Surgical approaches for screw fixation of calcaneal fractures: a systematic review

Abstract

To systematically review and summarize the evidence related to different screw configurations in the internal fixation treatment of calcaneal fractures. This systematic review (PROSPERO registration CRD420261389986) employed a comprehensive literature search of PubMed/MEDLINE, Embase, the Cochrane Library, and Web of Science from database inception to December 16, 2025. Studies reporting on different screw configurations in the internal fixation treatment of calcaneal fractures were included. Twenty-three studies (1364 patients) were analyzed. AOFAS hindfoot scores ranged from 76 to 93, with two randomized controlled trials confirming functional equivalence between percutaneous screw fixation and open plate fixation (88.3 vs. 86.4 and 82.0 vs. 82.2, respectively). Wound complication rates were consistently lower with percutaneous or minimally invasive approaches (0–7%) compared with extensile lateral plating (10–28%). Because most included head-to-head studies differed in approach (and sometimes in construct complexity) rather than isolating single configuration variables (e.g., screw number, orientation, and trajectory independent of plate use), the evidence does not permit identification of a single “optimal” screw configuration. Böhler’s angle restoration was equivalent in most head-to-head comparisons, though one study demonstrated superior radiographic improvement in the screw cohort. Hardware removal rates favored screw fixation over plate fixation in direct comparisons. Omission of the sustentaculum tali screw engagement was associated with greater Böhler’s angle loss. Long-term follow-up to 16 years revealed progressive functional decline, underscoring the need for extended surveillance. Percutaneous and minimally invasive screw fixation appears to achieve functional outcomes equivalent to extensile lateral plate fixation while conferring a lower wound complication burden. Sustentaculum tali engagement seems to be important for supporting configuration-dependent radiographic maintenance. Nevertheless, configuration-specific comparative evidence isolating screw number/trajectory/construct design remains limited; therefore, the definitive optimal screw configuration cannot be concluded from the current literature. Evidence for Sanders type IV fractures remains insufficient. Long-term randomized trials incorporating subtalar arthritis as a primary endpoint are needed to define the definitive role of this technique. CRD420261389986.