle range of motion, repeated measures ANOVA was also applied to assess changes in dorsiflexion and plantarflexion (Tables 6 and 7 ). Mauchly’s test of sphericity indicated that the sphericity assumption was violated for both dorsiflexion (W = 0.684, P < 0.01) and plantarflexion (W = 0.710, P < 0.01); therefore, the Greenhouse–Geisser correction was applied. There were statistically significant differences in both dorsiflexion and plantarflexion between the two groups (P < 0.01), across time points (P < 0.01), and significant interaction effects between group and time (P < 0.01). Both dorsiflexion and plantarflexion improved significantly over time in both groups (P < 0.01), with the observation group showing a faster recovery rate than the control group (Fig. 1 B and Fig. 1 C.) Table 6 Comparison of Ankle Dorsiflexion Range of Motion (°) Between the Two Groups Time Point Observation Group (mean ± SD) Control Group (mean ± SD) F-value p-value 1 month postoperative 24.15 ± 0.65 18.58 ± 0.65 36.79 < 0.01 3 months postoperative 30.76 ± 0.73 22.09 ± 0.73 70.27 < 0.01 6 months postoperative 31.73 ± 0.63 23.79 ± 0.63 78.86 < 0.01 Source of Variation F-value p-value Between Groups 68.73 < 0.01 Over Time 278.45 < 0.01 Interaction (Group × Time) 15.98 < 0.01 Table 7 Comparison of Ankle Plantarflexion Range of Motion (°) Between the Two Groups Time Point Observation Group (mean ± SD) Control Group (mean ± SD) F-value p-value 1 month postoperative 36.15 ± 0.67 30.97 ± 0.67 29.56 < 0.01 3 months postoperative 42.33 ± 0.65 39.42 ± 0.65 10.12 < 0.01 6 months postoperative 44.27 ± 0.65 40.15 ± 0.65 20.32 < 0.01 Source of Variation F-value p-value Between Groups 23.64 < 0.01 Over Time 363.22 < 0.01 Interaction (Group × Time) 27.54 < 0.01 Case Case 1 A 43-year-old male patient sustained a right calcaneal fracture caused by a fall from height. The fracture was classified as Sanders type II. The patient underwent closed reduction using reverse traction with a Kirschner wire retractor combined with Kirschner wire lever-assisted reduction. Preoperative X-rays, intraoperative reduction status, and postoperative follow-up X-rays are illustrated in Figs. 2. Figure 2. Clinical data of Case 1 . (A, B) Preoperative radiographs of the patient. (C, D) Intraoperative reduction technique demonstrating the surgical approach and incision. (E, F) Intraoperative fluoroscopy to confirm screw placement and quality of reduction. (G, H) Postoperative radiographs on day 1. (I, J) Range of dorsiflexion and plantarflexion of the ankle one month postoperatively. (K, L) Radiographs at 3 months postoperatively. Case 2 A 38-year-old male patient sustained a right calcaneal fracture due to a fall from height. The fracture was classified as Sanders type III. The patient was treated with closed reduction using reverse traction via a Kirschner wire retractor combined with Kirschner wire lever-assisted reduction. Preoperative radiographs, intraoperative reduction status, and postoperative follow-up radiographs are shown in Figs. 3. Figure 3. Clinical data of Case 2 . (A, B) Preoperative radiographs of the patient. (C, D) Intraoperative views showing the surgical incision. (E, F) Postoperative radiographs on day 1. (G, H) Radiographs at 3 months postoperatively. (I, J, K) Ankle dorsiflexion and plantarflexion range of motion at 1 month postoperatively. Discussion Calcaneal fractures are among the more common types of fractures in the skeletal system. When fractures exhibit significant displacement, joint surface incongruity, alterations in calcaneal height, width, or length, or are complicated by neurovascular injuries, traditional open reduction and internal fixation (ORIF) with plate fixation is typically employed. This approach requires a large incision to adequately expose the calcaneus, which results in extensive soft tissue dissection and traction, compromising local blood supply and impairing postoperative soft tissue healing. Consequently, this increases the risk of postoperative complications such as infection and skin necrosis 6 . Moreover, ORIF demands favorable soft tissue conditions around the fracture site, usually necessitating surgery only after swelling subsides and skin wrinkles appear (7–10 days post-injury), but even then, complications like skin necrosis are not uncommon 7 . The extensive periosteal and soft tissue stripping during exposure often leads to considerable intraoperative bleeding, increased local tissue tension, and in severe cases, wound edge necrosis and poor drainage, thereby elevating the incidence of complications such as infection and allergic reactions 6 . Traditional ORIF with plate fixation causes significant damage to the surrounding soft tissues and bone, often leading to increased postoperative pain and thus hindering early functional rehabilitation, ultimately impairing joint recovery. Patients typically require prolonged bed rest and rehabilitation for several months before gradually returning to normal daily activities and work. Although the lateral “L”-shaped incision provides adequate fracture visualization, it also results in substantial soft tissue damage, with severe cases experiencing plate exposure or osteomyelitis as complications 8 . Postoperative prolonged joint immobilization and trauma-induced inflammatory reactions frequently result in subtalar and surrounding joint adhesions and stiffness, reducing ankle joint mobility and causing pain and gait abnormalities. Consequently, minimally invasive calcaneal fracture treatment has increasingly gained favor among clinicians. With advancements in medical technology and deeper understanding of calcaneal fractures, minimally invasive techniques have been gradually incorporated into clinical practice, offering patients alternative therapeutic options. Our study demonstrated that the minimally invasive group showed superior outcomes in terms of preoperative waiting time, operative time, hospital stay, fracture healing time, blood loss, hospitalization costs, and postoperative pain compared to the open reduction group (P < 0.05), consistent with findings by Changjun Guo and colleagues 6 , 9 . This study utilized a bilateral Kirschner wire retractor, which effectively improves surgical outcomes by enabling reverse traction to correct calcaneal height. Fluoroscopy was employed to adjust the traction forces on medial and lateral Kirschner wires, and after height restoration, the axial view of the calcaneus was assessed, revealing widened calcaneal width. This method provides sustained traction to reduce the fractured calcaneus, allowing precise control of the degree of distraction via fluoroscopic guidance, facilitating fracture reduction, correcting varus deformity, and restoring length and height. These results align with related studies 10 – 12 . The Kirschner wire retractor offers several advantages: (1) it expands the talocalcaneal joint space, providing adequate room for closed lever reduction of the collapsed posterior articular surface, with adjustable bilateral traction forces to correct calcaneal varus; (2) it provides continuous traction to maintain restored calcaneal height, length, Böhler’s angle, Gissane’s angle, and varus angle, while the calcaneal width is maintained with forceps until the end of surgery 13 . All patients in the observation group underwent minimally invasive closed reduction and hollow screw fixation, which avoids large incisions and significantly shortens preoperative waiting time. Our results showed that the observation group had shorter preoperative waiting time, operative time, fracture healing time, hospital stay, and lower hospitalization costs and blood loss than the control group (P < 0.05). Postoperative 3-month follow-up demonstrated significant improvement in Böhler’s and Gissane’s angles compared to preoperative values in both groups (P 0.05), indicating that closed reduction and internal fixation can achieve comparable anatomical restoration to open reduction. These findings are consistent with similar studies, supporting faster patient recovery, shorter hospital stays, reduced medical costs, and alleviated patient and family burden, in line with Enhanced Recovery After Surgery (ERAS) principles 1 , 14 – 19 . Early closed reduction with screw fixation was traditionally limited to extra-articular fractures and simple Sanders type II fractures, but with advancements in techniques and treatment concepts, it has been increasingly applied to Sanders type III fractures 12 , 20 . In this study, among 33 patients in the observation group, 14 had Sanders type III fractures, and their AOFAS ankle–hindfoot scores showed no significant difference compared to the control group (P > 0.05), suggesting that the minimally invasive technique is applicable to Sanders type III fractures. Previous studies have emphasized the necessity of surgeons’ thorough preoperative understanding of fracture classification, surgical expertise, and use of advanced imaging to achieve anatomical reduction and precise screw placement, thereby minimizing surgical trauma and soft tissue complications 6 , 9 , 21 . Furthermore, screw fixation results in significantly lower postoperative pain VAS scores compared to plate fixation, enabling earlier rehabilitation and better functional recovery, facilitating faster return to normal life 3 , 22 , 23 . Our study also found that pain scores within the first 3 postoperative days were significantly lower in the observation group than in controls (P < 0.05), which likely reduces psychological burden and promotes more active engagement in rehabilitation, accelerating both physical and mental recovery. Despite its benefits, the minimally invasive approach has limitations: (1) increased fluoroscopy raises radiation exposure for surgeons and patients; (2) lack of direct visualization makes intra-articular fracture reduction challenging, relying on fluoroscopy and Kirschner wire manipulation; (3) the 2.0 mm Kirschner wires offer limited traction force, sometimes resulting in suboptimal calcaneal height and postoperative height loss. Conclusion In summary, minimally invasive reverse traction closed reduction using a Kirschner wire retractor with hollow screw fixation for Sanders II and III calcaneal fractures offers less surgical trauma, shorter hospital stay, lower costs, reduced blood loss, and faster anatomical recovery. It also decreases postoperative pain and soft tissue damage, allowing earlier rehabilitation and quicker return to daily activities. However, it requires high surgical skill and increases intraoperative fluoroscopy and radiation exposure. More studies with larger samples are needed to further validate these findings. Declarations Ethical approval Clinical Trial Number.: MR-37-25-017040 Declaration of competing interest The author declares no conflict of interest. Funding This work was supported by the National Natural Science Foundation of China (No. 82302031), the Natural Science Foundation of Shandong Province (No. ZR2024QH033). Author Contribution Futian Zhang : Writing–original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation. Longxin An : Methodology, Investigation, Formal analysis, Data curation. Weiqiang Zhang : Investigation, Formal analysis, Data curation. Wenjing Zhang : Investigation, Data curation. Zilong Deng : Investigation, Formal analysis. Naibo Feng : Writing–original draft, Visualization, Validation, Supervision, Project administration. Fan Zhang : Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation. Acknowledgments None. Data Availability All data generated or analysed during this study are included in this published article and its supplementary information files. Data is available from the corresponding author on reasonable request. 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Percutaneous reduction and screw fixation for all types of intra-articular calcaneal fractures. Musculoskelet Surg. 2020;105:97–103. 10.1007/s12306-019-00635-w . Ahluwalia R, Lewis TL, Musbahi O, Reichert I. Minimally Invasive Surgery vs Nonoperative Treatment for Displaced Intraarticular Calcaneal Fracture: A Prospective Propensity Score Matched Cohort Study With 2-Year Follow-up. Foot Ankle Int. 2024;45:456–66. 10.1177/10711007241230550 . Kato M, et al. Comparison of the Outcomes of Plating, Screw Fixation, and Pinning in Sanders Type II Fractures: A Multicenter (TRON) Retrospective Study. J Foot Ankle Surg. 2024;63:171–5. 10.1053/j.jfas.2023.10.002 . Liu GT, Vanpelt MD, Lalli T, Raspovic KM, Wukich DK. Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most? Clin Podiatr Med Surg. 2019;36:173–84. 10.1016/j.cpm.2018.10.002 . Bloomer AK, et al. Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures. Foot Ankle Int. 2022;43:509–19. 10.1177/10711007211058689 . Chun DI, et al. A Novel Prediction Model for Determining Coronal Length of Calcaneus Using CT: A Guide for Surgery of Calcaneal Fracture. J Foot Ankle Surg. 2021;60:724–8. 10.1053/j.jfas.2021.01.008 . 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-8805019","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592417093,"identity":"3dc96467-f905-4dc8-b73a-5cab62975d13","order_by":0,"name":"Futian Zhang","email":"","orcid":"","institution":"Weifang People's Hospital, Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Futian","middleName":"","lastName":"Zhang","suffix":""},{"id":592417096,"identity":"c01f222e-ff8a-4ad0-8ed0-6f760c531ca6","order_by":1,"name":"Longxin An","email":"","orcid":"","institution":"Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Longxin","middleName":"","lastName":"An","suffix":""},{"id":592417098,"identity":"47587c95-d326-4818-bd4e-b2717bdde020","order_by":2,"name":"Weiqiang Zhang","email":"","orcid":"","institution":"Weifang People's Hospital, Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weiqiang","middleName":"","lastName":"Zhang","suffix":""},{"id":592417099,"identity":"77522c69-8a5c-4e01-8e97-68354bc45ba0","order_by":3,"name":"Wenjing Zhang","email":"","orcid":"","institution":"Weifang People's Hospital, Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenjing","middleName":"","lastName":"Zhang","suffix":""},{"id":592417100,"identity":"b9f1f0f1-1a26-4b34-80c4-2553e7b05b8f","order_by":4,"name":"Zilong Deng","email":"","orcid":"","institution":"Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zilong","middleName":"","lastName":"Deng","suffix":""},{"id":592417101,"identity":"5fa0d443-76ba-4e54-8969-92b2070d87f6","order_by":5,"name":"Fan Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDCCAxAqAUR8YGCw4eHnbyCohbEBqoVxBgNDmozkjAOkaTlsY9CQgF8H3/Hm5w8+7qnL45/dfrHh547zPAYMBxg/fMzBrUXyzDHDxhnP2Iol7pwpbOw9c5vHnLmBWXLmNtxaDG7kMDbzHOBJbLiRk/6At+02j2XDATZmXsJaJBLn38hJbPzbdo7H4EACUVoMEjfcSD/YzNt2gLAWkF9mzjiQkLgRpFe2LZlHcsbBZrx+AYbYgw8fDtQlzruR/rDxbZudPT9/88EPH/FoQQLA4IUAcEQRBdgfEKtyFIyCUTAKRhgAAMIYX07idMZ8AAAAAElFTkSuQmCC","orcid":"","institution":"Weifang People's Hospital, Shandong Second Medical University","correspondingAuthor":true,"prefix":"","firstName":"Fan","middleName":"","lastName":"Zhang","suffix":""},{"id":592417102,"identity":"5f46d978-f563-46e1-b004-50d12069865d","order_by":6,"name":"Naibo Feng","email":"","orcid":"","institution":"Weifang People's Hospital, Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Naibo","middleName":"","lastName":"Feng","suffix":""}],"badges":[],"createdAt":"2026-02-06 09:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8805019/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8805019/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102854243,"identity":"5a8a800c-bab4-4c9f-b2d0-820ab978cac0","added_by":"auto","created_at":"2026-02-17 14:47:43","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64047,"visible":true,"origin":"","legend":"\u003cp\u003eRecovery outcomes of the affected limbs over time in both groups. (A) VAS scores in both groups (p \u0026lt; 0.01). (B) Plantarflexion and (C) dorsiflexion range of motion (p \u0026lt; 0.01).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8805019/v1/0c9bdffc7683f95f1fd32e19.jpeg"},{"id":102854244,"identity":"41199daa-5d5f-449f-9117-473da530f4e8","added_by":"auto","created_at":"2026-02-17 14:47:43","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":317429,"visible":true,"origin":"","legend":"\u003cp\u003eClinical data of Case 1. (A, B) Preoperative radiographs of the patient. (C, D) Intraoperative reduction technique demonstrating the surgical approach and incision. (E, F) Intraoperative fluoroscopy to confirm screw placement and quality of reduction. (G, H) Postoperative radiographs on day 1. (I, J) Range of dorsiflexion and plantarflexion of the ankle one month postoperatively. (K, L) Radiographs at 3 months postoperatively.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8805019/v1/af067cebd6dddf3375939398.jpeg"},{"id":102854245,"identity":"5a11dac7-3cf6-4a36-a5e8-19ab59be24d5","added_by":"auto","created_at":"2026-02-17 14:47:43","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":339239,"visible":true,"origin":"","legend":"\u003cp\u003eClinical data of Case 2.\u003cstrong\u003e \u003c/strong\u003e(A, B) Preoperative radiographs of the patient. (C, D) Intraoperative views showing the surgical incision. (E, F) Postoperative radiographs on day 1. (G, H) Radiographs at 3 months postoperatively. (I, J, K) Ankle dorsiflexion and plantarflexion range of motion at 1 month postoperatively.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8805019/v1/8945cbfd2a49d2cdd0595f9e.jpeg"},{"id":102964387,"identity":"f1ca1b2d-8ccb-4077-85c1-c95b7bffb4ba","added_by":"auto","created_at":"2026-02-19 04:22:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1856083,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8805019/v1/ef81f1d4-c6d5-4981-a4b8-f3121f8d4e07.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimally Invasive Reverse Traction Using Kirschner Wire Retractor for Sanders II and III Calcaneal Fractures: Clinical Outcomes and Advantages","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs the largest tarsal bone in the human foot, the calcaneus plays a fundamental role in weight-bearing and locomotion due to its unique anatomical and physiological structure. It is essential for daily activities and athletic function. Calcaneal fractures, however, commonly result from axial loading injuries, such as falls from a height, where the talus impacts the calcaneus. Notably, approximately 75% of these fractures are intra-articular, and conservative treatment is associated with a higher risk of complications such as nonunion, post-traumatic arthritis, and joint deformity\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Surgical treatment via the traditional lateral \"L\"-shaped approach has been linked to a significant incidence of postoperative complications, making the management of calcaneal fractures a longstanding challenge in orthopedic surgery \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Conventional open reduction and internal fixation (ORIF) techniques often require large incisions, pose a high risk of soft tissue injury, and carry a substantial risk of wound complications, all of which result in increased patient morbidity and prolonged recovery.\u003c/p\u003e \u003cp\u003eWith continuous advancements in medical technology, the concept of minimally invasive surgery (MIS) has gained widespread acceptance in orthopedics. Minimally invasive techniques for calcaneal fracture management aim to reduce incision size and soft tissue damage, thereby promoting faster recovery and minimizing complications \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. These procedures often involve refined techniques such as traction, prying, and clamping, combined with precise surgical instruments, which help to overcome many of the limitations of traditional approaches and provide improved clinical outcomes and patient quality of life.\u003c/p\u003e \u003cp\u003eSince January 2024, our department has employed a novel minimally invasive technique for the treatment of Sanders type II and III calcaneal fractures, utilizing a Kirschner wire distractor for reverse traction, closed reduction, and cannulated screw fixation. In this study, we present a comparative analysis of the clinical outcomes between this new technique and conventional closed reduction with cannulated screw fixation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\n\u003ch3\u003e1. General Information\u003c/h3\u003e\n\u003cp\u003eBetween January 2024 and December 2024, a total of 40 patients with calcaneal fractures were treated in our department. After excluding elderly patients (\u0026ge;\u0026thinsp;65 years), those with concomitant fractures, pathological or old fractures, and open fractures, 33 patients met the inclusion criteria. Additionally, from January 2023 to December 2023, 70 patients with calcaneal fractures were admitted to our department; following the same exclusion criteria, 33 patients were randomly selected to serve as the control group. This study was approved by the Institutional Ethics Committee, and informed consent was obtained from all patients.\u003c/p\u003e \u003cp\u003eThe patients were divided into two groups: the observation group (n\u0026thinsp;=\u0026thinsp;33), treated with reverse traction using a Kirschner wire distractor combined with closed reduction and cannulated screw fixation; and the control group (n\u0026thinsp;=\u0026thinsp;33), treated with traditional open reduction and internal fixation using a lateral plate. There were no statistically significant differences between the two groups in terms of sex, age, Sanders classification, side of injury, or mechanism of injury (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (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\u003eComparison of Baseline Clinical Characteristics Between the Two Groups\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\u003eObservation Group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \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\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \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\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.15\u0026thinsp;\u0026plusmn;\u0026thinsp;9.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.42\u0026thinsp;\u0026plusmn;\u0026thinsp;10.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture Type\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSanders Type II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \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\u003eSanders Type III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \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\u003eInjured Side\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \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\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \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\u003eCause of Injury\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=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall from height\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \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\u003eTraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \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 \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e2. Perioperative Management\u003c/h3\u003e\n\u003cp\u003eAll patients received prophylactic intravenous cefuroxime sodium 30 minutes prior to surgery, with dosage and administration according to the manufacturer\u0026rsquo;s instructions. On the second postoperative day, patients began isometric muscle contraction exercises. Joint mobility and weight-bearing activities were initiated based on the progress of fracture healing. Rivaroxaban was administered for thromboprophylaxis. Patients underwent routine follow-up every two weeks after surgery.\u003c/p\u003e\n\u003ch3\u003e3. Surgical Technique\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eAnesthesia and Positioning\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAll procedures were performed under combined spinal-epidural anesthesia. Patients in the observation group were positioned prone. The surgical technique followed the principle of \u0026ldquo;traction, prying, and clamping\u0026rdquo; to achieve reduction.\u003c/p\u003e\n\u003ch3\u003eObservation Group: Minimally Invasive Fixation with Kirschner Wire Distractor, Reverse Traction, and Cannulated Screws\u003c/h3\u003e\n\u003cp\u003eIn the observation group, a minimally invasive technique combining closed reduction and percutaneous fixation was employed. A 2.0 mm Kirschner wire (K-wire) was transversely inserted into the tibial Chaput tubercle, and another into the posterior tuberosity of the calcaneus. These wires were aligned as parallel as possible and connected bilaterally to a specialized K-wire distractor. The wire ends were bent to prevent slippage. Reverse traction was applied under fluoroscopic guidance to restore calcaneal height (\"traction\" step).\u003c/p\u003e \u003cp\u003eUnder Broden views (20\u0026deg;, 30\u0026deg;, and 40\u0026deg;), a 4.0 mm K-wire was inserted from the plantar aspect of the calcaneus to create a channel. Through this, a 2.0 mm K-wire was used to elevate the collapsed posterior articular surface under fluoroscopic monitoring in multiple planes (\"prying\" step).\u003c/p\u003e \u003cp\u003eOnce axial fluoroscopy confirmed lateral wall widening, a\u0026thinsp;~\u0026thinsp;1 cm lateral incision was made just above the Achilles tendon insertion. Blunt dissection along the medial calcaneal surface exposed the sustentaculum tali. A custom-designed reduction clamp was inserted percutaneously to compress and reduce the lateral wall (\"clamping\" step).\u003c/p\u003e \u003cp\u003eReduction quality was confirmed by fluoroscopy, assessing restoration of the B\u0026ouml;hler and Gissane angles. In cases with comminution of the posterior tuberosity, additional 4.0 mm K-wires were used for further elevation. Preoperative CT imaging guided individualized reduction strategies based on fracture morphology. Following satisfactory reduction, percutaneous guidewires were inserted\u0026thinsp;~\u0026thinsp;2 cm below the lateral malleolus, posterior to the peroneal tendons, to guide cannulated screw placement. A 4.0 mm cannulated screw was first inserted to compress the subtalar joint surface, followed by additional 5.0 mm screws along the fracture lines. Longitudinal fixation was achieved by inserting screws from the calcaneal tuberosity toward the anterior process. For posterior tuberosity fragments, an additional screw was inserted through the Achilles tendon incision. Final C-arm fluoroscopy confirmed satisfactory reduction and hardware placement. The Achilles tendon incision was closed, while the percutaneous screw sites were left unsutured and covered with sterile gauze.\u003c/p\u003e \u003cp\u003eTechnical Notes:\u003c/p\u003e\n\u003ch3\u003e1) Avoid suturing small incisions for cannulated screws to prevent soft tissue necrosis.\u003c/h3\u003e\n\u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePlace the screw for joint surface fixation posterior to the peroneal tendons to prevent sural nerve injury.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003e3) Perform intraoperative fluoroscopy in axial, lateral, and Broden views to assess reduction.\u003c/h3\u003e\n\u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eScrew placement should consider fracture line distribution to restore calcaneal support and prevent secondary collapse. Fixation across the subtalar joint with a sustentacular screw ensures articular stability.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003e5) In difficult reductions, a sinus tarsi approach may be used for direct visualization and reduction.\u003c/h3\u003e\n\n\u003ch3\u003e6) Accurate C-arm positioning and foot positioning before draping are essential for standard imaging.\u003c/h3\u003e\n\n\u003ch3\u003eControl Group (Open Reduction and Plate Fixation):\u003c/h3\u003e\n\u003cp\u003eA traditional L-shaped lateral approach was used. A single-layer dissection exposed the calcaneus to the periosteum. Two 2.0 mm K-wires were placed anterior and posterior to the subtalar joint for exposure. After restoring the B\u0026ouml;hler and Gissane angles, temporary K-wire fixation was performed. Satisfactory reduction was confirmed with fluoroscopy. Fixation was completed using a calcaneal plate and cancellous screws. A drain was placed, and the incision was closed in a single layer and dressed with sterile gauze.\u003c/p\u003e\n\u003ch3\u003e4. Outcome Measures\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e4. Outcome Measures\u003c/div\u003e \u003cp\u003eThe following parameters were recorded: length of hospital stay, hospitalization cost, operative time, number of intraoperative fluoroscopy exposures, and postoperative pain visual analogue scale (VAS) scores. Pre- and postoperative measurements of B\u0026ouml;hler and Gissane angles were compared within and between groups. Ankle and hindfoot function were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, with outcomes categorized as excellent (90\u0026ndash;100), good (75\u0026ndash;89), fair (50\u0026ndash;74), and poor (\u0026lt;\u0026thinsp;50).\u003c/p\u003e\n\u003ch3\u003e5. Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eData processing and analysis were performed using R v4.4.1, along with Zstats v1.0 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.zstats.net).Continuou\u003c/span\u003e\u003cspan address=\"http://www.zstats.net).Continuou\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003es variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (X̄ \u0026plusmn; s) and compared using independent sample t-tests. Comparisons included hospital stay, cost, operative time, number of fluoroscopies, fracture healing time, postoperative VAS scores, changes in B\u0026ouml;hler and Gissane angles, and AOFAS scores. A P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Surgical Outcomes\u003c/h3\u003e\n\u003cp\u003eThe surgical parameters of the two groups, including operative time (minutes), intraoperative blood loss (mL), and total incision length (cm), are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All procedures were performed by the same surgical team. The observation group showed significantly better outcomes than the control group in terms of shorter operative time, reduced blood loss, and smaller total incision length (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, the number of intraoperative fluoroscopy exposures was significantly higher in the observation group compared to the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\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 Surgical Parameters Between the Two Groups\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=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation Group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e105.42\u0026thinsp;\u0026plusmn;\u0026thinsp;23.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e133.52\u0026thinsp;\u0026plusmn;\u0026thinsp;43.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative blood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e48.79\u0026thinsp;\u0026plusmn;\u0026thinsp;7.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e102.27\u0026thinsp;\u0026plusmn;\u0026thinsp;18.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-15.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal incision length (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-117.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of fluoroscopies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e81.48\u0026thinsp;\u0026plusmn;\u0026thinsp;22.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e2. Clinical Data\u003c/h3\u003e\n\u003cp\u003eHospitalization-related parameters, including length of hospital stay and total hospitalization costs, were compared between the two groups. The observation group demonstrated significantly shorter hospital stays and lower overall hospitalization expenses compared to the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Hospitalization Parameters Between the Two Groups\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=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation Group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.09\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-5.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hospitalization cost (\u0026yen;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15,172.18\u0026thinsp;\u0026plusmn;\u0026thinsp;6,222.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e26,071.21\u0026thinsp;\u0026plusmn;\u0026thinsp;11,721.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e3. Radiographic Outcomes\u003c/h3\u003e\n\u003cp\u003ePreoperative and postoperative Gissane and B\u0026ouml;hler angles were compared between the two groups. Paired-sample t-tests were used to evaluate the effectiveness of the surgical interventions. Both groups showed statistically significant improvements in Gissane and B\u0026ouml;hler angles postoperatively compared to preoperative values (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Preoperative comparisons of Gissane and B\u0026ouml;hler angles between the two groups showed no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, both parameters demonstrated significant improvements postoperatively in each group compared to their respective preoperative values, indicating the effectiveness of surgical intervention (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Postoperative comparisons between the two groups revealed no significant differences in either Gissane or B\u0026ouml;hler angle (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting that both surgical approaches are effective in restoring the anatomical structure of the calcaneus.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Radiographic Parameters Between the Two Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreoperative (\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePostoperative (\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGissane angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;65.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.39\u0026thinsp;\u0026plusmn;\u0026thinsp;3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;69.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(t, p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.71, 0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25, 0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eB\u0026ouml;hler angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;26.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;35.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(t, p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98, 0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;2.86, 0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e4. Follow-up Data\u003c/h3\u003e\n\u003cp\u003eAll patients in both groups completed effective follow-up. Repeated measures analysis of variance (ANOVA) was performed to analyze changes in VAS scores (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Mauchly\u0026rsquo;s test of sphericity indicated that the sphericity assumption was met (W\u0026thinsp;=\u0026thinsp;0.841, P\u0026thinsp;=\u0026thinsp;0.55), allowing the use of standard repeated measures ANOVA. There were statistically significant differences in VAS scores between the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), across different time points (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and a significant interaction effect between group and time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). As time progressed, VAS scores decreased significantly in both groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with a more rapid decline observed in the observation group compared to the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of VAS Pain Scores Between the Two Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation Group (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eControl Group (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Day 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e486.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Day 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e4.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e183.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Day 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Day 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSource of Variation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eF-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween Groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e180.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e917.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInteraction (Group \u0026times; Time)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e118.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eRegarding ankle range of motion, repeated measures ANOVA was also applied to assess changes in dorsiflexion and plantarflexion (Tables\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e and \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Mauchly\u0026rsquo;s test of sphericity indicated that the sphericity assumption was violated for both dorsiflexion (W\u0026thinsp;=\u0026thinsp;0.684, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and plantarflexion (W\u0026thinsp;=\u0026thinsp;0.710, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01); therefore, the Greenhouse\u0026ndash;Geisser correction was applied. There were statistically significant differences in both dorsiflexion and plantarflexion between the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), across time points (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and significant interaction effects between group and time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Both dorsiflexion and plantarflexion improved significantly over time in both groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with the observation group showing a faster recovery rate than the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC.)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Ankle Dorsiflexion Range of Motion (\u0026deg;) Between the Two Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation Group (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eControl Group (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e18.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e22.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e23.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSource of Variation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eF-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween Groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e68.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e278.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInteraction (Group \u0026times; Time)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\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 \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Ankle Plantarflexion Range of Motion (\u0026deg;) Between the Two Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation Group (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eControl Group (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e30.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e39.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months postoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e40.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSource of Variation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eF-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween Groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e23.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e363.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInteraction (Group \u0026times; Time)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e27.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eCase\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eCase 1\u003c/strong\u003e \u003cp\u003eA 43-year-old male patient sustained a right calcaneal fracture caused by a fall from height. The fracture was classified as Sanders type II. The patient underwent closed reduction using reverse traction with a Kirschner wire retractor combined with Kirschner wire lever-assisted reduction. Preoperative X-rays, intraoperative reduction status, and postoperative follow-up X-rays are illustrated in Figs.\u0026nbsp;2.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2.\u003c/b\u003e Clinical data of Case \u003cspan refid=\"FPar1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. (A, B) Preoperative radiographs of the patient. (C, D) Intraoperative reduction technique demonstrating the surgical approach and incision. (E, F) Intraoperative fluoroscopy to confirm screw placement and quality of reduction. (G, H) Postoperative radiographs on day 1. (I, J) Range of dorsiflexion and plantarflexion of the ankle one month postoperatively. (K, L) Radiographs at 3 months postoperatively.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 2\u003c/strong\u003e \u003cp\u003eA 38-year-old male patient sustained a right calcaneal fracture due to a fall from height. The fracture was classified as Sanders type III. The patient was treated with closed reduction using reverse traction via a Kirschner wire retractor combined with Kirschner wire lever-assisted reduction. Preoperative radiographs, intraoperative reduction status, and postoperative follow-up radiographs are shown in Figs.\u0026nbsp;3.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3.\u003c/b\u003e Clinical data of Case \u003cspan refid=\"FPar2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. (A, B) Preoperative radiographs of the patient. (C, D) Intraoperative views showing the surgical incision. (E, F) Postoperative radiographs on day 1. (G, H) Radiographs at 3 months postoperatively. (I, J, K) Ankle dorsiflexion and plantarflexion range of motion at 1 month postoperatively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCalcaneal fractures are among the more common types of fractures in the skeletal system. When fractures exhibit significant displacement, joint surface incongruity, alterations in calcaneal height, width, or length, or are complicated by neurovascular injuries, traditional open reduction and internal fixation (ORIF) with plate fixation is typically employed. This approach requires a large incision to adequately expose the calcaneus, which results in extensive soft tissue dissection and traction, compromising local blood supply and impairing postoperative soft tissue healing. Consequently, this increases the risk of postoperative complications such as infection and skin necrosis \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Moreover, ORIF demands favorable soft tissue conditions around the fracture site, usually necessitating surgery only after swelling subsides and skin wrinkles appear (7\u0026ndash;10 days post-injury), but even then, complications like skin necrosis are not uncommon \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The extensive periosteal and soft tissue stripping during exposure often leads to considerable intraoperative bleeding, increased local tissue tension, and in severe cases, wound edge necrosis and poor drainage, thereby elevating the incidence of complications such as infection and allergic reactions \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTraditional ORIF with plate fixation causes significant damage to the surrounding soft tissues and bone, often leading to increased postoperative pain and thus hindering early functional rehabilitation, ultimately impairing joint recovery. Patients typically require prolonged bed rest and rehabilitation for several months before gradually returning to normal daily activities and work. Although the lateral \u0026ldquo;L\u0026rdquo;-shaped incision provides adequate fracture visualization, it also results in substantial soft tissue damage, with severe cases experiencing plate exposure or osteomyelitis as complications \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Postoperative prolonged joint immobilization and trauma-induced inflammatory reactions frequently result in subtalar and surrounding joint adhesions and stiffness, reducing ankle joint mobility and causing pain and gait abnormalities. Consequently, minimally invasive calcaneal fracture treatment has increasingly gained favor among clinicians.\u003c/p\u003e \u003cp\u003eWith advancements in medical technology and deeper understanding of calcaneal fractures, minimally invasive techniques have been gradually incorporated into clinical practice, offering patients alternative therapeutic options. Our study demonstrated that the minimally invasive group showed superior outcomes in terms of preoperative waiting time, operative time, hospital stay, fracture healing time, blood loss, hospitalization costs, and postoperative pain compared to the open reduction group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), consistent with findings by Changjun Guo and colleagues \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. This study utilized a bilateral Kirschner wire retractor, which effectively improves surgical outcomes by enabling reverse traction to correct calcaneal height. Fluoroscopy was employed to adjust the traction forces on medial and lateral Kirschner wires, and after height restoration, the axial view of the calcaneus was assessed, revealing widened calcaneal width. This method provides sustained traction to reduce the fractured calcaneus, allowing precise control of the degree of distraction via fluoroscopic guidance, facilitating fracture reduction, correcting varus deformity, and restoring length and height. These results align with related studies \u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The Kirschner wire retractor offers several advantages: (1) it expands the talocalcaneal joint space, providing adequate room for closed lever reduction of the collapsed posterior articular surface, with adjustable bilateral traction forces to correct calcaneal varus; (2) it provides continuous traction to maintain restored calcaneal height, length, B\u0026ouml;hler\u0026rsquo;s angle, Gissane\u0026rsquo;s angle, and varus angle, while the calcaneal width is maintained with forceps until the end of surgery \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAll patients in the observation group underwent minimally invasive closed reduction and hollow screw fixation, which avoids large incisions and significantly shortens preoperative waiting time. Our results showed that the observation group had shorter preoperative waiting time, operative time, fracture healing time, hospital stay, and lower hospitalization costs and blood loss than the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Postoperative 3-month follow-up demonstrated significant improvement in B\u0026ouml;hler\u0026rsquo;s and Gissane\u0026rsquo;s angles compared to preoperative values in both groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with no significant difference between groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating that closed reduction and internal fixation can achieve comparable anatomical restoration to open reduction. These findings are consistent with similar studies, supporting faster patient recovery, shorter hospital stays, reduced medical costs, and alleviated patient and family burden, in line with Enhanced Recovery After Surgery (ERAS) principles \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Early closed reduction with screw fixation was traditionally limited to extra-articular fractures and simple Sanders type II fractures, but with advancements in techniques and treatment concepts, it has been increasingly applied to Sanders type III fractures \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. In this study, among 33 patients in the observation group, 14 had Sanders type III fractures, and their AOFAS ankle\u0026ndash;hindfoot scores showed no significant difference compared to the control group (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting that the minimally invasive technique is applicable to Sanders type III fractures. Previous studies have emphasized the necessity of surgeons\u0026rsquo; thorough preoperative understanding of fracture classification, surgical expertise, and use of advanced imaging to achieve anatomical reduction and precise screw placement, thereby minimizing surgical trauma and soft tissue complications \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Furthermore, screw fixation results in significantly lower postoperative pain VAS scores compared to plate fixation, enabling earlier rehabilitation and better functional recovery, facilitating faster return to normal life \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Our study also found that pain scores within the first 3 postoperative days were significantly lower in the observation group than in controls (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), which likely reduces psychological burden and promotes more active engagement in rehabilitation, accelerating both physical and mental recovery.\u003c/p\u003e \u003cp\u003eDespite its benefits, the minimally invasive approach has limitations: (1) increased fluoroscopy raises radiation exposure for surgeons and patients; (2) lack of direct visualization makes intra-articular fracture reduction challenging, relying on fluoroscopy and Kirschner wire manipulation; (3) the 2.0 mm Kirschner wires offer limited traction force, sometimes resulting in suboptimal calcaneal height and postoperative height loss.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, minimally invasive reverse traction closed reduction using a Kirschner wire retractor with hollow screw fixation for Sanders II and III calcaneal fractures offers less surgical trauma, shorter hospital stay, lower costs, reduced blood loss, and faster anatomical recovery. It also decreases postoperative pain and soft tissue damage, allowing earlier rehabilitation and quicker return to daily activities. However, it requires high surgical skill and increases intraoperative fluoroscopy and radiation exposure. More studies with larger samples are needed to further validate these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical approval\u003c/h2\u003e \u003cp\u003eClinical Trial Number.: MR-37-25-017040\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eDeclaration of competing interest\u003c/h2\u003e \u003cp\u003eThe author declares no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by the National Natural Science Foundation of China (No. 82302031), the Natural Science Foundation of Shandong Province (No. ZR2024QH033).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFutian Zhang : Writing\u0026ndash;original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation. Longxin An : Methodology, Investigation, Formal analysis, Data curation. Weiqiang Zhang : Investigation, Formal analysis, Data curation. Wenjing Zhang : Investigation, Data curation. Zilong Deng : Investigation, Formal analysis. Naibo Feng : Writing\u0026ndash;original draft, Visualization, Validation, Supervision, Project administration. Fan Zhang : Writing \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files. Data is available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChotikkakamthorn N, Chanajit A, Tharmviboonsri T, Chuckpaiwong B, Harnroongroj T. Minimal invasive surgery in the management of intra-articular calcaneal fractures: A retrospective comparison of screw fixation alone versus screw with small locking plate fixation techniques. Acta Orthop Traumatol Turc. 2021;55:258\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5152/j.aott.2021.20003\u003c/span\u003e\u003cspan address=\"10.5152/j.aott.2021.20003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGougoulias N, McBride D, Maffulli N. Outcomes of management of displaced intra-articular calcaneal fractures. 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J Foot Ankle Surg. 2021;60:724\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.jfas.2021.01.008\u003c/span\u003e\u003cspan address=\"10.1053/j.jfas.2021.01.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\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":"Calcaneal fracture, Minimally invasive treatment, Reverse traction, Kirschner wire distractor, Screw fixation","lastPublishedDoi":"10.21203/rs.3.rs-8805019/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8805019/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis retrospective study evaluated the clinical efficacy of a minimally invasive technique involving reverse traction reduction using a Kirschner wire distractor combined with cannulated screw fixation for treating Sanders type II and III calcaneal fractures. A total of 66 patients were analyzed, with 33 treated using the novel minimally invasive method and 33 treated with conventional open reduction and internal fixation using plates. Compared to the control group, the minimally invasive group showed significantly reduced intraoperative blood loss, operative time, hospital stay, and treatment costs, though it required more intraoperative fluoroscopy. Fracture healing time was comparable between groups. At 3 months postoperatively, radiographic outcomes including B\u0026ouml;hler and Gissane angles improved significantly in both groups without significant differences between them. The minimally invasive group experienced lower postoperative pain scores and fewer complications. At final follow-up, this group also demonstrated higher AOFAS ankle\u0026ndash;hindfoot scores and a greater rate of excellent and good outcomes. These findings suggest that the described minimally invasive approach is a safe and effective alternative to traditional open surgery, offering advantages in surgical trauma, recovery time, and complication rates, although the increased need for fluoroscopy warrants consideration.\u003c/p\u003e","manuscriptTitle":"Minimally Invasive Reverse Traction Using Kirschner Wire Retractor for Sanders II and III Calcaneal Fractures: Clinical Outcomes and Advantages","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 14:47:19","doi":"10.21203/rs.3.rs-8805019/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":"6b3319cf-b18f-44d2-ad50-59d524cc33d0","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T21:09:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 14:47:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8805019","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8805019","identity":"rs-8805019","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}