Minimalinvasive Beckenchirurgie

The pelvis is the mechanical connection between the lower extremities and the spinal column. The aim of surgical treatment for pelvic and acetabular injuries is to compensate the strong mechanical forces needed here, without compromising wound healing and restricting muscle function due to additional soft tissue damage. In recent years, minimally invasive stabilizing techniques, which reduce surgical risks and recovery time as well as improving outcomes, have become increasingly established. The increased use of improved imaging modalities also plays a significant role here. Surgical errors can be avoided in the osteosynthesis of acetabular fractures by means of intraoperative visualization using 3D image converters. Navigated percutaneous pelvic sacroiliac screw fixation is the main procedure to be used for pelvic and acetabular navigation. New software enables a 2D representation of the hip area and a 3D calculation of instrument and implant positions, thereby reducing X-ray exposure and increasing intraoperative safety.     

三维透视断层成像导航下微创治疗髋臼骨折初步报道

目的 探讨术中三维透视断层成像导航下髋臼骨折微创治疗的安全性及临床疗效.方法 2008年8月-2010年1月,对12例无明显移位的髋臼骨折患者采取三维透视断层成像导航下经皮微创螺钉内固定治疗.其中男7例,女5例:年龄28～57岁,平均38.1岁.致伤原因:交通事故伤9例,高处坠落伤3例.骨折按AO分型:A2.2型1例,...     

Stellenwert der Navigation in der Beckenchirurgie

Definitive therapy of pelvic ring and acetabulum injuries often requires access with extensive deep exposure, thereby causing additional surgical soft tissue trauma. Computed-assisted navigated surgical procedures for percutaneous screw fixation are being applied in practice with increasing success. In addition to the advantage of preserving the soft tissue envelope, the navigation system achieves greater precision in implant insertion and minimizes radiation exposure. Non- or scarcely dislocated as well as unstable fractures are particularly suited for this procedure. When treatment goals are taken into consideration – anatomic reduction and exercise-allowing stabilization – navigated percutaneous surgical procedures on the pelvis and acetabulum are, in selected cases, a promising alternative to conventional surgical procedures.     

透视导航下经皮螺钉固定治疗髋臼骨折

目的探讨导航技术在经皮螺钉固定治疗髋臼骨折中的临床应用。方法2005年5月至2007年8月，使用C臂透视导航设备对带34个髋臼损伤的33例患者行导航下髋臼骨折经皮螺钉固定术。骨折按照AO分型，A3型21个，B1型8个，B2型2个和c1型3个。受伤到手术的平均时间为5．6d（2—8d）。2例患者髋臼骨折需要小切口切开复位。结果共放置空心螺钉43枚，放置1枚空心螺钉平均费时24．6rain，平均X线透视28．4s。将导航下图像与实时C臂机摄片进行对照，放置螺钉后验证位置平均偏差为1．96mm，平均偏差角度为2．45。。术中出血少，其中1枚螺钉出现偏移。术后1例患者出现股神经损伤症状，2个月后恢复，该神经症状与髋臼骨折使用小切口复位有关，与螺钉固定无关。术后无感染及内固定失败。关节功能评分：优25例，良5例，一般3例，优良率91％。结论经皮螺钉固定可以有效早期治疗髋臼损伤，透视导航技术可使螺钉固定的安置更加准确和安全，既减少了手术和X线暴露时间，又有利于患者早期的康复治疗。     

Image guidance in pelvic and acetabular surgery--expectations, success and limitations

During the last decade navigation techniques in pelvic and acetabular surgery have been described. Nowadays, available techniques include CT-based navigation, 2D C-arm navigation and 3D C-arm navigation. The main indication is the navigated percutaneous SI screw fixation, but acetabular screw fixations are also reported. In this article, based upon a literature review and our own clinical experiences, the indications for and limitations of navigated techniques in pelvic and acetabular surgery are described.     

Computer assisted pelvic and acetabular surgery. Clinical experiences and indications

CT based navigation has been used in spine surgery since 1994. Several clinical studies could show an increase in precision compared to the conventional technique and thus nowadays the navigated pedicle screw placement is a routine procedure in many hospitals.Based upon the experience in spine surgery the CT based navigation module was used for percutaneous screw fixations in minimally displaced pelvic ring and acetabular fractures.After preclinical experimental trials the C-arm navigation was used for 19 screw fixations. The postoperative control of the screw position was performed with postop. X-ray and CT.Overall 23 of the 24 screws were placed correctly. In one SI screw the postoperative CT could reveal a ventral cortex perforation of the sacrum without any clinical symptoms.Based upon this limited clinical experience we see the indication for CT based navigation in minimally displaced acetabular fractures or in SI screw fixations in case of sacral dysplasia. The C-arm based navigation with adequate image quality is our method of choice for SI screw fixation in traumatic or degenerative instabilities, especially if reduction maneuvers are necessary.     

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

Introduction

Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation.

Methods

This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients.

Results

The average time to operation was 4 days. Average blood loss was 110 mL. Operative time averaged 95 min. Maximum fracture displacement averaged 10 mm preoperatively and 1.3 mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigné score, functional outcome was good to excellent in all patients.

Discussion and conclusion

Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.     

Perkutane navigierte Ballonreposition einer dislozierten Acetabulumfraktur

Kyphoplasty is a well proven surgical procedure for osteoporotic fractures in spine surgery. Anatomic reconstruction of the joint is the primary aim in the treatment of acetabular fractures. To achieve this, extensive approaches with entry related morbidity are usually needed. Percutaneous stabilisations are still limited for non- or minimally displaced fractures.For displaced acetabular fractures, there are percutaneous procedures described with intraoperative CT control or by the use of a 3D C-arm. The case of an anterior column posterior hemitranverse fracture with an articular step in the weight bearing area is presented. In this case, a kyphoplasty balloon was placed by use of 3D C-arm navigation. After 2D C-arm controlled fracture reduction, the supra-acetabular screw was inserted percutaneously using the previous 3D navigation data set.With the combination of kyphoplasty technique, intraoperative 3D C-arm control and 3D C-arm based navigation, this displaced acetabular fracture could be reduced and fixed percutaneously. Anatomic reconstruction of the joint remains the primary aim.     

Percutaneous screw fixation of acetabular fractures with 2D fluoroscopy-based computerized navigation

Introduction

The treatment of displaced acetabular fractures with formal open reduction and internal fixation has gained general acceptance. However, extensile exposure can lead to complications. Two-dimensional fluoroscopy-based computerized navigation for placement of percutaneous screw across non-displaced acetabular fractures has attracted interest by making use of stored patient-specific imaging data to provide real-time guidance in multiple image planes during implant placement. The purpose of the present study was to document early treatment results and complications associated with this new technique and evaluate its clinical application to displaced acetabular fractures amenable to closed or limited open reduction.

Materials and methods

Eighteen adult patients with 12 non-displaced and 8 displaced acetabular fractures were treated with percutaneous screw fixation under the guidance of a fluoroscopy-based navigation system. There were 14 men and four women with a mean age of 42.1 years (range 19–54 years). According to the AO and Orthopaedic Trauma Association Classification, there were nine 62-A3, five 62-B1, three 62-B2, and three 62-B3. The mean follow-up was 21 months (range 12–28 months). The mean time from injury to surgery was 4 days (range 2–7 days).

Results

A total of 30 acetabular screws were inserted, including 21 anterior column screws and 9 posterior column screws. The average operation time was 24.6 min (range 16–47 min) from the image acquisition to wound closure. The average fluoroscopic time was 28.4 s (range 11–58 s). Compared to the final position of the screw, the average deviated distance of wire tip was 2.5 mm (range 1.1–3.6 mm) and the average trajectory difference was 2.45° (range 1.5°–4.6°). Maximal gap displacement averaged 10 mm (range 2–22 mm) preoperatively and 3 mm (range 0–5 mm) postoperatively; while maximal step displacement averaged 4 mm (range 1–10 mm) preoperatively and 2 mm (range 0–4 mm) postoperatively. One patient sustained a transient femoral nerve palsy and resolved 2 months after the operation. No superficial or deep infection occurred. Using the rating system of D’Aubigne and Postel, 13 patients had excellent results, 4 patients had good results, and 1 patient had a fair result.

Conclusion

Percutaneous screw fixation of acetabular fractures with 2D fluoroscopy-based navigation could be applied not only to non-displaced fractures but also to displaced fractures amenable to closed or limited open reduction.     

三维"C"型臂透视导航下治疗髋臼骨折

 目的 探讨术中使用三维野C冶型臂透视导航下髋臼骨折微创治疗的安全性及临床疗效。 方法 2008年 8月至 2010年 12月, 对 20例无明显移位的髋臼骨折患者采用三维野C冶型臂透视导航 下经皮微创螺钉内固定治疗, 男 9例, 女 11例;年龄 26~54岁, 平均(37.1±1.2)岁。致伤原因: 交通伤 15 例, 高处坠落伤 5例。骨折按 AO分型: A1.1型 2例, A2.2型 3例, A2.3型 4例, A3.2型 2例, A3.3型 2例, B1.1型 2例, B2.2型 2例, B3.1型 1例,C2.1型 1例, C2.3型 1例。结果 伤后至入: 时间为 2~46h, 平均(8.6±0.2) h。入: 后行骨牵引 3~14d后手术。术中共置入空心钉 46枚, 平均每枚置入时间 为(22.6±1.2) min。除 1枚空心钉因术中采集图像时出现较大偏差需重新置入外, 其余均一次性准确置 入, 成功率为 97.8%。置入后术中使用三维野C冶型臂进行透视成像验证所有螺钉均未进入关节间隙, 与 术后 CT扫描验证结果一致, 符合率 100%。术后切口均一期愈合, 无内固定失败。 20例患者均获得随 访, 随访时间 12~28个月, 平均(22.8±1.7)个月。末次随访 X线片示骨折愈合, 螺钉置入位置满意。结论 术中三维透视成像导航下对无明显移位髋臼骨折进行经皮微创内固定, 可有效重建髋臼关节面的平整 性, 提高螺钉置入的精确度, 减少切口长度与出血量, 降低手术对患者的损害, 减少术后并发症的发生, 有利于患者功能康复。     

Transgluteal posterior column screw stabilization for fractures of the acetabulum: a technical trick

SUMMARY:: The traditional exposure of high posterior column or transverse acetabular fractures can pose a challenge for lag screw stabilization. The authors describe an adjunctive percutaneous transgluteal lag screw technique for the internal fixation of the high posterior column. In the senior author's experience, this technique has been helpful to achieve the optimal trajectory for a stable perpendicular lag screw to maintain an anatomical reduction. In our experience, this technique has been used in conjunction with the standard Kocher-Langenbeck exposure and posterior column plating techniques.     

Comparative strength of three methods of fixation of transverse acetabular fractures.

With the advent of percutaneously placed lag screws for fixation of acetabular fractures, this study evaluated the strength of lag screw fixation compared with traditional fixation techniques of transverse acetabular fractures. Ten formalin-treated human, cadaveric pelvic specimens with bilateral, transtectal transverse acetabular fractures were used for this study. The right acetabular fractures were fixed with a five-hole plate and four screws with the central hole spanning the posterior fracture site. The left acetabular fractures were fixed with two lag screws, one each in the anterior and posterior columns, or with a screw and wire construct stabilizing both columns. The specimens were loaded to implant failure. Stiffness, yield strength, maximum load at failure, and site of failure was recorded. The plate and screw construct showed significantly greater yield and maximum strength when compared with the two lag screws. The stiffness of the lag screw method was 39% higher than that of the plating method, but this result was not statistically significant. In addition, the plate and screw method provided significantly greater maximum strength than the screw and wire technique. The quadrilateral plate seemed to be the weakest area of fixation because 83% of the implant failures occurred in this region. In patients in whom the risks of formal open reduction and internal fixation of acetabular fractures outweigh the possible benefits, such as in patients with burns or degloved skin, the advent of computer-assisted and fluoroscopically guided percutaneous surgical techniques have been instrumental. This study showed there is greater strength of fixation with a plate and screw construct, possibly secondary to supplementary fixation distal to the quadrilateral plate. However, lag screw fixation provided relatively greater stiffness, which may account for its clinical success. Percutaneous lag screw fixation of appropriate transverse acetabular fractures is a viable option.     

BK 2112 Gonarthrose

This article presents an overview of the possibilities of navigated procedures in pelvic ring and acetabular fractures from our experimental and clinical experiences. First of all, various navigated procedures for sacroiliac (SI) screw fixation were assessed in cadaveric studies (n=80 screws) and compared with the conventional technique. Subsequently, clinical comparison was made of the 2D fluoroscopic navigated procedure (n=35) and the conventional technique (n=23) and by a retrospective survey all SI screw fixations from a 7-year period conducted in our hospital (n=139) were analyzed. Experimental studies in human cadaveric models (n=10 screws) for supra-acetabular percutaneous screw placement (parallel to the quadrilateral surface) via 3D-fluoroscopic navigated procedure were performed and compared with clinical case studies. Conclusion: we found a significant prolongation of the procedural time for navigated inserted iliosacral screws in comparison to those that were inserted by the conventional technique. In contrast, intraoperative fluoroscopic exposure time was decreased by approximately 50% by using the navigated technique. Furthermore, the failure rate in screw positioning was around four times higher using the conventional technique versus the navigated procedure. The failure rate increased significantly according to the practical experience of the surgeon. For acetabular surgery the 2D-fluoroscopic based navigation is a helpful tool, whereas the 3D-fluoroscopic navigation procedure reveals a high learning curve. While navigated iliosacral screw fixation is well-established, the use of navigation in acetabular surgery will remain limited, for the time being, to individual cases.     

An innovative method of fracture reduction in an arthroscopically assisted cannulated screw fixation of an Ideberg type III glenoid fracture

Significantly displaced intra-articular glenoid fractures treated nonoperatively have been found to have poor functional outcomes. For this reason, most are treated with open reduction and internal fixation. Conventional open techniques involve extensive exposure and soft tissue dissection. Moreover, visualization of the fracture and its reduction can also be difficult even with standard open techniques. We present a case of an Ideberg type III glenoid fracture treated with an arthroscopically assisted percutaneous screw fixation, using the coracoid as a reduction aide. This reduction technique is not previously reported in the literature. Arthroscopically assisted percutaneous glenoid fixation has showed promising early results in the literature. In our case, the fracture united and the patient returned to all his normal daily activities by 7 weeks postoperatively. This suggests arthroscopically assisted glenoid fixation provides good functional and radiological outcomes, without the need for extensive soft tissue dissection.     

Is there a role for percutaneous pelvic and acetabular reconstruction?

The primary goal in the treatment of pelvic fractures is the restoration of haemodynamic stability. The secondary goal is the reconstruction of stability and symmetry of the pelvic ring. Percutaneous reconstruction can only be accepted if these goals are met. The type of definitive surgery is dependent of the degree of instability of the anterior and posterior pelvic ring. Retrograde transpubic screw fixation of pubic rami fractures is a good alternative to external fixation or plate and screw osteosynthesis. The technique of screw placement and image intensifier control is explained. Internal fixation of pure sacroiliac dislocations, fracture-dislocations of the sacroiliac joint and sacral fractures can be fixed with sacroiliac screws, placed percutaneously. Reduction of the fracture or dislocation is performed closed, or open if anatomy cannot be restored in a closed manner. The primary goal in the treatment of acetabular fractures is to restore anatomy. Reduction comes before fixation. The goal of minimising approaches cannot be more important. In most cases open reduction will be necessary to achieve anatomical reconstruction. Only the experienced acetabular surgeon will be able to decide when and how he can restore anatomy through a less invasive approach or with a percutaneous procedure. The anterior column screw can be inserted through a separate incision in addition to a Kocher-Langenbeck approach. It is the same screw as the retrograde transpubic screw but placed in the opposite direction. The posterior column screw is placed percutaneously from the lateral cortex of the ilium in the direction of the posterior column. Techniques of placement of both screws are demonstrated. Open reduction and internal fixation remains the standard of care in stabilisation of pelvic and acetabular fractures. Only the experienced surgeon will be able to judge if percutaneous procedures can be an alternative or a useful additive to conventional techniques.     

The use of a 3D-printed personalised drill guide for posterior column lag screw fixation in displaced transverse acetabular fracture: A case report

Introduction and importanceAnterior column plate combined with posterior column screws have been effectively used for treatment of displaced transverse acetabular fractures. This article presents the use of 3D-printed technology for customising a guide template to appropriately place posterior column screw.Case presentationA 50-year-old female suffered displaced juxtatectal fracture of the right acetabulum. A personalised guide for antegrade posterior column screw placement was designed based on the data of her pelvic CT-scan. This guide and a prototype of her right acetabulum - created by mirroring the intact left acetabulum - were 3D-printed for preoperative evaluation and pre-contouring of reconstruction plate. Modified Stoppa approach and additional lateral window were used for direct reduction, anterior column plate and posterior column lag screw fixation. Post-operative CT-scan showed good reduction and nearly ideal screw position.Clinical discussionAnterior column plate and antegrade posterior column screw could provide joint stability and early mobilisation for displaced transverse acetabular fractures. However, determination of optimal entry point, direction and length for screw insertion is still technically demanding. The 3-D reconstruction images of hemipelvic specimen allowed us to identify the safe bone corridor, design a drill guide to put the proper guide pin and conduct preoperative trial. All those resulted in appropriate real screw fixation with reduction of soft tissue damage, X-ray exposure and time of operation.ConclusionThe use of 3D-printed personalised guide for posterior column screw fixation is a promising alternative option for treatment of displaced transverse acetabular fracture where 3D-navigation system is not available.     

Closed reduction and percutaneous fixation of anterior column acetabular fractures.

OBJECTIVE: The current standard treatment of anterior column acetabular fractures includes formal open reduction with internal fixation (ORIF) through a variety of anterior approaches. These approaches have been associated with significant blood loss, infection, lengthy operative times, and neurovascular complications. It therefore seems reasonable to consider less invasive alternatives to conventional treatment methods. A technique for percutaneous reduction and fixation of a particular acetabular fracture pattern is presented. Execution of this technique has been facilitated by the use of image-guided surgical navigation. MATERIALS AND METHODS: A retrospective review was performed on 23 patients who had suffered an acute anterior column fracture of the acetabulum (OTA 62-A3.2, 62-A3.3, 62-B3.2, 62-B3.3) managed with closed reduction and internal fixation using large-bore cannulated screws over an 11-year period. An additional three patients treated during the study period underwent formal ORIF with plates and screws after failure of attempted closed reduction, and were not included in this analysis. Eight of the 23 patients had an associated posterior hemitransverse fracture that was also managed with minimally invasive fixation. A variety of surgical navigation techniques were used to allow accurate percutaneous screw placement: CT-guided percutaneous fixation was performed in 10 patients (1990-1995); fluoroscopy alone was used in four patients (1995-1998); and computer-assisted virtual fluoroscopy was used in nine patients (1999-2002). Some fractures were nondisplaced but potentially unstable, and involved the superior weight-bearing dome; others required closed manipulation using Schanz-pin joysticks placed into the iliac wings and held in place with a temporary external fixator. One patient required a limited open reduction followed by percutaneous screw fixation. After confirmation of adequate reduction, one to three large-bore cannulated screws were placed percutaneously using previously defined safe trajectories. All patients were managed postoperatively with early mobilization and physical therapy. RESULTS: The average preoperative and postoperative displacements were 8.9 and 2.4 mm, respectively. No patient had a loss of reduction during healing. As experience was gained with the computer-assisted imaging, total fluoroscopy times were as little as 6 s, and were routinely kept below 45 s. None of the patients experienced infection, significant blood loss, or iatrogenic neurologic or visceral injury. No symptomatic heterotopic ossification was noted. Of those patients available for follow-up at a minimum of 2 years, the average HSS self-administered hip score was 91. CONCLUSION: We believe that our findings substantiate percutaneous reduction and internal fixation of anterior column acetabular fractures as a safe and effective alternative to formal ORIF, with a low anticipated complication rate and excellent outcome.     

单切口钢板结合经皮拉力螺钉治疗髋臼骨折

目的 探讨单切口钢板结合经皮拉力螺钉内固定治疗髋臼骨折的临床疗效.方法 采用K-L入路行钢板内固定并结合前柱经皮拉力螺钉内固定治疗13例复杂髋臼骨折患者.结果 按Matta标准评价髋臼骨折复位质量:解剖复位7例,满意复位5例,不满意复位1例.髋关节功能参照改良的Merle d′Aubigné-Postel功能评分标准:优6例,良4例,可2例,差1例.并发症:坐骨神经损伤1例,异位骨化2例,创伤性关节炎1例.结论 单切口钢板结合经皮拉力螺钉治疗髋臼骨折创伤较小,固定可靠,临床效果满意,是处理髋臼骨折的一种可行方法.     

Percutaneous fixation of scaphoid fractures.

The scaphoid proximal pole and waist fractures presented here were treated by a novel dorsal percutaneous technique with arthroscopic assistance. All fractures healed, with good final functional results and no complications. The advantages of the dorsal percutaneous approach to scaphoid fixation are: (1) the proximal-to-distal placement of the guide pin and screw allow for more precise placement along the central axis of the scaphoid, which decreases healing time and reduces risk of screw thread exposure. (2) The dorsal approach avoids injuring the vulnerable volar ligament anatomy. And (3) the insertion of the screw from the proximal to distal direction allows the more rigid fixation of proximal scaphoid fractures. Arthroscopy allows confirmation of fracture reduction and screw implantation as well as evaluation of concurrent ligament injuries not detected with standard imaging. Percutaneous K-wires act as joysticks to reduce and compress fracture fragments prior to fixation. The presented technique allows for early, rigid internal fixation with minimal associated morbidity. Patients successfully treated with this technique include those with stable and unstable acute fractures of the scaphoid at all locations, including the proximal pole. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique. This technique allows for faster rehabilitation and an earlier return to work or avocation without restriction once CT scan confirms a solid union. Some articles document extraordinary rapid healing by standard radiographs; however, we caution that scaphoid bone healing cannot accurately be determined without CT scan. Percutaneous, arthroscopically assisted internal fixation by a dorsal approach may be considered in all acute scaphoid fractures selected for surgical fixation. The dorsal guidewire permits dorsal and volar implantation of a cannulated screw along the central axis of the scaphoid. This technique permits the reduction of displaced fractures and the stable repair of fractures of the proximal pole. In addition, selected scaphoid fibrous union or delayed union may also be repaired, with realistic expectations of healing. The proven benefits of the percutaneous technique include decreased soft tissue trauma; arthroscopic visualization of the fracture, ensuring anatomic reduction; and stable fixation, allowing early physical rehabilitation. The theoretical benefits of the technique include decreased risk of interruption of the tenuous scaphoid blood supply. Percutaneous internal fixation of scaphoid fractures provides faster rehabilitation, earlier return to work, and quicker bony union in most patients.     

Calcaneus fractures: facts, controversies and recent developments

The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be reliably proven intra-operatively either with Brodén views, high-resolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures. The benefits of newly developed plate designs and subtalar arthrolysis at the time of hardware removal remains to be proven in further studies. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.