SLR - July 2020 - McKenna T. Green

Comparison of Sinus Tarsi Approach and Extensile Lateral Approach for Calcaneal Fractures: A Systematic Review of Overlapping Meta-Analyses 

Reference: Yu T, Xiong Y, Kang A, et al. Comparison of Sinus Tarsi Approach and Extensile Lateral Approach for Calcaneal Fractures: A Systematic Review of Overlapping Meta-Analyses . J Orthop Surg (Hong Kong). 2020;28(2):2309499020915282. doi:10.1177/2309499020915282

Scientific Literature Review

Reviewed By: McKenna T. Green, DPM 
Residency Program: Detroit Medical Center – Detroit, MI

Podiatric Relevance: Calcaneal fractures account for only approximately 2 percent of all total fractures, but up to 60 percent of foot fractures. They lead to substantial financial consequences for patients, notably in work related accidents from a fall from height which can lead to bilateral calcaneal fractures. In the literature there is inconclusive data regarding the best approach for surgical incision. The goal of this article was to perform a systematic review of overlapping meta-analyses of the sinus tarsi (STA) versus extensile lateral approach (ELA) to determine the superior approach for calcaneal fracture reduction.

Methods: A literature search was performed by two authors, which included any papers which included meta-analysis of randomized control trials (RCTs) or cohort studies (CS) of the STA vs ELA published prior to October 2019. The methodological quality was assessed via an Assessment of Multiple Systematic Reviews instrument and utilized to determine the quality of the literature and the meta-analyses included. A heterogeneity assessment was determined by an I squared test. Next, the included data underwent a Jadad decision algorithm by three researchers to determine which article represented the highest level of evidence. 

Results: A total of five articles graded evidence Level III that were published from 2017 to 2018 were included. Included in these studies were a total of 11 RCTs and 12 CS. The five meta-analyses were inconsistent in results for Sander’s Type II and III fractures. Utilizing the Jadad algorithm, the authors determined that the article by Bai et al provided the highest quality data. This paper concluded that the STA technique provided shorter operation time and lower complication rate than ELA, without sacrificing the anatomical and functional recovery. 

Conclusions: The authors determined that the multiple meta-analyses failed to find consistent conclusions regarding the STA vs ELA, possibly due to variabilities in cited literature, data extraction, statistical methods as well as the clinical questions. Most of the meta-analyses agreed that there was no significant difference between recovered Bohler’s angle between groups and were also in concordance that STA had lower wound complication rates. However, the studies had contradicting conclusions in reference to the operating time. Therefore, this study’s systematic review of multiple studies supported the STA due to similar rates in the VAS, AOFAS scores, and Bohler’s angle versus the  ELA, but in addition had lower wound complication rates and shorter operating times. The inability for these studies to compare the initial Sanders II and III fractures is a significant limitation to this study, which could lead to further high impact studies of the two incisions that includes a comparison of pre and post reduction angles. With the combined nature of this study comparing a fairly large sample of calcaneal fractures, surgeons can more confidently confirm the STA is not an inferior approach to the historically more common ELA. 

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