SLR - February 2021 - Kyle D. Miller

Quality of Reduction of Displaced Intra-Articular Calcaneal Fractures using a Sinus Tarsi versus Extensile Lateral Approach

Reference: Busel G, Mir HR, Merimee S, Patel R, Atassi O, De La Fuente G, Donohue D, Maxson B, Infante A, Shah A, Watson D, Downes K, Sanders RW. Quality of Reduction of Displaced Intra-Articular Calcaneal Fractures Using a Sinus Tarsi versus Extensile Lateral Approach. J Orthop Trauma. 2020 Sep 18.

Level of Evidence: Level IV

Scientific Literature Review

Reviewed By: Kyle D. Miller, DPM
Residency Program: Inova Fairfax Medical Campus – Falls Church, VA

Podiatric Relevance: Calcaneal fractures that are treated with operative intervention can present with varying fracture morphologies which makes them technically difficult to reduce and fixate. Depending on the fracture pattern two commonly utilized approaches can be utilized, the traditional lateral extensile (ELA) or the less invasive sinus tarsi approach (STA). Most literature comparing these methods focus on wound-healing complication rates and functional outcomes however a paucity of literature exists comparing adequacy of reduction with CT and stratification by Sanders classification.  

Methods: This was a retrospective review of 83 fractures, 37 of which were Sanders II and 46 of which were Sanders III fractures. Approaches were selected based on each of the seven surgeons’ preference. Post-operative CT scans were evaluated from poor (>3 millimeter step, >10 millimeter gap, and or >15 degree angulation) to excellent (no gap, step or angulation.) Bohler’s and Gissane’s angle were also evaluated on plain radiographs and graded as normal, high, or low. An adjusted linear regression type model was utilized to compare surgical approach and degree of joint reduction while adjusting for demographic and injury characteristics. The authors hypothesized there would be no difference in radiographic reduction between the groups. 

Results: Eighty-three fractures in 77 patients were evaluated with average age of 42 years. Fractures were classified using Sanders classification without further stratification into A/B/C. Thirty-six were treated with STA, and 47 using ELA. Average time to surgery was five days for STA, and 14 days for ELA. Radiographic evaluation showed that restoration of Bohler’s angle using ELA was 91.5 percent while STA was 77.8 percent. There were no differences regarding the critical angle of Gissane. Post-operative CT demonstrated ELA to have an overall better reduction quality. No difference was found between groups for Sanders type II fracture patterns however for type III, ELA trended toward better reduction quality however was not statistically significant.  

Conclusions: There are multiple factors to consider when deciding on which approach to use for any given calcaneal fracture. Timing is thought to be key however even with earlier treatment using STA, post-operative CT showed more favorable reduction in ELA even if on a delayed basis however this was not statistically significant. Without randomization this study design does introduce some selection bias. However, with that said each group for both Sanders type II/III and STA/ELA had nearly even split. The authors describe the STA as an important adjunct however should complex patterns or delays in treatments occur ELA is “critically important” for a good outcome.

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