The Journal of Foot & Ankle Surgery 59 (2020) 356−366

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The Journal of Foot & Ankle Surgery

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Review Articles

Lateral Extensile Approach Versus Minimal Incision Approach for Open

Reduction and Internal Fixation of Displaced Intra-articular Calcaneal
Fractures: A Meta-analysis
Andrea Seat, MS, DPM, AACFAS1, Christopher Seat, DPM2
1
Resident PGY-3, Department of Podiatry, Jesse Brown VA Medical Center, Chicago, IL
2
Owner and Podiatrist, Private Practice, Oklahoma City, OK

A R T I C L E I N F O A B S T R A C T

Level of Clinical Evidence: 1 Treatment of displaced intra-articular calcaneal fractures remains controversial. Therefore, the purpose of this
Keywords: large meta-analysis was to report the outcomes of the lateral extensile approach versus the minimal incision
anatomic reduction calcaneus approach including complications, anatomic reduction, functional outcomes, and timing and to report results
calcaneus fracture when only randomized control trials were compared. Five electronic databases were searched for articles directly
minimally invasive comparing the 2 above approaches. Inclusion criteria included articles published from January 2007 to April 2017,
sinus tarsi approach adults (>18 years old) with closed, Sanders type II or III fractures, mean follow-up time of ≥12 months, and ≥1 pri-
wound complication mary outcome reported. Seventeen randomized control trials and 10 retrospective studies were included. There
were 2179 participants with 2274 fractures, and mean follow-up of 22.41 months. Our results revealed no statisti-
cally significant difference in Gissane’s angle, calcaneal width, calcaneal length, deep infection, or subtalar stiff-
ness. When taking into consideration only randomized control trials, there was no statistically significant
difference between groups comparing postoperative Bohler’s or Gissane’s angle. There was a statistically signifi-
cant difference in wound complications, superficial infection, sural nerve injury, visual analog scale (VAS) and
American Orthopaedic Foot & Ankle Society (AOFAS) scores, operative time, time to operating room, calcaneal
height, and postoperative Bohler’s angle (when all studies were considered), all in favor of the minimal incision
approach. These results remained statistically significant when only the randomized controlled trials were com-
pared, with the exception of Bohler’s angle and VAS and AOFAS scores. The results of this meta-analysis indicate
that the minimal incision approach is a good alternative to the standard lateral extensile approach.
© 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.

Calcaneal fractures constitute »60% of all tarsal fractures, making
them the most commonly fractured bone of the tarsus. They account
for 1% to 2% of fractures overall (1). Seventy-five percent of all calcaneal
fractures are displaced intra-articular calcaneal fractures (DIACFs) (2).
Despite a paucity of studies conducted on DIACFs, their treatment
remains controversial (3,4). Independent meta-analyses based on ran-
domized controlled trials (RCTs) have shown better clinical and radio-
logical outcomes with earlier return to work after surgical management
of DIACFs (5,6). Conservative treatment often results in subtalar arthro-
sis, malunion, and poor functional outcome (7,8). Currently, the ques-
tion at hand is which surgical treatment provides the optimum result
for DIACFs.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Andrea Seat MS, DPM, AACFAS, Oklahoma Foot & Ankle
Treatment Center, 5500 N Portland Ave., Oklahoma City, OK 73112.
E-mail address: andreamseat@gmail.com (A. Seat).
The standard, surgical open reduction and internal fixation (ORIF),
has been done via the L-shaped lateral extensile approach (LEA). This
approach allows for excellent visualization and access for fracture
reduction. In regard to delicate soft tissue management, much attention
has been paid to this approach via the creation of full-thickness flaps
and a “no touch” technique (9,10). Despite the attempts at meticulous
soft tissue handling, the LEA has been fraught with wound healing com-
plications, with reports ranging from 5.8% to 43%. Other complications
of this approach include deep and superficial infections, hematoma for-
mation, sural nerve injuries, peroneal tendon injuries, and subtalar
arthritis (4,10−54).
These complications, more specifically related to wound healing,
have spurred the development of more minimally invasive techniques
for calcaneal fracture reduction and fixation. In recent years, many sur-
geons have described their techniques, including percutaneous fixation,
external fixation, arthroscopy-assisted fixation, sinus tarsi approach
(STA), and other minimal incision techniques including medial, lateral,
posterior, or combined (8,10,11,15−27,39−54). Of these techniques,
STA has gained the most favor because of a lower incidence of wound

1067-2516/$ - see front matter © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
https://doi.org/10.1053/j.jfas.2019.08.007
 A. Seat, C. Seat / The Journal of Foot & Ankle Surgery 59 (2020) 356−366 357

complications and secondary intervention, while still providing direct
visualization of the posterior facet (10,19,27). Some have argued that
these minimal incision approaches (MIAs) are technically difficult, with
poor visualization of the fracture site and difficulty with manipulation
(10,16). However, studies have shown that MIA allows direct
reconstruction of the posterior facet, percutaneous reduction of the
tuberosity, and strong fixation of the fracture with plates and/or screws
(8,10−27).
To determine which approach may be more beneficial for patients,
several studies have been published that compare LEA and MIA; how-
ever, some were limited by small sample size, and they did not consis-
tently report similar outcomes or results. Therefore, the purpose of this
study was to undertake a large meta-analysis with a sizeable number of
RCTs to report the outcomes of LEA versus MIA, including complications
(wound complications, infection, sural nerve injury, subtalar stiffness),
anatomic reduction via postoperative radiographic angles (Bohler’s
angle, Gissane’s angle, and calcaneal height, length, and width), func-
tional outcomes (American Orthopaedic Foot & Ankle Society [AOFAS]
and visual analog scale [VAS] scores), and timing (operating room [OR]
time, time to surgery). Additionally, as a secondary outcome, we pres-
ent results when only RCTs are compared. Our hypothesis is that MIA
will have results similar to LEA in regard to anatomic reduction, but
with less wound healing complications.
Materials and Methods
Study Identification and Search Strategy
Inclusion and Exclusion Criteria
Inclusion criteria included articles published from January 2007 to April 2017, parallel
trials with 2 intervention groups comparing LEA and MIA for ORIF of DIACF in adults
(>18 years old) with closed, Sanders type II or III intra-articular fractures, a mean average
follow-up time of ≥12 months, and ≥1 of our primary outcomes reported. Exclusion crite-
ria included Sanders I and IV fractures, open or extra-articular fractures, patients
<18 years old, patients without internal hardware fixation, patients without an incision
(percutaneous approach), and mean average follow-up time <12 months.
Data Extraction
Both authors independently assessed eligibly of each study for inclusion. Data collec-
tion included primary author and year, study design method (RCT, observational cohort
study), location, sample size, follow-up time (Table 1), patient demographics (age, per-
centage male, Sanders classification, smoking status, diabetes mellitus status), risk of bias,
and primary outcomes, which included complications (wound complications, infection,
sural nerve injury, subtalar stiffness), anatomic reduction via postoperative radiographic
angles (Bohler’s angle; Gissane’s angle; calcaneal height, length, and width), functional
outcomes (AOFAS and VAS scores), and timing (OR time, time to surgery).
The secondary outcome was a sensitivity analysis to compare meta-analysis out-
comes between all trials and with only the RCTs included. In the case of missing informa-
tion, an attempt was made to contact the primary author for clarification.
Quality Assessment
Risk of bias was used for quality assessment and was evaluated by the 2 review
authors independently. The items included are as follows: random sequence generation,
allocation concealment, blinding of participants and personnel, blinding of outcome
assessment, incomplete outcome data, selective reporting and any other bias. Each of the
above was assessed as low, high, or unclear risk of bias.

This meta-analysis was conducted in adherence to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA). Both authors (A.S., C.S.) systematically
searched 5 electronic databases (Medline, PubMed, Cochrane Database of Systemic
Reviews, Cochrane Controlled Trials Register, and Google Scholar Selection) from January
2007 to April 2017 to identify comparative studies between 2 techniques used for ORIF of
DIACF. RCTs were preferred, but due to so few being available, observational studies were
also considered. Search terms included (calcaneus OR calcaneal OR calcaneum OR calcis
OR heel), fracture, sinus tarsi, (minimal OR minimally OR limited OR small incision), and
(extensile OR extended OR lateral OR L-shaped incision).
Statistical Analysis
Statistical analysis was performed with Review Manager Software version 5.3 (Rev-
Man; The Nordic Cochrane Center). Statistical heterogeneity was evaluated using I2 statis-
tics, with substantial heterogeneity existing when I2 > 50%. For outcomes, when I2 < 50%,
a fixed-effects model was used in the meta-analysis, whereas a random-effects model
was adopted for I2 > 50%. Dichotomous data were presented as risk ratio (RR) and contin-
uous variables as mean difference (MD), both with 95% confidence interval (CI); p < .05
was considered statistically significant.

Table 1
Study characteristics (N = 2274 Fractures)

Study Design Location LEA Fractures MI Fractures Follow-Up

(mo; LEA/MI)

Basile et al, 2016 (18) RCT Italy 20 18 24/24

Chen, 2010 (48) RCT China 25 25 12/12
Chen et al, 2011 (24) RCT China 40 38 24/24
De Boer et al, 2015 (39) CS Netherlands 49 61 60/90
Geng et al, 2013 (43) RCT China 20 20 12/12
Jin et al, 2017 (22) RCT China 35 29 16/17
Khurana et al, 2017 (53) RCT India 9 12 12/12
Kline et al, 2013 (10) CS USA 79 33 32/29
Kumar et al, 2014 (8) RCT India 23 22 12/12
Li et al, 2016 (19) RCT China 29 31 12/12
Moon and Lee, 2009 (52) CS Korea 20 12 40/36
Qi et al, 2009 (41) RCT China 40 40 12/12
Qi et al, 2013 (46) RCT China 82 75 12/12
Rammelt et al, 2004 (51) CS Germany 20 33 25/30
Sun, 2012 (45) RCT China 74 70 13/13
Takasaka et al, 2016 (21) CS Brazil 23 27 12/12
Wang, 2011 (42) RTC China 20 20 12/12
Wang, 2015 (49) RTC China 42 42 12/12
Weber 2008 (17) CS Switzerland 26 24 25/32
Wu et al, 2012 (40) CS China 178 213 12/12
Xia et al, 2014 (23) RTC China 53 64 19/19
Xiao, 2012 (47) RTC China 25 25 13/13
Yeap et al, 2016 (20) CS Malaysia 12 14 18/17
Yeo et al, 2015 (16) CS ROK 60 40 57/46
Zhan et al, 2016 (50) RTC China 27 30 37/37
Zhou et al, 2015 (44) RTC China 80 80 12/12
Zhou et al, 2017 (54) CS China 37 28 15/15
Abbreviations: CS, case study; LEA, lateral extensile approach; MI, minimal incision; ROK, Republic of Korea; RCT, randomized controlled trial.
358 A. Seat, C. Seat / The Journal of Foot & Ankle Surgery 59 (2020) 356−366

Fig. 1. Flow diagram of included studies in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISM) statement.

Results Specific demographic information can be found in Table 2. Twenty-

The initial search provided 1510 articles, and after a review of cita-
tion titles and abstracts and identification of duplicates or obvious
study exclusions, 61 full-text articles remained and were reviewed for
eligibility. After thorough review, 27 studies were chosen (Fig. 1). Sev-
enteen RCTs and 10 retrospective cohort studies were included that
compared LEA with MIA for ORIF of DIACF.
A total of 2179 participants were included in this study (1080
[49.56%] MIA and 1099 [50.44%] LEA), which accounted for 2274
fractures (1126 [49.52%] MIA and 1148 [50.48%] LEA). Twenty-three
of 27 studies reported on whether patients were male or female.
Male patients made up 1456 (76.60%) of the study population,
701 (75.89%) and 751 (77.50%) in the MIA and LEA groups,
respectively. The mean average follow-up time was 22.41 months
(range 12 to 90).
two studies recorded mean age values. The mean average age of the
MIA and LEA groups was 42.29 (range 18 to 76) and 42.22 (range 18 to
68), respectively, which showed no statistically significant difference
(MD 0.06, 95% CI −0.36 to 0.48, p = .78). Nine studies included data on
smoking and 7 studies on patients with diabetes mellitus, with no sta-
tistically significant difference between groups (p = .88 and .32). When
comparing Sanders II and III fractures, 1179 (71.85%) of the DIACFs
were Sanders II fractures, 596 (73.40%) in the MIA and 583 (70.33%) in
the LEA groups. There was no significant difference between groups
(p = .31 and .40).
Complications
Twenty-five studies reported results on wound complications
(Fig. 2). The wound complication rate for MIA was 26 of 1053 patients

Table 2
Demographics comparison

Demographic Measure Studies (n) Fractures (n) MIA (n) LEA (n) Statistical Method Effect Estimate

Mean age 25 1810 43.6 43.8 MD (IV, Fixed, 95% CI) 0.06 (-0.36 to 0.48), p = .78
Male 26 1898 705 751 RR (M-H, Fixed, 95%CI) 0.97 (0.92 to 1.02), p = .18
Sanders II 20 1641 596 583 RR (M-H, Fixed, 95%CI) 1.03 (0.97 to 1.09), p = .31
Sanders III 20 1641 218 245 RR (M-H, Fixed, 95%CI) 0.94 (0.82 to 1.08), p = .40
Smoker 9 892 54 73 RR (M-H, Fixed, 95%CI) 1.02 (0.75 to 1.39), p = .88
Diabetes 7 480 12 10 RR (M-H, Fixed, 95%CI) 1.49 (0.68 to 3.27), p = .32
Abbreviations: CI, confidence interval; IV, Inverse Variance; LEA, lateral extensile approach; MD, mean difference; M-H, Mantel-Haenszel; MIA, minimal incision approach; RR, risk ratio.
 A. Seat, C. Seat / The Journal of Foot & Ankle Surgery 59 (2020) 356−366 359

Fig. 2. Table and forest plot comparing wound complications of minimally invasive approach versus lateral extensile approach (all studies).

(2.47%), and 177 of 1070 patients (16.54%) for the LEA. This reached sta-
tistical significance in favor of the MIA group (MD 0.19, 95% CI 0.13 to
0.27, p < .001). When only RCTs were analyzed (Fig. 3), overall wound
complications in 11 studies were 14 of 609 patients (2.30%) and 112 of
599 patients (18.70%) in the MIA and LEA groups, respectively, which
remained statistically significant (MD 0.15, 95% CI 0.10 to 0.25,
p < .001). Nine studies reported infection rates (Fig. 4). The overall
infection rates for the MIA and LEA groups were 17 of 804 patients
(2.11%) and 47 of 719 patients (6.54%), which reached statistical
significance (MD 0.37, 95% CI 0.23 to 0.61, p < .001). When dividing the
infections into deep and superficial infections, deep infection rate was 6
of 378 patients (1.59%) and 14 of 341 patients (4.11%) in the MIA and
LEA groups, which did not reach significance (MD 0.48, 95% CI 0.22 to
1.07, p = .07), and superficial infection rate was 11 of 426 patients
(2.58%) and 33 of 378 patients (8.73%) in the MIA and LEA groups,
which was statistically significant (MD 0.32, 95% CI 0.17 to 0.61,
p < .001). Seven studies reported on sural nerve injury, which was 3 of
334 patients (0.90%) and 25 of 374 patients (6.68%) in the MIA and LEA

Fig. 3. Table and forest plot comparing wound complications of minimally invasive approach versus lateral extensile approach (randomized control trial only).
360 A. Seat, C. Seat / The Journal of Foot & Ankle Surgery 59 (2020) 356−366
Fig. 4. Table and forest plot comparing infection rates of minimally invasive approach versus lateral extensile approach.
groups, which was significant (MD 0.25, 95% CI 0.11 to 0.59, p < .001).
Postoperative subtalar joint (STJ) stiffness was reported in 5 studies and
was 12 of 138 patients (8.70%) and 23 of 169 patients (13.61%) in the
MIA and LEA groups, which did not reach statistical significance (MD
10.64, 95% CI 0.34 to 1.20, p = .16).
Anatomic Reduction
Twenty-one studies evaluated postoperative Bohler’s angle for ana-
tomic reduction (Fig. 5). When evaluating all studies, there was a statis-
tically significant difference in favor of MIA (MD −0.91, 95% CI −1.70
to −0.13, p = .02), but this significance was lost when comparing just
the 14 RCTs (MD −0.79, 95% CI −1.82 to 0.25, p = .14). Fifteen studies
evaluated postoperative Gissane’s angle (Fig. 6), which did not reach
statistical significance (MD −0.18, 95% CI −0.39 to 0.03, p = .09). When
the 10 RCTs were evaluated, this remained statistically insignificant
(MD −0.29, 95% CI −0.57 to −0.01, p = .051). Five studies evaluated
postoperative calcaneal height, which reached statistical significance in
favor of MIA (MD −0.77, 95% CI −1.19 to −0.35, p < .001). Seven studies
evaluated postoperative calcaneal width, which did not reach statistical
significance (MD −0.05, 95% CI −0.32 to 0.23, p = .75). Four studies
evaluated postoperative calcaneal length, and this was not statistically
significant (MD −0.32, 95% CI −1.25 to 0.62, p = .51) (Fig. 7).
Functional Recovery
Fourteen studies evaluated AOFAS scores (Fig. 8), averaging 86.14
(80.8 to 92.2) and 84.12 (74.1 to 91.8) in the MIA and LEA groups,
respectively, which was statistically significant in favor of MIA (MD
1.47, 95% CI 0.71 to 2023), p < .001). This significance was lost when
comparing only the 6 RCTs (MD 0.75, 95% CI −0.67 to 2.18, p = .30).
Eight studies evaluated VAS scores (Fig. 8). The average VAS for MIA
and LEA were 2.19 (1.1 to 3.2) and 2.76 (1.8 to 3.9), which reached sta-
tistical significance in favor of MIA (MD −0.48, 95% CI −0.69 to −0.28,
p < .001). This was lost when comparing only the 4 RCTs (MD −0.48,
95% CI −0.78 to −0.18, p = .06).
Timing
Eleven studies took into account OR time (Fig. 9), averaging 74.70
minutes (19.40 to 122.15) and 103.46 minutes (66.20 to 187.15) in the
MIA and LEA groups, respectively, which reached statistical significance
(MD −28.41, 95% CI −39.13 to 17.68, p < .001). This remained statisti-
cally significant when comparing only the 5 RCTs (MD −40.95, 95%
CI −54.51 to −27.39, p < .001). Thirteen studies reported on time from
injury to surgery (Fig. 9), averaging 6.88 days (2.0 to 11.8) and
9.95 days (5.6 to 19.4) in the MIA and LEA groups, which reached statis-
tical significance (MD −2.61, 95% CI −3.77 to −1.45, p < .001). When
considering only the 6 RCTs, this remained significant (MD −3.08, 95%
CI −5.07 to −1.09, p = .002).
Discussion
In recent years, a surge toward MIA for DIACF has been undertaken
by many foot and ankle surgeons to avoid the wound healing complica-
tions associated with the LEA (8,14−26). Although the LEA allows for
excellent visualization of the fracture and access for fracture reduction
and fixation, it has been well documented that there is a high rate of
wound healing complications (4,10−13,32). Proponents of the LEA
would argue that the MIA does not allow adequate visualization of the
fracture site and is technically difficult to perform (10,16). Because of
this ongoing controversy, and the recent publication of studies directly
 A. Seat, C. Seat / The Journal of Foot & Ankle Surgery 59 (2020) 356−366
Fig. 5. Table and forest plot comparing postop Bohler’s angle of minimally invasive approach versus lateral extensile approach.
comparing these 2 techniques (8,10−24,39−53), we decided that a
meta-analysis would be beneficial to advance the evidence-based med-
icine for treating DIACF.
Our results revealed that when comparing the LEA and MIA, there
was no statistically significant difference in anatomic reduction with
regard to Gissane’s angle, calcaneal width, or calcaneal length. This was
also true for deep infection and STJ stiffness. When taking into consid-
eration RCTs only, there was no statistically significant difference
between groups when comparing postoperative Bohler’s or Gissane’s
angle.
Our results did reveal a statistically significant difference in wound
complications, superficial infection, sural nerve injury, VAS and AOFAS
scores, operative time, time to OR, calcaneal height, and postoperative
Bohler’s angle (when all studies were considered), all in favor of MIA.
These results remained statistically significant when only the random-
ized controlled trials were compared, with the exception of Bohler’s
angle and VAS and AOFAS scores.
Determining the most appropriate treatment for DIACF is important
in our society, since they are the most commonly fractured tarsal bones
and have a high morbidity to patients, as they are fraught with compli-
cations, even when surgically treated (1,4,10−13,32). This poses a sig-
nificant socioeconomic burden, as many patients with this injury are
young and active and perform jobs of manual labor (18). Additionally,
361
high complication rates lead to increased medical costs for further
treatment and the potential for additional surgery in the future.
Decreased operative time leads to decreased hospital costs and patient
morbidity and may help to reduce some of the socioeconomic burden.
Decreased operative times have also been shown to have fewer wound
healing complications and postoperative infections (32). Our results
revealed that patients who underwent MIA had a significantly shorter
OR time than those who underwent LEA (p < .001). These results
remained statistically significant when evaluating RCTs only (p < .001).
A study by Abidi et al (37) showed higher wound healing complica-
tions with ORIF of DIACF when there was an increased number of days
between injury and surgery. Patients in their study who had surgery
after an average of 4.8 days had wound complication rates of 16.6%
compared with 42% in patients who had surgery 10 days after their ini-
tial injury (37). The authors mentioned that the increased calcaneal
width resulted in prolonged tension on the lateral flap, which could
potentially account for more wound healing complications with
delayed time to surgery (37). In our study, there was less delay in time
from injury to surgery in favor of the MIA group (p < .001), which
remained significant when considering RCTs only (p = .002).
A well-documented complication of DIACF is the formation of STJ
arthritis, which is why anatomic reduction of the posterior facet is of
the utmost importance. Radnay et al (28) showed that patients who
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Fig. 6. Table and forest plot comparing postop Gissane’s angle of minimally invasive approach versus lateral extensile approach.

Fig. 7. Table and forest plot comparing postop calcaneal height, width, and length of minimally invasive approach versus lateral extensile approach.
 A. Seat, C. Seat / The Journal of Foot & Ankle Surgery 59 (2020) 356−366
Fig. 8. Table and forest plot comparing American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scores 12 months after surgery for minimally invasive approach
versus lateral extensile approach.
develop posttraumatic STJ arthritis after sustaining a calcaneal frac-
ture that subsequently required a STJ fusion faired significantly bet-
ter if they had been treated operatively. This is due to the restoration
of the calcaneal height and shape, and most importantly, alignment
of the posterior facet (28). It has been shown that restoration of the
posterior facet is essential to restore normal gait, provide earlier
return to work, and reduce the need for STJ arthrodesis (8,30,31).
Another publication showed that 1 to 2 mm of posterior facet incon-
gruity produced significant unloading in the depressed fragment and
redistribution of the overall pressure to parts of the facet that were
previously unloaded, and resulted in an adverse affect on functional
outcome (33). Bohler’s angle is used to determine restoration of the
depressed posterior facet. It has been published that a Bohler’s angle
of 15° to 36° is an independent predictor of satisfaction rate (4).
Lower Bohler’s angles are associated with a higher incidence of
STJ arthritis (27). Our study showed that there was no statistically
significant difference in Bohler’s angle (anatomic reduction)
363
between the LEA and MIA groups, when taking only RCTs into
consideration (p = .14).
Along with restoring Bohler’s angle, it is important to restore the
height and width of the calcaneus. Decreased height of the calcaneal
body results in a shortened Achilles lever arm, limb length discrepancy,
and shoe wear difficulty, often times with the malleoli contacting the
shoe counter (38). When you combine the reduced height with a
decreased Bohler's angle, it results in decreased talocalcaneal angle or
“horizontal talus,” which leads to loss of ankle dorsiflexion with ante-
rior tibiotalar neck impingement, as well as talonavicular subluxation.
Significant ankle pain and eventually flatfoot deformity can result from
this impingement. Increased heel width is associated with shoe wear
difficulty, calcaneal-fibular abutment, and peroneal tendon impinge-
ment (38). The results of our study showed a statistically significant dif-
ference in postoperative calcaneal height in favor of MIA (p < .001) and
no statistically significant difference in calcaneal width between the
groups (p = .75).
364 A. Seat, C. Seat / The Journal of Foot & Ankle Surgery 59 (2020) 356−366

Fig. 9. Table and forest plot comparing operation time and time from injury to surgery of minimally invasive approach versus lateral extensile approach.

An important factor that deserves some discussion, and was not
analyzed in this study because only 2 studies performed it, is postoper-
ative computed tomography (CT) to evaluate alignment of the posterior
facet and presence of a stepoff. CT is extremely sensitive and specific
for looking at joint congruity, particularly the coronal plane view of the
posterior facet (30). The study by Basile et al (18) evaluated postopera-
tive anatomic reduction using CT scans and showed that outcome
scores of patients that had even small residual stepoff defects of the
posterior facet faired significantly worse than patients with anatomic
reduction (p < .001). They had 4 patients in the LEA group and 2
patients in the MIA group with near anatomic reduction (stepoff of <2
mm), and 2 patients in each group had developed mild STJ arthritis
at 2-year follow up (18). The study by Kumar et al (8) also showed
no difference in postoperative anatomic reduction between LEA and
MIA using CT scan.
The AOFAS form is a commonly used scoring system evaluating clin-
ical outcomes and patient progress after undergoing foot and ankle
surgery. Many studies document similar AOFAS scores when comparing
LEA and MIA. A previous meta-analysis comparing the 2 techniques
stated that there was no significant difference found when evaluating
AOFAS scores (34). However, we found a statistically significant differ-
ence in AOFAS scores in favor of the MIA group (p < .001), although this
was no longer statistically significant when comparing RCTs only
(p = .30). We also found a statistically significant difference in VAS scores
in favor of MIA (p = .02), which also lost its significance when comparing
RCTs only (p = .06). The higher scores may relate to smaller incisions, less
soft tissue manipulation, and decreased operative times with MIA.
It is well recognized that LEA comes with the burden of wound
healing complications, with reports ranging from 5.8% to 43%
(1,4,10−13,32). This is despite delicate and meticulous soft tissue man-
agement via the creation of full-thickness flaps and a no-touch tech-
nique (9,10). The wound healing process with LEA depends on the soft
tissue overlying the lateral wall, which is primarily supplied by the lat-
eral calcaneal artery. This artery is particularly thin and vulnerable and
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in close proximity to the vertical arm of the incision (19,35). A study by
Bibbo et al (36) revealed that when the lateral calcaneal artery is able to
be dopplered preoperatively, the chance of wound healing complica-
tions decreases significantly. Of 90 fractures that were treated opera-
tively in his study, 5 patients did not have a dopplerable lateral
calcaneal artery, and all 5 had wound healing complications. Only 1 of
the other 85 patients had wound healing complications (36). MIA offers
a much smaller incision and avoids this artery completely. Our meta-
analysis revealed that a total of 26 of 1053 patients (2.47%) treated with
MIA compared with 177 of 1070 patients (16.54%) with LEA had wound
complications, which was a statistically significant difference (p < .001),
and remained significant when comparing RCTs only (p < .001).
DIACFs in this study comprised Sanders type II or III fractures. The
RCT by Basile et al (18) compared these 2 fracture types and found no
statistically significant difference regarding AOFAS, VAS, and Foot Func-
tion Index scores, either in or between the 2 groups. Another important
finding in their study showed that there was no difference in postoper-
ative STJ range of motion when comparing LEA and MIA, but they did
find, however, that range of motion of the STJ was significantly posi-
tively related to patient satisfaction in both groups (18). In our study,
there was no statistically significant difference in STJ stiffness (p = .16).
The present study does have some limitations. Average follow-up
times varied greatly between studies and ranged from as little as
12 months to 90 months, with an overall average follow-up of 22.41
months. Second, the placement of the minimal incisions varied among
studies, and the types of fixation used varied as well, with some using
screws only, plates only, a combination of plates and screws, locking
plates, and plates specifically designed for minimal incision techniques.
Third, the method by which postoperative clinical outcome scores were
measured varied between the studies, with AOFAS being the most com-
monly used, although it is not a validated scoring system. Additionally,
the studies were not consistent in reporting complications other than
wound healing complications. Also, studies were included from multi-
ple countries where training levels may differ. Although some of these
limitations have the potential to lead to heterogeneity, no significant
heterogeneity was observed between the variables, indicating that the
results are reliable. The strengths of this study include that it is the
largest meta-analysis to date comparing LEA and MIA, with 2274 total
fractures, and we incorporated 17 RCTs, the largest number of any
meta-analysis comparing these 2 techniques. Sample size is important,
since the outcome of calcaneal fractures is multifactorial, and one can-
not draw valuable conclusions unless the assessment includes a large
number of individuals. Other meta-analyses have recently been pub-
lished comparing the results of LEA and MIA, but these studies had a
relatively small number of RCTs and smaller patient sample sizes and
did not report the same number of outcomes as the current study.
In conclusion, LEA produced adequate anatomic reduction, but at
the cost of a high rate of wound complications. MIA was shown to have
shorter OR times, less delay to surgery, and a much lower complication
rate, without affecting the restoration of Bohler’s angle as well as other
radiographic parameters. MIA was also more favorable in regard to
AOFAS and VAS scores before sensitivity analysis was performed. The
results of this meta-analysis indicate that the MIA is a good alternative
to the LEA in patients undergoing ORIF of DIACF.
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