SLR - March 2020 - Jonathon J. Srour

Comparison between Percutaneous Screws and Plate Fixation via Sinus Tarsi Approach for Calcaneal Fractures: An 8-10 Year Follow-Up Study

Reference: Weng Q, Dai F, Tu Q, Liu Y, Lutchooman V, Hong J, Yu Y. Comparison between Percutaneous Screws and Plate Fixation via Sinus Tarsi Approach for Calcaneal Fractures: An 8-10 Year Follow-Up Study. Orthopaedic Surgery. December 2019; 9999 (9999).

Scientific Literature Review

Reviewed By: Jonathon J. Srour, DPM
Residency Program: MedStar Georgetown University Hospital – Washington, DC

Podiatric Relevance: One of the most difficult pathologies facing the podiatric surgeon is the calcaneal fracture. Historically, clinicians have favored non-surgical treatment due to unpredictable reductions as well as wound dehiscence. However, operative reduction is now considered standard for displaced intra-articular calcaneal fractures. Multiple high-powered studies have shown decreased long-term consequences when these are treated with open reduction and internal fixation by a lateral extensile approach. The benefits of this approach have been offset by the large amount of wound problems. Thus, many surgeons have been in favor of approaches with smaller incisions. This study compares two of the more popular of these: the sinus tarsi approach and percutaneous screw fixation with calcium sulfate cement grafting. It retrospectively analyzed 150 patients with intra-articular calcaneal fractures who underwent one of these two procedures and was followed for an average of 8.7 years.

Methods: This was a Level IV retrospective clinical trial. Patients were selected who were admitted for displaced intra-articular calcaneal fractures from June 2009 to November 2013 and placed into either the percutaneous fixation or the sinus tarsi approach treatment based on the patient’s wishes and the classification of the fracture. A total of 150 feet underwent percutaneous fixation (78 cases) or sinus tarsi approach (72 cases). Outcomes were then evaluated through a combination of AOFAS hindfoot scores, postoperative wound-related complications, radiographic evaluation with measures of Bohler’s angle, Gissane’s angle, calcaneal height, width and length.

Results: There was no significant difference in the AOFAS scores between the percutaneous reduction group and the sinus tarsi approach group at one, three, five, and eight years of follow-up. Sixty-three patients were deemed to be good or excellent in the percutaneous reduction group and 66 patients were deemed to be good/excellent in the sinus tarsi approach group. However, specifically for Sanders III fractures, the good/excellent rate was 33.3 percent in the STA group vs 76.9 percent in the percutaneous reduction group (P=0.029). Overall, there were 12.8% complications in the percutaneous reduction group and 27.8 percent complications in the sinus tarsi approach group. Specifically, there were more wound complications in the sinus tarsi approach group (p=0.0412). X-rays showed increased calcaneal width in the percutaneous reduction group but no statistically significant differences in Bohler’s/Gissane’s angle.

Conclusions: There were no statistically significant differences found clinically between the two groups. However, when stratifying for Sanders type III fractures specifically, this study showed the sinus tarsi approach method to be more effective. There were a number of limitations given the nature of the retrospective comparison study design, including, but not limited to, concerns for selection bias into surgical groups since surgeons and patients could influence selection and sample size.  Both percutaneous reduction and sinus tarsi approach have merit and should be considered as viable procedures when dealing with displaced intra-articular calcaneal fractures. Future higher-level studies are needed to evaluate outcomes associated with each procedure.

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