Quality of Reduction of Displaced Intra-articular Calcaneal Fractures Using a Sinus Tarsi Versus Extensile Lateral Approach

Abstract

Objective: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs).Design: Retrospective.Setting: Level 1 and level 2 academic centers.Patients: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs.Methods: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity:

Surgeon Learning Curve for the Sinus Tarsi Approach to Intra-articular Calcaneus Fractures – Improvement with Experience

“…Only 1 patient required surgical debridement for acute infection, and 50% of the patients in their cohort required implant removal at mean 13 months postoperatively. Busel et al 9 found 7 of 36 DIACFs (19.4%) treated using STA were excellent and 13 of 36 (36.1%) were good in their series. Using the same grading criteria as those authors, our results demonstrate most achieved good or excellent reductions (85%) and most Sanders II were excellent.…”

“…To mitigate soft-tissue challenges faced with the ELA, the STA is increasingly being used for treatment of DIACF, with reports of equivalent comparative outcomes. 5,7–9 Previous work has demonstrated that surgeon experience inversely correlates with complication rates. 16–18 This holds true for other complex fractures.…”

“…However, they were unable to associate a temporal relationship between wound complications based on surgeon experience nor was reduction quality evaluated quantitatively. Nosewicz et al 13 and Busel et al 9 both reported their results of ORIF of DIACF using the STA evaluated using postoperative CT scans although they did not stratify reduction quality by surgeon experience. Our results suggest surgeons improve with each successive case and particularly in the Sanders III/IV fractures.…”

“…These criteria have been previously reported, although not rigorously tested against clinical or functional outcome. 9,13,14…”

A Stepwise Minimally Invasive Sinus Tarsi Approach to Open Reduction and Internal Fixation of Displaced Intra-articular Calcaneal Fractures: Technique Tip

“…7,11,20 However, the STA, with its narrow field of exposure, can represent a challenge to inexperienced surgeons dealing with complex intra-articular fractures of the calcaneus, leading to inferior quality of reduction. 6 The current article will describe a step-by-step technical note to successful ORIF of DIACF using a minimally invasive STA.…”