Exposure of the Calcaneus via the Sinus Tarsi Approach versus the Lateral Extensile Approach: A Cadaveric Study

Category: Hindfoot; Trauma Introduction/Purpose: The lateral extensile approach (LEA) to the calcaneus has long been a popular surgical approach to treat calcaneal fractures. However, high rates of wound complications have led surgeons to investigate alternative approaches. As a result, the sinus tarsi approach has grown in popularity. The lateral extensile approach affords substantial visualization of the calcaneus. However, this visualization has never been compared in a quantitative manner to the sinus tarsi approach (STA). The objective of this cadaveric study is to compare calcaneal visualization afforded by a sinus tarsi approach and a lateral extensile approach. Methods: Seven pair-matched, fresh-frozen, below-knee cadaver specimens were obtained. For each pair, one side received an LEA and the other side received a STA. To identify areas of the calcaneus accessible by instrument, a curette was used to mark the visualized calcaneal surfaces. The calcaneus was then disarticulated and cleared of all soft tissue. The curette markings were then identified and marked with blue surgical marker. Photos were taken of each calcaneus, and visualized surface areas were calculated using Image J software. Results: There were no statistically significant differences in the articular surfaces accessible between the two approaches (831.99 mm2 for LEA vs. 903.41 mm2 for STA, p=0.53) including the anterior, middle, and posterior facets. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA (p=0.02). The LEA allowed better exposure to the lateral wall (p<0.01) and superior greater tuberosity of the calcaneus (p=0.05). Conclusion: In comparison to the LEA, the STA allows for equivalent exposure to articular surfaces. While the LEA allows for greater exposure of the lateral wall and posterior tuberosity, direct visualization of these structures may not warrant the higher risk of wound complications. Surgeons should be mindful of these differences when choosing a surgical approach in the treatment of calcaneal fractures.

Trochanteric osteotomy in revision total hip arthroplasty

Trochanteric osteotomy is a technique that allows expanded exposure and access to the femoral canal and acetabulum for a number of indications. There has been renewed interest in variants of this technique, including the trochanteric slide osteotomy (TSO), extended trochanter osteotomy (ETO), and the transfemoral approach, for both septic and aseptic revision total hip arthroplasty (THA). Osteotomy fixation is crucial for achieving union, and wire and cable-plate systems are the most common techniques. TSO involves the creation of a greater trochanter fragment with preserved abductor attachment proximally and vastus lateralis attachment distally. This technique may be particularly useful in the setting of abductor deficiency or when augmented acetabular exposure is needed. ETO is a posterior-laterally based extensile approach that has been successfully utilized for aseptic and septic indications; most series report a greater than 90% rate of union. The transfemoral approach, as known as the Wagner osteotomy, is an extensile femoral approach and is more anterior-based than the alternate posterior-based ETO. It may be particularly useful for anterior-based approaches and anterior femoral remodelling; rates of union after this approach in most reports have been close to 100%. Cite this article: EFORT Open Rev 2020;5:477-485. DOI: 10.1302/2058-5241.5.190063

Subtalar Arthroscopy

The subtalar joint plays an important role in the movement of the ankle and foot. The complex anatomy of the subtalar joint makes it difficult for surgeons to evaluate the entire joint even with extensile approach. The arthroscopy of posterior subtalar joint was first described by Parisien in 1985. The development of good quality small-diameter arthroscopes and refined arthroscopic techniques has contributed to the improvement of the subtalar arthroscopy. The reported advantages of the subtalar arthroscopy include faster postoperative recovery and decreased postoperative pain. The subtalar arthroscopy can be applied as a diagnostic and therapeutic tool. The diagnostic indications are persistent pain, swelling, stiffness, or locking of the subtalar area resistant to conservative treatment. Therapeutic indications include debridement of sinus tarsi syndrome and chondromalacia, excision of subtalar impingement lesions and osteophytes, lysis of adhesions with post-traumatic arthrofibrosis, synovectomy, removal of loose bodies, removal of a symptomatic os trigonum, calcaneal fracture assessment and reduction, and arthroscopic arthrodesis of the subtalar joint. The subtalar arthroscopy can be done in supine position using thigh holder or in lateral decubitus position. The arthroscope generally used is a 2.7-mm 30 degrees short arthroscope. Noninvasive distraction with a strap around the hindfoot can be helpful. Usually anterolateral, middle, and posterolateral portals are utilized for inspection and instrumentation within the subtalar joint. After insertion of the arthroscope, thorough inspection of the joint can be done using 13-point examination techniques. Two-portal posterior subtalar arthroscopy in prone position can be performed as well with 4.0-mm 30 degrees arthroscope, depending on the type and location of the subtalar pathology. The joint capsule and the adjacent fatty tissue should be partially resected for better visualization. The subtalar arthroscopy is a technically demanding procedure, which requires proper instrumentation and careful operative technique. Possible complications after subtalar arthroscopy are nerve damage and persistent wound drainage. In conclusion, the ankle arthroscopy is a safe adjunctive procedure for the treatment of ankle fractures. It can be performed as well for the evaluation and management of syndesmotic injury, and for persistent pain following the definitive treatment of ankle fractures.

The Use of Cryopreserved Umbilical Cord in Open Reduction and Internal Fixation of Calcaneus Fractures.

Calcaneal fractures are caused by a sudden, high-velocity impact on the heel [1]. The complication rate after open reduction and internal fixation of calcaneal fractures operated on by a lateral extensile approach range from 10 to 20%. Some of the worst perioperative complications associated with calcaneal fractures are tissue or bone infection, and/or wound complications. A retrospective review of 39 consecutive patients treated for calcaneus fracture by open reduction and internal fixation (ORIF) via a lateral extensile approach, was performed on 19 consecutive patients with 20 calcaneus fractures were treated with application of Clarix® cryopreserved umbilical cord (CUC) compared to a control group of 20 consecutive patients. The overall complication rate in the control group was 35%, compared to the cUC group of 10% (p=0.13). Additionally, the readmission rate and re-operation rate in the cUC group was lower than the control group (10% vs 30%, respectively; p=0.24). The use of cUC directly on the bone and hardware at the time of open reduction and internal fixation can be used as an adjunct to decrease wound complications, re-operations, and infection rates.