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

Background The purpose of this study was to evaluate the optimal timing and measures of the sinus tarsi approach for calcaneus fractures to avoid iatrogenic injury of the sural nerve and to assess for wound complications. Methods: A case series of 53 patients with calcaneus fractures treated by a single surgeon with the sinus tarsi approach was retrospectively analyzed. On the basis of the delay time from injury to surgery, patients were classified into 4 groups: immediate (0–3 days), early (4–6 days), intermediate (7–14 days), and late (14–18 days). All patients were followed for at least 1 year to observe wound conditions. The rate of wound complications and iatrogenic sural nerve injury was described. Incisions were classified into 2 groups: group A included patients with incisions extending posterior to the lateral malleolus, and group B included patients with incisions confined anterior to the lateral malleolus. The rates of nerve injury were compared between both groups. Forty-three patients with 52 Sanders type II fractures were included. Results: The average time to surgery from injury was 8.8 days (range, 0–18 days). The overall postoperative rate of wound complications was 5.8% (3 of 52). In the immediate group, deep infections and wound necrosis were found in 2 of 8 fractures (25%). In the early group, 1 of 15 fractures developed superficial infection (6.7%). In the intermediate and late groups, no wound complication was identified. Iatrogenic sural nerve injury was recorded in 5 of 52 patients (9.6%). Group A had 33% (4 of 12) nerve injuries and group B had 2.5% (1 of 40) ( P = .009). In 70% of cases, a main branch of the sural nerve was directly under the incision. Conclusions: The sinus tarsi approach was generally effective and safe for calcaneus fractures. However, it was relatively risky to perform open reduction and internal fixation by the sinus tarsi approach within 6 days of injury. Because the sural nerve is in the vicinity of the approach, iatrogenic injury should be avoided by the use of careful planning and meticulous manipulations. Level of Evidence Therapeutic; Level III, comparative study.

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Radiographic and Postoperative Outcomes of Plate Versus Screw Constructs in Open Reduction and Internal Fixation of Calcaneus Fractures via the Sinus Tarsi

Foot & Ankle International ◽

10.1177/1071100719848063 ◽

2019 ◽

Vol 40 (8) ◽

pp. 929-935 ◽

Cited By ~ 5

Author(s):

Charles C. Pitts ◽

Adam Almaguer ◽

John T. Wilson ◽

Jonathan H. Quade ◽

Michael D. Johnson

Keyword(s):

Cannulated Screw ◽

Wound Complications ◽

Cannulated Screws ◽

Radiographic Outcomes ◽

Sinus Tarsi ◽

Sinus Tarsi Approach ◽

Significant Difference ◽

Group 2 ◽

Calcaneus Fractures ◽

Group 1

Background: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high-energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatment, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study was to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After institutional review board approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and fractures with less than 6 weeks of postoperative weightbearing, which were excluded for radiographic outcomes. A total of 51 fractures underwent ORIF using cannulated screws alone (group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (group 2). Sixty-one fractures (41 vs 20, respectively) met criteria for radiographic comparison. The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, unplanned return to the operating room (OR), and cost comparison. Results: There was no statistically significant difference between preoperative Bohler angles for group 1 (14.4 degrees) versus group 2 (12.2 degrees) ( P = .44), nor was there a significant difference between postoperative Bohler angles for group 1 (30.1 degrees) versus group 2 (27.1 degrees) ( P = .14). Similarly, preoperative Gissane angles for group 1 (130.5 degrees) and group 2 (133.4 degrees) ( P = .54) and postoperative Gissane angles for group 1 (118.2 degrees) and group 2 (119.8 degrees) ( P = .44) showed no statistically significant difference. There were a total of 3 wound complications in group 1 versus 2 wound complications in group 2 ( P = .66). There was no statistically significant difference in operative duration ( P = .97) or the number of unplanned returns to the OR between the 2 groups ( P = .68). Based on the implants used at this institution, and depending on the number of screws used, the estimated cost range of a plate construct was $1070 to $1235, while the estimated cost range of a cannulated screw construct was $717 to $1264. Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Furthermore, the amount of angular correction achieved by initial reduction showed no statistically significant difference between groups, and the amount of reduction lost between initial and final postoperative radiographs showed no statistically significant difference between groups. With regard to the 2 techniques, there was no statistically significant difference in rates of postoperative complications and return to the OR. Our data suggest that fixation using cannulated screws alone versus sinus tarsi plate provides similar radiographic outcomes and risk of complications. The 2 techniques were also similar in terms of implant costs. Our results indicate that either technique effectively improved radiographic parameters. Level of Evidence: Level III, retrospective comparative study.

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00484 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0048

Author(s):

S. Blake Wallace ◽

David O’Neill ◽

Anish Narayanan ◽

George T. Liu ◽

Avneesh Chhabra ◽

...

Keyword(s):

Smoking Status ◽

Case Series ◽

Wound Complication ◽

Wound Complications ◽

Complication Rates ◽

Sinus Tarsi ◽

Radiographic Measurements ◽

Sinus Tarsi Approach ◽

Significant Difference ◽

Calcaneus Fractures

Category: Trauma; Hindfoot Introduction/Purpose: Fractures of the calcaneus are life-changing events with a major socioeconomic impact from lost productivity. Traditional operative treatment with the extensile lateral approach has shown relatively high rates of wound complications. Less invasive approaches can improve fracture alignment and decrease wound healing complications. The purpose of this study is to report our experience with the sinus tarsi approach in treating calcaneus fractures. Methods: We retrospectively identified patients at our institution treated with a limited sinus tarsi approach for calcaneus fractures from 2009-2018. Demographic and radiographic data were collected including: age, sex, mechanism of injury, occupation, presence of diabetes, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements. Results: Our analysis included 105 fractures in 100 patients: 86% males, 42% smokers, 4% diabetics, with an average body mass index of 26.5. The fractures were: Sanders type 2 (32%), type 3 (48%), type 4 (18%), and 2% were a tongue-type variant. Preoperatively 38% of fractures displayed a negative angle, 50% had an angle 0-20 degrees, and 12% over 20 degrees; postoperatively 13% had an angle 0-20 degrees, and 87% had an angle over 20 degrees. Of patients working prior to the injury, 72% had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 12% (12/100), with only 2% (2/100) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p=0.55). Conclusion: The limited sinus tarsi approach for depressed calcaneus fractures allows radiographic restoration of calcaneal height with a low rate of wound complications, even amongst active smokers. To the authors’ best knowledge, this is the largest published case series of calcaneus fractures treated with the sinus tarsi approach. Further follow up is needed to determine the success of this approach in mitigating long term complications.

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Wound Complications in Calcaneus Fractures Treated with the Sinus Tarsi Approach

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000385 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0003

Author(s):

Michael Swords ◽

Candice Brady ◽

John Popovich

Keyword(s):

Wound Care ◽

Wound Complications ◽

Consecutive Series ◽

Secondary Surgery ◽

Sinus Tarsi ◽

Sinus Tarsi Approach ◽

Oral Steroids ◽

Insulin Dependent ◽

Calcaneus Fractures ◽

Time From Injury

Category: Trauma Introduction/Purpose: The purpose of this study is to evaluate risk factors and complications associated with surgical treatment of calcaneus fractures using a sinus tarsi approach in a consecutive series of 164 displaced intra articular calcaneus fractures treated with a sinus tarsi approach. Methods: 150 patients with a total of 164 displaced intra articular calcaneus fractures were treated by a single surgeon using a sinus tarsi approach. Age, nicotine use, diabetes, steroid use, time from injury to surgery were all recorded. Time of suture removal, post operative antibiotics, local wound care and need for secondary surgery for wound problems were recorded. Results: average age was 49.5 years old. follow up averaged 309 days. 60 (39.2%) used nicotine, 14 (8.54%) were diabetics with 3 insulin dependent, 6 used oral steroids or DMARDs, eight fractures (4.88%) were open fractures. Average time from injury to surgery was 10.63 days. Sutures were removed at an average of 16.25 days. 7 patients developed incisional complications. 6 were treated successfully with antibiotics and local wound care. 1 patient require secondary surgery for wound complications. There was no difference in patients treated less then 14 days or more then 14 days from injury. there was no difference in complications in smokers vs. non smokers or diabetics vs. non diabetics. Conclusion: The sinus tarsi approach is a safe surgical approach with an acceptable complication rate for fixation of displaced intra articular calcaneus fractures.

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Radiographic Outcomes of Plate vs Screw Constructs in Open Reduction and Internal Fixation of Calcaneus Fractures via the Sinus Tarsi Approach

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00343 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0034

Author(s):

Charles Pitts ◽

Adam Almaguer ◽

Jack Wilson ◽

Michael Johnson

Keyword(s):

Cannulated Screw ◽

Wound Complications ◽

Cannulated Screws ◽

Radiographic Outcomes ◽

Sinus Tarsi ◽

Sinus Tarsi Approach ◽

Significant Difference ◽

Group 2 ◽

Calcaneus Fractures ◽

Group 1

Category: Hindfoot, Trauma Introduction/Purpose: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatments, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study is to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After IRB approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and clinical follow up less than 6 weeks. A total of 51 fractures underwent ORIF using cannulated screws alone (Group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (Group 2). The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, and unplanned return to OR. Results: There was no statistically significant difference between preoperative Bohler angles for Group 1 (14.5 degrees) versus Group 2 (12.3 degrees) (p=0.35), nor was there a significant difference between postoperative Bohler angles between Group 1 (30.1 degrees) and Group 2 (27.0 degrees) (p=0.09). Similarly, preoperative Gissane angles for Group 1 (128.4 degrees) and Group 2 (134.5 degrees) (p=0.17) and postoperative Gissane angles for Group 1 (116.7 degrees) and Group 2 (118.8 degrees) (p=0.44) showed no statistically significant difference. There were a total of 3 wound complications in Group 1 versus 2 wound complications in Group 2 (p=0.76). There was no statistically significant difference in operative duration (p=0.97) or the number of unplanned returns to the OR between the two groups (p=0.77). Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Both techniques had similar rates of postoperative complications and return to the OR. Our data suggests that fixation using cannulated screws alone versus sinus tarsi plate provide similar radiographic outcomes and risk of complications. The two techniques are also similar in terms of implant costs. Our results indicate that either technique effectively improves radiographic parameters.

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Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures

Foot & Ankle International ◽

10.1177/10711007211058689 ◽

2022 ◽

pp. 107110072110586

Author(s):

Ainsley K. Bloomer ◽

R. Randall McKnight ◽

Nicholas R. Johnson ◽

David M. Macknet ◽

Meghan K. Wally ◽

...

Keyword(s):

Case Series ◽

Retrospective Case ◽

Worker's Compensation ◽

Level Of Evidence ◽

Worker’S Compensation ◽

Subtalar Arthrodesis ◽

Sinus Tarsi ◽

Retrospective Case Series ◽

Sinus Tarsi Approach ◽

Calcaneus Fractures

Background: The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach. Methods: A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker’s compensation claims. Plain radiographs were used to characterize injuries and review outcomes. Results: Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker’s compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union. Conclusion: In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion. Level of Evidence: Level IV, retrospective case series.

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Sinus Tarsi Approach for Open Treatment and Internal Fixation of Displaced Intra-articular Calcaneal Fractures in High-Risk Patients: The New Gold Standard?

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00157 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0015

Author(s):

James P. Davies ◽

W. Bret Smith ◽

Steven Steinlauf ◽

Mary Millikin

Keyword(s):

High Risk ◽

Gold Standard ◽

Wound Complication ◽

Lateral Approach ◽

Wound Complications ◽

Complication Rates ◽

Calcaneal Fractures ◽

Sinus Tarsi ◽

Sinus Tarsi Approach ◽

Extensile Lateral Approach

Category: Ankle, Diabetes, Hindfoot, Trauma Introduction/Purpose: Intra-articular calcaneal fractures offer unique challenges. Wound problems and infection are significant complications in the surgical treatment of calcaneal fractures which in turn can be debilitating to patients and outcomes. The literature suggests varying wound complication rates but 21% up to 33% using the traditional extensile lateral approach in some studies. The extensile lateral approach has historically been accepted as the gold standard for fixation and treatment of these fractures. Recently there has been resurgent interest in alternative approaches to the fixation of intra-articular calcaneal fractures. Of interest is the potential of the sinus tarsi approach to decrease wound complications while having comparable reduction quality to the higher wound risk extensile lateral approach. Methods: A multi-center retrospective chart review study was implemented. The study objective was to review wound complication of the sinus tarsi approach compared with outcomes from the traditional extensile approach for fixation of displaced intra-articular calcaneal fractures. Specifically; examining a population of patients considered at high risk for wound issues, comparing radiographic and clinical outcomes. Results: In the high-risk group, only one primary complications resulted, including one patient with a history of an open fracture. All fractures healed with adequate maintenance of alignment. Chi- squared analysis resulted in a statistically significant difference in complication rates between sinus tarsi and the traditional extensile lateral approach at the 95% confidence level. Conclusion: In both high-risk and lower-risk cohorts of patients, a low rate of infection and wound problems was encountered. A limited approach through a sinus tarsi incision provides a viable option to treat displaced intra-articular calcaneus fracture patients with risk factors for wound issues. The patients all healed both their soft tissue wounds and fractures. Functional return was consistent with other study populations. Our study adds another cohort of patient data demonstrating the advantage of the sinus tarsi approach when compared to the extensile lateral in terms of decreased wound complications while maintaining quality of reductions and clinical outcomes.

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Sinus tarsi approach vs. extensile lateral approach for intra-articular calcaneal fracture

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00286 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0028

Author(s):

Methee Khongphaophong

Keyword(s):

Hospital Stay ◽

Open Reduction ◽

Operative Time ◽

Locking Plate ◽

Calcaneal Fracture ◽

Lateral Approach ◽

Wound Complications ◽

Sinus Tarsi ◽

Sinus Tarsi Approach ◽

Extensile Lateral Approach

Category: Trauma Introduction/Purpose: The options of operative treatment for intra-articular calcaneal fracture still remains controversial. Extensile lateral approach allow excellent exposure to fracture, but bring high rate of wound complications. The aim of this study was to compare the outcome of intra-articular calcaneal fracture treated with open reduction and internal fixation via an extensile lateral versus. Sinus tarsi approach Methods: Prospective study of 62 intra-articular calcaneal fractures treated by open reduction and internal fixation between 2014, October to 2017, June. 29 were treated with extensile lateral approach with calcaneal locking plate(Wright medical, Tennessee), 33 sinus tarsi approach(4 cases need additional mini medial incision approaches for SanderIII AC, BC) with mini-calcaneal locking plate(Normed, Florida). Durations until operation, operative time, foot functional index(total score), visual analog scale, SF-36, Bohler’s angle, angle of Gissane, wound complications and duration of hospital stay were recorded post-operatively and minimal 6 months follow up. Results: Compared 2 groups with demographic datas.Average duration until operation; extensile group was 13.32 days, sinus tarsi group was 6.08 days, p <0.001. Operative time; extensile group was 123.41minutes vs. sinus tarsi group was 91.20 minutes, p <0.001. Wound complications was 24.13% in extensile group vs. 6.06% in sinus tarsi group, p =0.045, Duration of post-operative admission was 6.68 days in extensile group vs. 3.10 days in sinus tarsi group p <0.001 FFI last visits was 25.36 in extensile group vs. 25.65 in sinus tarsi group, p =0.969, VAS activity was 29.68 in extensile group vs. 28.54 in sinus tarsi group, p=0.271. Conclusion: Sinus tarsi approach with mini-calcaneal locking plate was a great option for treatment of intra-articular calcaneal fracture. This approach brought lower rate of wound complications, earlier operations, shorter operation times and shorter hospital stay compared to extensile lateral approach.

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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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Return to work after surgical treatment for displaced calcaneus fractures treated with a sinus tarsi approach

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00474 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0047

Author(s):

Michael Swords ◽

Ann Simon

Keyword(s):

Surgical Treatment ◽

Return To Work ◽

Weight Bearing ◽

High Energy ◽

High Rate ◽

Prolonged Standing ◽

Sinus Tarsi ◽

Variable Angle ◽

Sinus Tarsi Approach ◽

Calcaneus Fractures

Category: Trauma Introduction/Purpose: Calcaneus fractures most often occur as a result of a high-energy injury in patients of working age. While it is known that patients will require time to recover, the rate of return to work and at what time frame is not well known. The purpose of this registry is to evaluate return to work issues after surgical treatment of a displaced calcaneus fracture treated operatively with plate fixation by a sinus tarsi approach. Methods: Subjects with displaced intra-articular calcaneal fractures surgically treated with a variable angle locking calcaneal plate by a sinus tarsi approach were included in a registry. Descriptive statistics were calculated for demographics, pre-operative, operative and post-operative characteristics. Results: The registry included 27 consecutive patients. According to Sanders classification, nine cases (33.3%) had type II fractures, sixteen cases (59.3%) had type III, and two cases (7.4) had type IV fractures. 23/27 (85%) patients were able to return to work at their pre injury occupation involving prolonged standing. Four (4) of the 23 patients required work restrictions, Return to work occurred at an average of 16.5 weeks from injury (range 9-22 weeks) for individuals with weight bearing occupations. One patient was able to return at 4 weeks to a temporary sit down position. Three (3) patients were unable to return to their prior occupation. Return to work information was unknown for 1 patient. Conclusion: The data demonstrates that patients treated for displaced intra articular calcaneus fractures with a variable angle locking plate by a sinus tarsi approach return to work to standing occupations at a high rate. The return to work data may be used to counsel patients and employers on realistic return to work expectations.

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