Sinus Tarsi Approach for the Treatment of Calcaneus Fractures: an Increasingly Used Technique
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Published:
Feb 17, 2023
Keywords:
Calcaneous, mini-invasive approach, sinus tarsi, fractures, complications
Main Article Content
Abstract
Objective: To describe functional and radiographic outcomes, and complications of osteosynthesis in calcaneus fractures with the sinus tarsi approach.
Materials and Methods: 54 displaced articular calcaneus fractures in 50 patients were assessed through preoperative foot radiographs (anteroposterior and lateral) and computerized tomography. AP and lateral radiographs were obtained in the immediate postoperative period (without weightbearing), after 6 and 12 weeks (with weightbearing), and at the end of follow-up, measuring the Böhler angle and quantifying the degree of subtalar and calcaneocuboid osteoarthritis. The AOFAS score was determined, registering wound complications, neurological injuries and necessary additional surgeries --such as osteosynthesis and subtalar arthrodesis hardware removal.
Results: Follow-up time was 30.8 months. The series consisted in 8 women and 42 men. The patients’ average age was 39.40±14 years (18-65). There were 40 Sanders type II, 13 type III, and 1 type IV fractures.The AOFAS score was excellent (12 patients), good (25), regular (12), and poor (5). The Böhler angle was 10.8°±10.4° before surgery, and 30.77°±8.24° at the end of follow-up (p<0.00001). 3.7% of the patients presented minor wound complications, while 5.6% presented major wound complications.
Conclusion: The sinus tarsi approach allows for acceptable reduction with good and excellent outcomes in most patients, coupled with few soft-tissue complications.
Materials and Methods: 54 displaced articular calcaneus fractures in 50 patients were assessed through preoperative foot radiographs (anteroposterior and lateral) and computerized tomography. AP and lateral radiographs were obtained in the immediate postoperative period (without weightbearing), after 6 and 12 weeks (with weightbearing), and at the end of follow-up, measuring the Böhler angle and quantifying the degree of subtalar and calcaneocuboid osteoarthritis. The AOFAS score was determined, registering wound complications, neurological injuries and necessary additional surgeries --such as osteosynthesis and subtalar arthrodesis hardware removal.
Results: Follow-up time was 30.8 months. The series consisted in 8 women and 42 men. The patients’ average age was 39.40±14 years (18-65). There were 40 Sanders type II, 13 type III, and 1 type IV fractures.The AOFAS score was excellent (12 patients), good (25), regular (12), and poor (5). The Böhler angle was 10.8°±10.4° before surgery, and 30.77°±8.24° at the end of follow-up (p<0.00001). 3.7% of the patients presented minor wound complications, while 5.6% presented major wound complications.
Conclusion: The sinus tarsi approach allows for acceptable reduction with good and excellent outcomes in most patients, coupled with few soft-tissue complications.
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How to Cite
Seletti, M., Slullitel, G., Calvi, J., & Pendino, A. (2023). Sinus Tarsi Approach for the Treatment of Calcaneus Fractures: an Increasingly Used Technique. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 88(1), 66-78. https://doi.org/10.15417/issn.1852-7434.2023.88.1.1586
Section
Clinical Research
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References
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treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84(10):1733-44. https://doi.org/10.2106/00004623-200210000-00001
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4. Al-Mudhaffar M. Wound complications following operative fixation of calcaneal fractures. Injury 2009;31(6):461-4. https://doi.org/10.1016/s0020-1383(00)00026-7
5. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18(1):1-6. https://doi.org/10.1097/00005131-200401000-00001
6. Slullitell G, Seri M. Abordaje miniinvasivo del seno del tarso para el tratamiento de las fracturas del calcáneo. Rev Asoc Argent Ortop Traumatol 2011;76(3):273-8. Disponible en:
https://www.aaot.org.ar/revista/2011/n3/Rev_Asoc_Argent_Ortop_Traumatol_2011_76(3)_273.pdf
7. Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, et al. Mini-open sinus tarsi approach with
percutaneous screw fixation of displaced calcaneal fractures: A prospective computed tomography-based study. Foot Ankle Int 2012;33(11):925-33. https://doi.org/10.3113/FAI.2012.0925
8. Schepers T, Backes M, Dingemans SA, de Jong VM, Luitse JSK. Similar anatomical reduction and lower
complication rates with the sinus tarsi approach compared with the extended lateral approach in displaced intraarticular calcaneal fractures. J Orthop Trauma 2017;31(6):293-8. https://doi.org/10.1097/BOT.0000000000000819
9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58(4):453-8. PMID: 773941
10. Böhler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg 1931;13(1):75-89.
Disponible en: https://journals.lww.com/jbjsjournal/Citation/1931/13010/DIAGNOSIS,_PATHOLOGY,_AND_
TREATMENT_OF_FRACTURES.10.aspx
11. Kinner B, Schieder S, Muller F, Pannek A, Roll C. Calcaneocuboid joint involvement in calcaneal fractures. J
Trauma 2010;68(5):1192-9. https://doi.org/10.1097/TA.0b013e3181b28b8c
12. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M, et al. Clinical rating systems for the
ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15(7):349-53. https://doi.org/10.1177/107110079401500701
13. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection,
1999. Am J Infect Control 1999;27:97-134. PMID: 10196487
14. Looijen RC, Misselyn D. Identification of postoperative step-offs and gaps with Brodén’s view following open
reduction and internal fixation of calcaneal fractures. Foot Ankle Int 2019;40(7):797-802. https://doi.org/10.1177/1071100719840812
15. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, et al. Operative versus nonoperative
treatment for closed, displaced, intraarticular fractures of the calcaneus: Randomised controlled trial. BMJ
2014;349:g4483. https://doi.org/10.1136/bmj.g4483
16. Khazen G, Khazen Rassi C. Sinus tarsi approach for calcaneal fractures. The new gold standard? Foot Ankle Clin 2020;25(4):667-81. https://doi.org/10.1016/j.fcl.2020.08.003
17. Schepers T. Sinus tarsi approach with screws-only fixation for displaced intraarticular calcaneal fractures. Clin
Podiatr Med Surg 2019;36(2):211-24. https:/doi.org/10.1016/j.cpm.2018.10.004
18. Kir MCX, Ayanoglu S, Cabuk L, Dedeoglu SS, Imren Y, Karslioglu B, et al. Mini-plate fixation via sinus tarsi
approach is superior to cannulated screw in intra-articular calcaneal fractures: A prospective randomized study.
Orthop Surg 2018;26(3):1-7. https://doi.org/10.1177/2309499018792742
19. Pitts C, Almaguer A, Wilson J, Quade JH, Johnson MD. Radiographic and postoperative outcomes of plate versus screw constructs in open reduction and internal fixation of calcaneus fractures via the Sinus Tarsi. Foot Ankle Int 2019;40(8):929-35. https://doi.org/10.1177/1071100719848063
20. Nelson JD, McIff TE, Moodie PG, Iverson JL, Horton GA. Biomechanical stability of intramedullary technique for fixation of joint depressed calcaneus fracture. Foot Ankle Int 2010;31(3):229-35. https://doi.org/10.1177/1071100719848063
21. Schepers T. The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop 2011;35(5):697-703. https://doi.org/10.1007/s00264-011-1223-9
22. Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma 1992;6(2):216-22. https://doi/org/10.1097/00005131-199206000-00014
23. Yeo QY, Kwek EB. Open reduction and internal fixation of displaced intra-articular calcaneal fractures with Norian Skeletal Repair System (SRS) bone cement: surgical technique, clinical and radiographical results. Ann Acad Med Singap 2014;43(10):515-6. PMID: 25434623
24. Geel CW, Flemister AS Jr. Standardized treatment of intra-articular calcaneal fractures using an oblique lateral
incision and no bone graft. J Trauma 2001;50(6):1083-9. https://doi.org/10.1097/00005373-200106000-00017
25. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal
fractures: long-term (10-20 years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma
2014;28(10):551-63. https://doi.org/10.1097/BOT.0000000000000169
26. Sangeorzan BJ, Ananthakrishnan D, Tencer AF. Contact characteristics of the subtalar joint after a simulated
calcaneus fracture. J Orthop Trauma 1995;9(3):251-8. PMID: 7623179
https://doi.org/10.1053/j.jfas.2003.11.010
2. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with non operative
treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84(10):1733-44. https://doi.org/10.2106/00004623-200210000-00001
3. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res1993;(290):87-95. https://doi.org/10.1097/00003086-199305000-00012
4. Al-Mudhaffar M. Wound complications following operative fixation of calcaneal fractures. Injury 2009;31(6):461-4. https://doi.org/10.1016/s0020-1383(00)00026-7
5. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18(1):1-6. https://doi.org/10.1097/00005131-200401000-00001
6. Slullitell G, Seri M. Abordaje miniinvasivo del seno del tarso para el tratamiento de las fracturas del calcáneo. Rev Asoc Argent Ortop Traumatol 2011;76(3):273-8. Disponible en:
https://www.aaot.org.ar/revista/2011/n3/Rev_Asoc_Argent_Ortop_Traumatol_2011_76(3)_273.pdf
7. Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, et al. Mini-open sinus tarsi approach with
percutaneous screw fixation of displaced calcaneal fractures: A prospective computed tomography-based study. Foot Ankle Int 2012;33(11):925-33. https://doi.org/10.3113/FAI.2012.0925
8. Schepers T, Backes M, Dingemans SA, de Jong VM, Luitse JSK. Similar anatomical reduction and lower
complication rates with the sinus tarsi approach compared with the extended lateral approach in displaced intraarticular calcaneal fractures. J Orthop Trauma 2017;31(6):293-8. https://doi.org/10.1097/BOT.0000000000000819
9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58(4):453-8. PMID: 773941
10. Böhler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg 1931;13(1):75-89.
Disponible en: https://journals.lww.com/jbjsjournal/Citation/1931/13010/DIAGNOSIS,_PATHOLOGY,_AND_
TREATMENT_OF_FRACTURES.10.aspx
11. Kinner B, Schieder S, Muller F, Pannek A, Roll C. Calcaneocuboid joint involvement in calcaneal fractures. J
Trauma 2010;68(5):1192-9. https://doi.org/10.1097/TA.0b013e3181b28b8c
12. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M, et al. Clinical rating systems for the
ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15(7):349-53. https://doi.org/10.1177/107110079401500701
13. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection,
1999. Am J Infect Control 1999;27:97-134. PMID: 10196487
14. Looijen RC, Misselyn D. Identification of postoperative step-offs and gaps with Brodén’s view following open
reduction and internal fixation of calcaneal fractures. Foot Ankle Int 2019;40(7):797-802. https://doi.org/10.1177/1071100719840812
15. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, et al. Operative versus nonoperative
treatment for closed, displaced, intraarticular fractures of the calcaneus: Randomised controlled trial. BMJ
2014;349:g4483. https://doi.org/10.1136/bmj.g4483
16. Khazen G, Khazen Rassi C. Sinus tarsi approach for calcaneal fractures. The new gold standard? Foot Ankle Clin 2020;25(4):667-81. https://doi.org/10.1016/j.fcl.2020.08.003
17. Schepers T. Sinus tarsi approach with screws-only fixation for displaced intraarticular calcaneal fractures. Clin
Podiatr Med Surg 2019;36(2):211-24. https:/doi.org/10.1016/j.cpm.2018.10.004
18. Kir MCX, Ayanoglu S, Cabuk L, Dedeoglu SS, Imren Y, Karslioglu B, et al. Mini-plate fixation via sinus tarsi
approach is superior to cannulated screw in intra-articular calcaneal fractures: A prospective randomized study.
Orthop Surg 2018;26(3):1-7. https://doi.org/10.1177/2309499018792742
19. Pitts C, Almaguer A, Wilson J, Quade JH, Johnson MD. Radiographic and postoperative outcomes of plate versus screw constructs in open reduction and internal fixation of calcaneus fractures via the Sinus Tarsi. Foot Ankle Int 2019;40(8):929-35. https://doi.org/10.1177/1071100719848063
20. Nelson JD, McIff TE, Moodie PG, Iverson JL, Horton GA. Biomechanical stability of intramedullary technique for fixation of joint depressed calcaneus fracture. Foot Ankle Int 2010;31(3):229-35. https://doi.org/10.1177/1071100719848063
21. Schepers T. The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop 2011;35(5):697-703. https://doi.org/10.1007/s00264-011-1223-9
22. Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma 1992;6(2):216-22. https://doi/org/10.1097/00005131-199206000-00014
23. Yeo QY, Kwek EB. Open reduction and internal fixation of displaced intra-articular calcaneal fractures with Norian Skeletal Repair System (SRS) bone cement: surgical technique, clinical and radiographical results. Ann Acad Med Singap 2014;43(10):515-6. PMID: 25434623
24. Geel CW, Flemister AS Jr. Standardized treatment of intra-articular calcaneal fractures using an oblique lateral
incision and no bone graft. J Trauma 2001;50(6):1083-9. https://doi.org/10.1097/00005373-200106000-00017
25. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal
fractures: long-term (10-20 years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma
2014;28(10):551-63. https://doi.org/10.1097/BOT.0000000000000169
26. Sangeorzan BJ, Ananthakrishnan D, Tencer AF. Contact characteristics of the subtalar joint after a simulated
calcaneus fracture. J Orthop Trauma 1995;9(3):251-8. PMID: 7623179