Subtalar joint preparation using the Two Portal posterior arthroscopic technique versus the sinus tarsi Open approach: A cadaver study

Category: Ankle, Arthroscopy, Basic Sciences/Biologics Introduction/Purpose: Subtalar fusion is the treatment of choice for subtalar arthritis when conservative management fails. Subtalar fusion can be done through open approach or arthroscopic technique. Arthroscopic technique is associated with rapid recovery; however, it requires adequate training and skill. Arthroscopic technique can be done through lateral or posterior portals. Sometimes it may be necessary to use accessory portal to open or distract the joint for adequate joint preparation. Use of accessory portal may result in injury to the neurovascular structure. Whatever the technique, one of the most important aspects of fusion is adequate preparation of the joint. Aim of our study is to compare the preparation of subtalar joint using sinus tarsi open approach and posterior subtalar scopy using 2 portal technique in cadaveric specimens. Methods: We used 20 below knee fresh-frozen cadaver legs for this cadaveric study. Subtalar joints of ten specimens were prepared through the lateral approach, while the remaining ten joints were prepared using sinus tarsi incisions. After the completion of preparation, all ankles were dissected open, photographic images of calcaneal and talar articular were taken. (Image)Surface areas of each articular facet and prepared area of the talus, distal tibia, and distal fibula were measured and analyzed. Results: Open technique results in better preparation of joint surface in calcaneus and overall. While open technique results in preparation of 92% joint surface (combined talus and calcaneus), arthroscopic technique results in in 80% of joint surface. Open technique results in better preparation of calcaneus (79vs 94%). The anterolateral corner of calcaneus was difficult to be reached using the scope and unprepared in most cases. There was no significant difference in the preparation of talar articular surface. (Table 1) Conclusion: Open sinus tarsi results in more joint preparation compared to 2 portal posterior arthroscopic technique. The less amount of joint preparation in arthroscopic technique is mostly due to less preparation of AL corner. Of calcaneus. When using posterior arthroscopic technique, it is advisable to use accessory portal to distract the joint to aid in adequate preparation.

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Subtalar Fusion Preparation: What Are We Really Doing? A Cadaver Study

Foot & Ankle Specialist ◽

10.1177/1938640019846970 ◽

2019 ◽

Vol 13 (3) ◽

pp. 201-206 ◽

Cited By ~ 1

Author(s):

Eildar Abyar ◽

Haley M. McKissack ◽

Martim C. Pinto ◽

Zachary L. Littlefield ◽

Leonardo V. Moraes ◽

...

Keyword(s):

Surface Area ◽

Subtalar Joint ◽

Cadaver Study ◽

Joint Surface ◽

Lateral Sinus ◽

Total Percentage ◽

Sinus Tarsi ◽

Lateral Incision ◽

Sinus Tarsi Approach ◽

Fresh Frozen

Introduction. The open, lateral sinus tarsi approach is the most commonly used technique for subtalar arthrodesis. In this cadaver study, we measured the maximum joint surface area that could be denuded of cartilage and subchondral bone through this approach. Methods. Nine fresh frozen above-knee specimens were used. The subtalar joint was accessed through a lateral incision from the fibular malleolus distally over the sinus tarsi area to the level of the calcaneocuboid joint. Cartilage was removed from the anterior, middle, and posterior facets of the calcaneus and talus using an osteotome and/or curette. ImageJ was used to calculate the surface areas of undenuded cartilage. Results. No specimens were 100% denuded of cartilage on all 6 measured surfaces. The greatest percentages of unprepared surface area remained on the middle facet of the talus (18.66%) and the middle facet of the calcaneus (14.51%). The anterior facet of the talus was 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 specimens. The anterior facet of the calcaneus was also 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 and 4 specimens, respectively. The average total unprepared surface area per specimen was 8.67%. Conclusion. The lateral sinus tarsi approach provides adequate denudation of cartilage of the subtalar joint in most cases. Total percentage of unprepared joint surface may range from approximately 2% to 18%. Future clinical studies are warranted to assess whether this technique results in optimal union rates. Levels of Evidence:V, Cadaveric Study

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Common Pitfalls in Subtalar Joint Preparation for Arthrodesis via Sinus Tarsi Approach

The Journal of Foot & Ankle Surgery ◽

10.1053/j.jfas.2019.08.006 ◽

2020 ◽

Vol 59 (2) ◽

pp. 253-257

Author(s):

Neil B. Patel ◽

Cody Blazek ◽

Rick Scanlan ◽

Jeffrey M. Manway ◽

Patrick R. Burns

Keyword(s):

Subtalar Joint ◽

Joint Preparation ◽

Sinus Tarsi ◽

Sinus Tarsi Approach

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The ACL of the Ankle Joint: A Cadaveric Evaluation of the Subtalar Intrinsic Ligaments and Optimal Surgical Approach

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00196 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0019

Author(s):

Naven Duggal ◽

Patrick M. Williamson ◽

Ara Nazarian

Keyword(s):

Ankle Joint ◽

Subtalar Joint ◽

Cruciate Ligament ◽

Surgical Approaches ◽

Ankle Sprains ◽

Anterior Border ◽

Lateral Ankle ◽

Sinus Tarsi ◽

Sinus Tarsi Approach ◽

Anterior Cruciate

Category: Ankle; Basic Sciences/Biologics; Sports Introduction/Purpose: The biomechanics of ankle sprains involves a multiplanar-supination motion and not the strict inversion as is often described. During supination, calcaneal inversion occurs at the anatomic subtalar joint. The intrinsic subtalar ligaments include a series of broad thick ligaments situated in the tarsal canal that separate the anterior and posterior compartments. The subtalar intrinsic ligaments are damaged in an estimated 25% to 80% of all lateral ankle sprains. We hypothesize that the intrinsic subtalar ligaments have a multiplanar role in ankle joint stabilization similar to that of the anterior cruciate ligament at the knee. The purpose of this study is to evaluate the efficacy of four surgical approaches to the subtalar ligaments through cadaveric dissection. Methods: Four fresh-frozen cadaveric ankle specimens were utilized. Ability to access the extrinsic lateral ankle ligament (anterior talofibular), the extrinsic subtalar ligaments (calcaneofibular, lateral talocalcaneal) and the intrinsic subtalar ligaments (interosseous talocalcaneal, cervical) was evaluated. The first cadaveric specimen was dissected as a baseline to identify the extrinsic and intrinsic subtalar ligaments. The three remaining cadaveric specimens were utilized to evaluate the efficacy of three standard surgical approaches (a curvilinear incision made over the distal anterior border of lateral malleolus, a posterolateral longitudinal incision, and an extensile sinus tarsi approach) to access both the extrinsic ankle and subtalar ligaments as well as the intrinsic subtalar ligaments. Ability to access all ligaments as well as identification of neurovascular structures at risk during the dissection was recorded for each approach. Results: The curvilinear incision made over the distal anterior border of the lateral malleolus provided access to the anterior talofibular, calcaneofibular ligaments. Branches of the superficial peroneal nerve were noted to be at direct risk. The posterior longitudinal incision provided access to the calcaneofibular, lateral talocalcaneal ligaments. Branches of the sural nerve were noted to be at direct risk with this approach. An extensile posterolateral incision improved access to the anterior talofibular ligament. An extensile sinus tarsi approach provided the most direct access to the interosseous talocalcaneal and cervical ligaments. Visualization of the calcaneofibular and lateral talocalcaneal was also provided with this incision. The saphenous and superficial nerve branches and the sinus tarsi artery were noted to be at risk. Conclusion: We hypothesize that the intrinsic subtalar ligaments have a multiplanar role in ankle joint stabilization similar to that of the anterior cruciate ligament at the knee. Accurate identification and optimal surgical approach to these structures has not been well described in the orthopaedic foot and ankle literature. This cadaveric study provides evidence that an extensile sinus tarsi approach can provide access to the extrinsic ankle and subtalar ligaments as well as the intrinsic ligaments of the subtalar joint.

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Miniopen vs Lateral Approach for Ankle Arthrodesis, Which Approach is Superior in Joint Preparation: A Cadaver Study

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00139 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0013

Author(s):

Karthikeyan Chinnakkannu ◽

Haley McKissack ◽

Gean C. Viner ◽

Jun Kit He ◽

Leonardo V. M. Moraes ◽

...

Keyword(s):

Surface Area ◽

Ankle Arthrodesis ◽

Lateral Approach ◽

Fixation Method ◽

Open Approach ◽

Ankle Arthritis ◽

Joint Preparation ◽

Significant Difference ◽

In Trans ◽

Mini Open

Category: Ankle, Ankle Arthritis, Arthroscopy, Basic Sciences/Biologics Introduction/Purpose: Ankle arthrodesis is a gold standard for end-stage ankle arthritis after conservative managements fail. It may be done through direct anterior, lateral, arthroscopic or mini open approaches. Joint preparation, apposition of joint surfaces and stable fixation are very important for successful outcomes. Ankle arthrodesis maybe associated with infection, chronic pain and nonunion - of these, nonunion is the most common complication reported. Achieving union is of utmost importance while minimizing complications associated with the procedure. Regardless of approach or fixation method, preparation of articular surface is of paramount importance for successful union and may be limited by the approach used. Our study aims to evaluate the difference between direct lateral and dual mini-open approaches (extended arthroscopic portals) in terms of joint preparation. Methods: We used 10 below knee fresh-frozen cadaver legs for this cadaveric study. Ankle joints of five specimens were prepared through the lateral approach, while the remaining five ankles were prepared using dual mini incisions. After the completion of preparation, all ankles were dissected to open, photographic images of tibial plafond and talar articular were taken. Surface areas of each articular facet and unprepared cartilage of the talus, distal tibia, and distal fibula were measured and analyzed using ImageJ software. Results: Significantly greater amount of total surface area was prepared among specimens using mini-open approach compared to those with trans-fibular approach. The percentage of total articulating surface area prepared (including talus and tibia/fibula), talus, tibia and fibula in trans-fibular approach were 76.9%, 77.7% and 75% respectively. The percentages were 90.9%, 92.9%, and 88.6% in mini-open approach. While the medial gutter was well prepared with mini incision technique (unprepared surface 44 .64% vs 91.08%), lateral gutter was well prepared in trans-fibular technique (88.82vs 82.04 square cm). There is no difference in the amount of unprepared surface of talar dome between the two approaches. When excluding the medial gutter, there was no significant difference between trans-fibular and mini open techniques (83.94 vs 90.85, p=0.1412). Conclusion: Joint preparation using the mini-open approach (extended arthroscopic portal) is equally as efficacious as the transfibular approach for preparation of the tibiotalar joint. When including preparation of the medial gutter, the mini-open approach provides superior joint preparation. This may be advantageous with decreased rate of nonunion and less complications. But many surgeons fuse only tibiotalar surface, considering that, both approaches yield equal amount of joint preparation. But it needs to be confirmed with clinical studies.

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

The Bone & Joint Journal ◽

10.1302/0301-620x.103b.bjj-2020-1313.r1 ◽

2021 ◽

pp. 1-8

Author(s):

Chul Hyun Park ◽

Hongfei Yan ◽

Jeongjin Park

Keyword(s):

Comparative Study ◽

Subtalar Joint ◽

Short Form ◽

Operation Time ◽

Wound Complications ◽

Calcaneal Fractures ◽

Aofas Score ◽

Sinus Tarsi ◽

Sinus Tarsi Approach

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 movement (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.

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Endoscopic versus Open Approach to the Infratemporal Fossa: A Cadaver Study

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0035-1549003 ◽

2015 ◽

Vol 76 (05) ◽

pp. 358-364 ◽

Cited By ~ 13

Author(s):

Ricardo Carrau ◽

Ahmed Tantawy ◽

Ahmed Ibraheim ◽

Arturo Solares ◽

Bradley Otto ◽

...

Keyword(s):

Infratemporal Fossa ◽

Cadaver Study ◽

Open Approach

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Anatomy of the Tarsal Canal and Sinus in Relation to the Subtalar Joint Capsule

Foot & Ankle International ◽

10.1177/1071100718788038 ◽

2018 ◽

Vol 39 (11) ◽

pp. 1360-1369 ◽

Cited By ~ 3

Author(s):

Reiko Yamaguchi ◽

Akimoto Nimura ◽

Kentaro Amaha ◽

Kumiko Yamaguchi ◽

Yuko Segawa ◽

...

Keyword(s):

Subtalar Joint ◽

Anatomical Study ◽

Joint Capsule ◽

Anterior Capsule ◽

Talocalcaneal Joint ◽

Sinus Tarsi ◽

Anatomical Relationship ◽

Synovial Tissues ◽

Fibrous Tissues ◽

Tarsal Canal

Background: Anatomical knowledge of the tarsal canal and sinus is still unclear owing to the complexity of the ligamentous structures within them, particularly the relationship with the capsules of the subtalar joints. The aim of this study was to examine the anatomical relationship between the fibrous tissues of the tarsal canal and sinus and the articular capsules of the subtalar joint. Methods: We conducted a descriptive anatomical study of 21 embalmed cadaveric ankles. For a macroscopic overview of the subtalar joint, we removed the talus in 18 ankles and separated the fibrous tissues from the surrounding connective tissues to analyze the layered relationship between the inferior extensor retinaculum (IER) and the subtalar joint capsule. Additionally, we histologically analyzed the tarsal canal and the medial and lateral sides of the tarsal sinus using Masson’s trichrome staining in 3 ankles. Results: The medial and intermediate roots of the IER and interosseous talocalcaneal ligament (ITCL) were located in the same layer and were connected to each other, between the capsules of the posterior talocalcaneal and talocalcaneonavicular joints. The intermediate root of the IER and the cervical ligament (CL) had adjacent attachments on the tarsal sinus, and synovial tissues originating from the joint capsules filled the remaining area in the tarsal canal and sinus. Conclusion: We determined that the tarsal canal and sinus tarsi contained 3 layered structures: the anterior capsule of the posterior talocalcaneal joint, including the anterior capsule ligament; the layer of ITCL and IER; and the posterior capsule of the talocalcaneonavicular joint, including the CL. Clinical Relevance: The results of this study may help with the understanding of the pathomechanism of subtalar instability and sinus tarsi syndrome, resulting in better treatment.

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