Delta frame triplanar external fixation for displaced intra-articular calcaneal fractures: mid- to long-term outcomes and comparative literature review: *A single-stage external fixation-based approach for restoring calcaneal anatomy*

Basal O., Jefferies J. G., Serdar J., Doral M. N.

International Orthopaedics, vol.50, no.1, pp.273-285, 2026 (SCI-Expanded, Scopus) identifier identifier

  • Publication Type: Article / Article
  • Volume: 50 Issue: 1
  • Publication Date: 2026
  • Doi Number: 10.1007/s00264-025-06675-1
  • Journal Name: International Orthopaedics
  • Journal Indexes: Science Citation Index Expanded (SCI-EXPANDED), Scopus, Abstracts in Social Gerontology, CINAHL, EMBASE, MEDLINE
  • Page Numbers: pp.273-285
  • Keywords: Calcaneus fracture, Compartment syndrome, DIACF, External fixator, High-energy trauma, Hindfoot injury, Sanders type IV
  • Hacettepe University Affiliated: Yes

Abstract

Purpose: Displaced intra-articular calcaneal fracture treatment may involve surgical intervention to restore the anatomy of the calcaneus and promote proper healing. Numerous surgical techniques, such as open reduction internal fixation (ORIF) or percutaneous fixation, have been utilized with varying degrees of success in achieving anatomical reduction and functional outcomes. However, complication rates are still high, and there is ongoing debate regarding the optimal surgical approach. This study presents a delta-frame triplanar external fixation technique combining intra- and extra-calcaneal distraction, specifically designed for Sanders III/IV fractures with soft-tissue compromise. Methods: The technique combines intra-calcaneal and extra-calcaneal distraction principles to restore calcaneal morphology in three planes. 18 patients with Sanders type III and IV DIACFs were definitively surgically treated using a delta type triplanar fixator in a single stage between 2017 and 2020. Calcaneal restoration was achieved through the intra- and extra-articular distraction principle. Outcome measures included clinical, radiological and patient-reported outcomes including the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the Foot and Ankle Disability Index (FADI). Results: Eighteen patients (mean age 38 years) representing 26 fractures were evaluated. Two patients required subtalar arthrodesis by one year post injury. The post-operative Bohler and Gissane angles averaged 29.1° and 112.4°, respectively. Calcaneal inclination angle, height, and Böhler angle were restored within appropriate limits in all cases. At a mean follow-up of 52 ± 8.6 months (range 42 to 84 months), mean AOFAS and FADI scores were 82.5 and 85.5, respectively. Conclusion: The delta-framed triplanar external fixation technique appears safe, yielding favorable radiological outcomes and a low complication rate in the management of displaced intra-articular calcaneus fractures. These findings suggest effective restoration of calcaneal anatomy using triplanar external fixation.