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

Abstract

Objective: To analyze the relationship between surgeon experience with the sinus tarsi approach (STA) and outcomes in the treatment of displaced intra-articular calcaneus fractures (DIACF). Setting: Single level 1 trauma center Design: Retrospective. Patients/Participants: 103 consecutive DIACF (OTA/AO 82C; Sanders II-IV) treated operatively using STA from 2015 to 2021. Intervention: Open management using the STA performed by two fellowship-trained orthopaedic traumatologists. Main Outcome Measurement: Quality of anatomic reduction based on postoperative CT scans and standard radiographs. Results: Sixty-six patients met inclusion criteria. Patients were primarily men (75.8%) with mean age 41 years (range 20-71 years), including 14 smokers (21.2%), 9 diabetics (13.6%), and 10 open fractures (15.2%). Sanders III fractures were most common (68.2% vs 28.5% and 6.1% Sanders II/IV respectively). Reduction quality was predominantly Good (59.1%, n=39) or Excellent (25.8%, n=17). Complications included wound necrosis (1), superficial infection (1), deep infection (1), and symptomatic posttraumatic arthritis requiring arthrodesis (3). There was a 29.3% reduction in likelihood of surgical complication with each year in surgeon experience with the STA and an 8.9% reduction per case (p<0.001). The likelihood of achieving a Good or Excellent reduction was 1.8 and 2.3 times greater than achieving a Fair reduction, respectively, for each year increase in surgeon experience with the STA (p=0.012 and 0.007, respectively). For each successive case, there was a 1.2 times greater likelihood of achieving a Good reduction (p=0.03). Conclusion: Surgeon experience plays a critical role in outcomes. We found that outcomes (reduction, complications) improve with each cumulative case and year of experience with the STA to treat DIACF. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.