SLR - August 2020 - Kenny Luong

Risk Factors for Surgical Site Infections with the Sinus Tarsi Approach in Displaced Intra-Articular Calcaneal Fractures: A Prospective Cohort Study with A Minimum of One-Year Follow-Up

Reference: Spierings KE, Sanders FRK, Nosewicz TI, Schepers T. Risk Factors for Surgical Site Infections with the Sinus Tarsi Approach in Displaced Intra-Articular Calcaneal Fractures: A Prospective Cohort Study with A Minimum of One-Year Follow-Up. Injury. 2020; 51 (7). 

Scientific Literature Review

Reviewed By: Kenny Luong, DPM
Residency Program: St Mary’s General Hospital – Passaic, New Jersey

Podiatric Relevance: Displaced intra-articular calcaneal fractures are high impact injuries that can result in potentially catastrophic infections and wound complications. The extensile lateral approach has been traditionally used for treatment of these types of calcaneal fracturs. However, recently, the sinus tarsi approach has gained in popularity. Studies have shown surgical site infection rates to be 3.6 percent-6.3 percent in sinus tarsi approaches, which is significantly lower than the complication rate in the ELA, ranging from 13.2 percent-31.2 percent. Although surgical site infections are low compared to extensile lateral approach, there has been minimal data quantifying risk factors for infections in the sinus tarsi approach. The aim of this study was to evaluate the rate of surgical site infections of sinus tarsi approach and to identify predictors for surgical site infections in calcaneal fractures. 

Methods: The authors performed a prospective cohort study of all patients treated with a sinus tarsi approach from August 1st, 2012 to January 31st, 2019 with at least one year follow up. Patients included had either an open or closed displaced intra-articular calcaneal fracture treated by either open reduction and internal fixation or primary subtalar arthrodesis. Patients were followed-up two weeks after surgery then again at eight weeks, six months and one year. The authors gathered patient characteristics, fracture characteristics and surgical characteristics. 

Results: A total of 237 calcaneal fractures in 214 patients were included in the study 72.2 percent of the patients were male and the mean age was 45.7 years. Open reduction with internal fixation (ORIF) was performed in 179 fractures and primary arthrodesis in 58 fractures. There was a total of 16 (6.8 percent) surgical site infections, nine (3.8 percent) were deep and seven (3.0 percent) were superficial. In a multivariate analysis, surgery within one week, ASA classification of two or higher, and more than 150cc of blood loss during the procedure were independent predictors of surgical site infection. All other characteristics including gender, age, BMI, smoking, presence of bilateral fractures or open fractures, Sanders classification, fixation type, tourniquet use, and duration of surgery were no statistically significant. 

Conclusions: This study confirms the low risk of surgical site infection in displaced intra-articular calcaneal fractures treat via a sinus tarsi approach with either open reduction internal fixation or primary STJ arthrodesis. Additionally, this study identified that surgery within a week of injury, ASA classification of two or more, and intra-operative blood loss of 150cc or more were significant predicators of surgical site infections. Given the conclusions from this study, it is important to understand the right time to take the patient to surgery with respect to the soft tissue envelope. Also, it is important to understand that during surgery preservation of blood supply and anatomical dissection are imperative for successful outcomes. Given that you may have patients with ASA of two or more with calcaneal fractures, there should be an understanding of an increased risk for surgical site infections. 

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