SLR - November 2017 - Meltem Ates

Similar Anatomical Reduction and Lower Complication Rates with the Sinus Tarsi Approach Compared with the Extended Lateral Approach in Displaced Intra-Articular Calcaneal Fractures

Reference: 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 Intra-Articular Calcaneal Fractures. J Orthop Trauma. 2017 June; 31 (6):293–298.

Scientific Literature Review

Reviewed By: Meltem Ates, DPM 
Residency Program: New York Presbyterian Queens—Flushing, New York                                                                                                                                                                             

Podiatric Relevance: Wound complications of two to 25 percent have been the main concern with use of extensive lateral approach (ELA) for open reduction internal fixation of displaced intra-articular calcaneal fractures. Less invasive techniques have been developed to reduce wound complications and operative time. A recent review article of 17 publications showed promising results in the use of the Sinus Tarsi Approach (STA). The purpose of this study was to obtain similarly good reductions and less wound complications with the STA approach.

Methods: This retrospective nonrandomized study included patients from 2012 to 2015 with closed intra-articular calcaneal fracture Sanders type II and III. The decision to perform an ELA or STA was left to the discretion of the treating three surgeons.

Patient characteristics included sex, age, diabetes mellitus, use of nicotine, drug abuse and ASA classification.

Fracture characteristics included measurement of the preoperative Bohler’s angle and CT classification based on lateral and axial CT images.

Treatment characteristics included type of approach, time to surgery, duration of the procedure, postoperative hospital admission, hospital readmission because of major complications and reoperation due to complication. All patients were seen at regular intervals postoperatively. The median follow-up was 22 months.

To assess anatomical reduction, postoperative CT scans were obtained and measured step-off posterior calcaneal joint. Value 0 to <1 mm indicated anatomic reduction, 3 to 5 mm was considered an approximate reduction and > 5mm was considered a failure of reduction. Also, postoperative Bohler’s angle was measured using lateral radiographs. The axis of tuber was measured using the axial view and considered normal with a varus/valgus angle of < 5 degrees. Statistical analysis was performed comparing all the characteristics.

Results: ELA was used in 60 patients and the STA in 65 patients. There were no significant differences in patient characteristics. Restoration of anatomy was similar in both groups. Rates of postoperative wound infection per surgeon and per fracture type were documented. There were four minor and no major wound complications in the STA group, and nine minor and eleven major complications found in the ELA group. Minor wound complication was confirmed with positive culture but was treated with oral antibiotics. Major wound complications included both a positive culture and osteomyelitis requiring implant removal and IV antibiotics. Time to surgery and postoperative duration of hospital admission were significantly different in both groups. STA was performed in median duration of 105 minutes and ELA with a median of 134 minutes.

Conclusions: Results indicated a significantly shorter operative time and a significant decrease in postoperative wound infections with the STA approach. Anatomic reduction results were similar to the ELA approach. The paper did not evaluate use of different plates/screws, use of tourniquets, different closure techniques and significant difference in dates to surgery. In addition, this is a short-term follow-up study without patient-related outcome measures. However, this study strengthens the evidence on similar anatomical reduction, fewer wound complications and shorter surgical time using the STA. This is a significant benefit with a less invasive approach. However, functional outcome needs to be investigated in a larger prospective study. 

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