Extended Sinus Tarsi Approach for Treatment of Displaced Intraarticular Calcaneal Fractures Compared to Extended Lateral Approach

Stable Clinical and Radiological Outcomes at Medium and over 5 Year Follow Up of Calcaneus Fracture Open Reduction Internal Fixation Using a Sinus Tarsi Approach

The sinus tarsi approach is increasingly growing in popularity for open reduction internal fixation of calcaneus fractures. Multiple studies have demonstrated favorable short-term results compared to the traditional extensile L incision, however long-term data over 5 years is currently limited to a single retrospective case series. Following local ethical approval, all patients who had completed a minimum 5 years from time of operation were contacted with a Standardized Telephone Questionnaire completed. This followed a previous retrospective chart review, with follow up telephone or clinic consultation performed by Davey et al. of this cohort at mean 35 months. Thirty-four fractures (31 patients) completed minimum 5 year follow up from the eligible group of 54 fractures (49 patients). Regarding functional outcomes, a significant improvement in mean Maryland Foot Score was observed between short- (mean 35.8 months) and medium-term (mean 81.9 months) of 77.6 (SD 15.0) to 86 (SD 7.9) (p = .0082). There was no significant difference in postoperative and long term radiographic Bohler's angle (p = .9683). Eleven feet (32%) proceeded to require reoperation, with removal of metal performed in 10 (29%), fusion in 2 (6%), and skin grafting following wound breakdown for 1 (3%). Four feet (12.9%) experienced post operative wound complications, including 3 (9.68%) cases of infection and 2 (6.45%) of delayed wound healing. This study demonstrated stable clinical and radiographic outcomes over 5 years following Calcaneus Fracture Open Reduction Internal Fixation using a sinus tarsi approach, supporting its continued usage when treating intraarticular calcaneus fractures for which operative intervention is indicated.

Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature

INTRODUCTION

To analyze recent literature comparing clinical outcomes of displaced intra-articular calcaneal fractures (DIACF) treated with open reduction and internal fixation using the extensile lateral approach (ELA) vs the minimally invasive sinus tarsi approach (STA), with a focus on wound complications.

MATERIALS AND METHODS

A comprehensive literature search was conducted utilizing PubMed, EMBASE, and Cochrane Library databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 2013 and 2022, level of evidence (LOE) I-III, head-to-head comparative studies reporting on clinical outcomes after DIACFs treated with ORIF using ELA versus STA, and literature with full-text written in English were included. Data collection included: publication year, study design, number of surgeons, number of participants, demographic data (mean age at time of surgery, percent male, body mass index, medical co-morbidities), preoperative data (mechanism of injury, Sanders classification, time from injury to surgical fixation), intraoperative data, and postoperative clinical and radiographic outcomes (Böhler angle, angle of Gissane, calcaneal height/length/width).

RESULTS

A total of 21 articles (4 randomized control trials, 17 cohort studies) comprising of 2086 patients with calcaneal fractures, treated with either ELA (n = 1129) or STA (n = 957) met inclusion criteria. The risk of postoperative wound-related complications (RR 2.82, 95 % CI: 2.00-3.98, I2=27 %) and the risk of reoperation (RR 1.85, 95 % CI: 0.69-5.00, I2=67 %) was higher in ELA patients comparted to STA patients. However, the increased risk of postoperative wound-related complications with an ELA vs. STA was shown to be trending downward in recent publications. The ELA group also experienced longer time to surgery, extended operative times, and prolonged hospital stays when compared to the STA group. Radiographic measurements at final follow-up, including Böhler angle, angle of Gissane, as well as calcaneal height, length, and width, showed no statistically significant differences between the two groups.

CONCLUSION

Surgical treatment of calcaneal fractures utilizing the ELA continues to have an increased rate of complications and reoperation when compared to the less invasive STA, yet recent trends in the literature show that this rate is decreasing. Operative treatment of calcaneal fractures via either an ELA or STA can both achieve comparable postoperative radiographic outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III.

Fixation of displaced intra-articular calcaneus fractures is safe using either sinus tarsi or extensile lateral approach

INTRODUCTION

Management of displaced intra-articular calcaneus fractures continues to challenge surgeons. Use of the extensile lateral surgical approach (ELA) had been standard practice however wound necrosis and infection have become deterrents. The sinus tarsi approach (STA) has gained popularity as a less invasive technique to optimize articular reduction while minimizing soft tissue injury. Our aim was to compare wound complications and infections following calcaneus fractures treated using ELA versus STA.

METHODS

Retrospective review of 139 displaced intra-articular calcaneus fractures (AO/OTA 82C; Sanders II-IV injuries) treated operatively at 2 level-I trauma centers using STA (n = 84) or ELA (n = 55) over a 3-year period with minimum 1-year follow up was performed. Demographic, injury, and treatment-related characteristics were collected. Primary outcomes of interest included wound complications, infection, reoperation, and American Orthopaedic Foot and Ankle Society ankle and hindfoot scores. Univariate comparisons between groups were conducted using Chi-Square, Mann-Whitney, and independent sample t-tests at the p < 0.05 significance level, where appropriate. Multivariable regression analysis was performed to identify risk factors for poor outcomes.

RESULTS

Demographic characteristics were homogenous between cohorts. Most sustained falls from height (77%). Sanders III fractures were most common (42%). Patients treated with STA went to surgery earlier (6.0 days STA vs 13.2 ELA, p < 0.001). No differences were seen in restoration of Bohler's angle, varus/valgus angle, or calcaneal height, yet the ELA significantly improved calcaneal width (-2 mm STA vs -13.3 mm ELA, p < 0.001). There were no significant differences in wound necrosis or deep infection based on surgical approach (12% STA vs 22% ELA, p = 0.15). Seven patients underwent subtalar arthrodesis for arthrosis (4% STA vs 7% ELA). No differences in AOFAS scores were seen. Risk factors for reoperation included Sanders type IV patterns (OR = 6.6, p = 0.001), increasing BMI (OR = 1.2, p = 0.021), and advanced age (OR = 1.1, p = 0.005), not surgical approach.

CONCLUSION

Despite prior concerns, use of ELA versus STA for fixation of displaced intra-articular calcaneus fractures was not associated with more complication risk, illustrating both are safe when indicated and executed appropriately.

A novel distractor-assisted reduction combined with the sinus tarsi approach for joint depression-type calcaneal fractures

PURPOSE

A novel percutaneous distractor with the advantage of axial and direct distraction was designed for the minimally invasive treatment of calcaneal fractures. The purpose of this study was to investigate the clinical results and complications of a novel distractor combined with sinus tarsi approach (STA) in treatment of the joint depression-type of calcaneal fractures.

METHODS

Fifty-four patients with the depression-type of calcaneal fractures (30 Sanders type II, 22 Sanders type III, 2 Sanders type IV) who were subjected to the novel distractor combined with STA were retrospectively assessed. Calcaneal height, width, and length; Bohler's angle; and the Gissane angle were evaluated pre-operatively and post-operatively. Clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) pain scores from the last follow-up. Complications were also recorded.

RESULTS

Fifty-two patients achieved an average follow-up of 24.3 months (range 18 to 34 months), and two patients were lost to follow-up six months post-operatively. There was significant difference between pre-operative and post-operative calcaneal height, width, and length; Bohler's angle; and Gissane angle (p < 0.01), but no significant difference was detected between the post-operative and normal side Bohler's angle (p > 0.05). The AOFAS ankle and hind foot score was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7 at the last follow-up. Nine (17.3%) patients developed complications: One experienced skin necrosis and two had screws loosening; three patients developed early degenerative changes of the subtalar joint; two had no symptoms; one had light pain around the subtalar joint without medical treatment; complex regional pain syndrome (CRPS) developed in one patient after seven months post-operatively; and two developed transient ankle stiffness.

CONCLUSION

The novel distractor combined with the STA effectively reconstructs the facet depression-type of calcaneal fractures (sanders type II and III) with minimal complications.

Modified sinus tarsi approach with a variable-angle locking anterolateral plate for Sanders type II and III calcaneal fractures

BACKGROUND

We compared the effectiveness of the extensile lateral approach (ELA) and modified sinus tarsi approach (MSTA) with a variable-angle locking anterolateral plate in treating Sanders type II and III calcaneal fractures.

METHODS

We reviewed 45 DIACFs treated by a single surgeon from 2017 to 2020. Open reduction using ELA and MSTA was performed in 25 and 20 patients, respectively. Follow-up evaluations included radiological assessments and clinical evaluations.

RESULTS

Pre- and postoperative radiologic parameters for the calcaneus were significantly different. The average American Orthopaedic Foot and Ankle Society scores were 81.24 and 85.00, the mean visual analogue scale scores were 2.28 and 1.65, and the wound-related complication rates were 64.0% and 15.0% in the ELA and MSTA groups, respectively. Bony union was achieved in all cases.

CONCLUSIONS

For Sanders type II and III fractures, MSTA seems to be a safer and more satisfactory method, with fewer postoperative complications.

Low Risk of Wound Complications With Sinus Tarsi Approach for Treatment of Calcaneus Fractures

BACKGROUND

Operative management displaced intra-articular calcaneus fractures is commonly associated with wound complications. Open reduction internal fixation is traditionally performed through the extensile lateral approach has relatively high rates of wound complications. The sinus tarsi approach to displaced intra-articular calcaneus fractures is a less invasive approach to achieve fracture reduction and fixation as well as reduce wound healing complications. The purpose of this study is to report the rates of wound complications associated with the sinus tarsi approach in the treatment of displaced intra-articular calcaneus fractures.

METHODS

We retrospectively identified patients treated with a limited sinus tarsi approach for displaced intra-articular calcaneus fractures from January 2009 to December 2018. Demographic and radiographic data were collected including age, gender, mechanism of injury, occupation, presence of diabetes mellitus, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements.

RESULTS

One hundred and five fractures were identified in 100 patients who underwent open reduction internal fixation for displaced intra-articular calcaneus fractures. Using the Sanders computed tomographic classification, we identified 32% Type 2, 48% Type 3, 18% Type 4, and 2% tongue-type variants. For the preoperative Bohler's angle, 38% of fractures displayed a negative angle, 50% had an angle 0° to 20°, and 12% over 20°. Postoperatively, all patients demonstrated an improvement in Bohler's angle with 13% with 0° to 20° and 87% over 20°. Approximately, 72% of patients working prior to the injury had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 11.9% (12/105), with 1.9% (2/105) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p = .55).

CONCLUSION

Operative management of displaced intra-articular calcaneus fractures through the sinus tarsi approach allows restoration of calcaneal height with a low rate of wound complications, even among active smokers.

Anatomical parameters of sustentaculum Tali screw placement in the Asian population: A retrospective radio-anatomical study

Purpose: This study aimed to determine the anatomical parameters of successful Sustentaculum Tali (ST) screw placement in the Asian population. Method: CT scans of unilateral feet of 110 participants were reviewed, retrospectively. The 3 D reconstruction of the calcaneus and morphometric measurements were performed by Mimics Research 19.0 and 3-Matic Research 11.0. Finally, six cadaveric feet were used for verification of the accuracy of the measurements. Results: We discovered a method to help place ST screw successfully: (1) The entry point located at the middle section of the lateral wall of posterior talar articular surface (PTAS), and the perpendicular distance from the entry point to the lateral edge of PTAS (PDEL) was 10.78 mm, (2) Screw was perpendicular to the z-axis, 66.98° to the y-axis (the longitudinal axis of the foot), (3) The length of the ST screw should be approximately 44.74 mm in male and 41.14 mm in female, and (4) The diameter of the ST screw should be approximately 4.0 mm in male and 3.5 mm in female. With this new method, all screws in six cadaveric feet were placed successfully into the middle of ST. Conclusions: In this study, we discovered a general approach to safely place ST screws in the Asian population, which may potentially help surgeons improve their success rate in surgical practice.

Surgical Treatment Using Sinus Tarsi Approach with Anterolateral Fragment Open-Door Technique in Sanders Type 3 and 4 Displaced Intraarticular Calcaneal Fracture

Although various outcomes of the sinus tarsi approach have been reported, these are limited to the Sanders type 2 displaced intraarticular calcaneal fractures (DIACF) because of the limited visibility of the posterior facet joint. In this study we aimed to (1) introduce a sinus tarsi approach combined with an anterolateral fragment open-door technique that enables adequate visibility of the innermost and middle portion of the posterior facet joint, and (2) evaluate the radiographic and clinical outcomes of the patients treated with that technique. This is a retrospective case-series study performed on medical records of 25 patients who presented with the Sanders type 3 or 4 DIACF and were treated with the sinus tarsi approach. The radiologic measurements showed significant corrections of the Bohler’s angle, calcaneal width, length, height, and articular step-off in both X-rays and CTs in the last follow-up period. The mean AOFAS score was 90.08 ± 6.44 at the last follow-up. Among all the follow-up patients, two cases (8%) had acute superficial infections, and no other wound complications occurred. Therefore, we suggest that the Sanders type 3 or 4 DIACF could be successfully treated with the proposed technique with low complications and bring out effective clinical and radiologic outcomes.

Sinus tarsi approach versus the extended lateral approach for displaced intra-articular calcaneal fractures: a systematic review and meta-analysis

BACKGROUND

The goal of this study was to review eligible randomized controlled trials to determine the efficacy of the sinus tarsi approach (STA) versus the extended lateral approach (ELA) for the treatment of displaced intra-articular calcaneal fractures (DIACF).

METHODS

Using appropriate keywords, we identified relevant studies using PubMed, the Cochrane Library, Embase, CNKI, VANFUN, and VIP. Key pertinent sources in the literature were also reviewed, and all articles published through June 2020 were considered for inclusion. For each study, we assessed odds ratios (ORs), mean difference (MD), and 95% confidence interval (95% CI) to assess and synthesize the outcomes.

RESULTS

We included 15 RCTs, with a total of 847 patients in the STA group and 959 in the ELA group. The results found that after STA and ELA, no significant difference in changes of Böhler's angle (WMD: 0.746, 95% CI: - 0.316-1.809), Gissane angle (WMD: - 0.710, 95% CI: - 2.157-0.737), calcaneal heights (WMD: 0.378, 95% CI: - 1.973-2.728), calcaneal widths (SMD: - 0.431, 95% CI: - 1.604- 0.742), calcaneal lengths (WMD: 0.691, 95% CI: - 0.749-2.131). Besides, there was no significant difference in the incidence of complications between the STA group and the ELA group (RR: 0.592, 95% CI: 0.336-1.045).

CONCLUSION

There was no difference in clinical efficacy between STA and ELA in treating DIACF. Besides, there is still a need of large-sample, high-quality, long-term randomized controlled trials to confirm the conclusion.

LEVEL OF EVIDENCE

Level I-High-Quality Prospective Randomized Study.

Mid- to long-term outcome in patients treated with a mini-open sinus-tarsi approach for calcaneal fractures

BACKGROUND

While the extended lateral approach was the gold standard for treatment of calcaneal fractures for decades, the mini-open approach through the sinus tarsi gained popularity in recent years. Although widely used, there are only a few reports available in the literature reporting on mid- to long-term results. Therefore, the purpose of the study was to report on mid- to long-term radiographic and clinical outcomes of calcaneal fractures treated surgically using a mini-open sinus tarsi approach.

MATERIALS AND METHODS

In this retrospective review, radiographic and clinical outcome measures of 30 consecutive patients (34 fractures) were analyzed. Conventional radiographs were used to measure the Boehler's angle before and after surgical fixation. Computed tomography (CT) scans were analyzed to distinguish between joint depression and tongue-type calcaneal fractures. Each calcaneal fracture was additionally categorized according to the Sanders classification. The clinical outcome was measured using a 5-point Likert scale ranging from 0 (very unsatisfied) to 4 (very satisfied), the Visual Analog Scale (VAS) for pain, and the Maryland Foot Score.

RESULTS

The Boehler's angle improved from 12.6 degrees preoperatively to 26.3 degrees postoperatively (P < 0.001). Loss of sagittal reduction (i.e., a decline of the Boehler's angle of > 5 degrees) from postoperative to the last follow-up was evident in nine (26%) fractures. Out of 29 patients with an available satisfaction score, 20 (69%) were very satisfied, 8 (28%) were satisfied, and one (3%) was moderately satisfied. Satisfaction at the last follow-up declined with higher age at surgery. An overall low complication rate was evident, with painful hardware needing removal being the most common complication.

CONCLUSIONS

Approaching calcaneus fractures through the sinus tarsi provides satisfactory mid- to long-term radiographic and clinical outcomes, independent of the severity of the fractures according to the Sanders classification.

LEVEL OF EVIDENCE

Level IV, Retrospective Case Series.

Randomized comparative study between extensile lateral and sinus tarsi approaches for the treatment of Sanders type 2 calcaneal fracture

AIMS

No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

METHODS

Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler's angle and calcaneal width, and posterior facet reduction.

RESULTS

Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001).

CONCLUSION

The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286-293.

Intra-articular Calcaneus Fractures: Current Concepts Review

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures.

Level of Evidence: Level V, expert opinion.