Sinus Tarsi Approach With Percutaneous Screw Fixation for Intra-Articular Calcaneal Fractures

Up and down - The impact of calcaneal fracture on medial gastrocnemius fascicle behavior and ankle biomechanics during heel-rise performance

BACKGROUND

Calcaneal fractures (CF) often result in reduced foot mobility and plantar flexor strength, despite intensive rehabilitation. While treatment mostly focuses on bone restoration, structural and functional adaptation of the ankle plantar flexors during movement is less understood.

RESEARCH QUESTION

To investigate medial gastrocnemius fascicle behavior and ankle biomechanics in patients with CF during bipedal heel-rise.

METHODS

Repetitive heel-rise was analyzed in 18 patients with unilateral CF (BMI: 27.3 ± 3.2 kgm-2, Age: 50 ± 13 years) and 18 healthy controls (BMI: 26.3 ± 3 kgm-2, Age: 48 ± 11 years) using motion capture and ultrasound. Patients were measured 3 and 12 months after surgery. Dynamic gastrocnemius fascicle length, pennation angle, thickness, ankle angle, ground reaction force, heel lift, and Böhler angle were assessed.

RESULTS

Between 3 and 12 months, pennation angle in patients increased by up to 33 % (p < 0.05), while fascicle length and thickness remained unchanged. Ankle plantarflexion and heel lift showed no improvement, while ground reaction force and symmetry increased by 12 % and 55 %, respectively. Compared to controls, patient's fascicle parameters showed no differences, while a reduced maximum plantarflexion and heel lift by up to 41 % remained. Ground reaction force recovered to control levels at 12 months. The average Böhler angle was 21.6° (9.8-41.6°).

SIGNIFICANCE

Impaired foot stability and alignment originating from altered calcaneal anatomy after fracture, rather than muscle deficits, primarily contribute to a reduced ankle joint function one year post-surgery.

Age-related traumatic anatomy and personalized medial incision design for calcaneal fractures in older adults using three-dimensional mapping

BACKGROUND

Calcaneal fractures usually arise from high-energy trauma and predominantly impact young individuals. In older adults (aged ≥ 50 years), declining bone density and muscle strength increase fracture risk from low-energy trauma, leading to a bimodal epidemiological distribution. The intricacies of calcaneal fractures in older adults, alongside osteoporosis and soft tissue fragility, complicate surgical intervention. This study aims to analyze age-related differences in calcaneal fracture characteristics using three-dimensional(3D) mapping and assess their impact on medial incision design.

METHOD

A total of 95 patients with closed calcaneal fractures were categorized into two groups: Younger (< 50 years, n = 61) and Older (≥ 50 years, n = 34). The process of 3D fracture mapping was executed utilizing Mimics and 3-matic software, alongside the reconstruction of soft tissue, which encompassed the posterior tibial neurovascular bundle. Differences in fracture distribution and incision parameters (length, α angle, D1, and D2) were statistically analyzed, with p < 0.05 considered statistically significant.

RESULTS

Fracture lines in both groups were predominantly located around the lateral Gissane's angle and critical weight-bearing areas of the calcaneus. In the Younger Group, fracture lines were long, continuous, and involved fewer fragments, correlating with high-energy trauma. The Older Group showed more comminuted lines, characteristic of osteoporotic fractures. The α angle and D1 distance were significantly smaller in the Older Group (p < 0.05), indicating closer proximity to the medial malleolus. D2 values were also smaller (p < 0.05), with 48.65% intersecting the neurovascular bundle compared to 31.34% in the Younger Group.

CONCLUSION

Age significantly influences medial wall fracture patterns and complexity in calcaneal injuries. A personalized medial incision based on fracture morphology provides better exposure and reduction compared to traditional methods. Although the incision is closer to the neurovascular bundle in older patients, meticulous surgical technique guarantees safety. The integration of a medial incision with sinus-tarsi (ST) approach minimizes the necessity for extensive lateral exposure, thereby diminishing soft tissue complications and improving surgical outcomes for the elderly population.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Emergency surgery of intra-articular calcaneal fractures using sinus tarsi approach with modified reduction technique

BACKGROUND

The purpose of this study was to evaluate emergency surgery of calcaneal fractures using the sinus tarsi approach (STA) with modified reduction technique in terms of complication rates, iconography results and functional outcome.

METHODS

We evaluated the outcomes of 26 patients treated in an emergency using STA with modified reduction technique. For that, we assessed Böhler´s angle, Gissane angle, reduction of the calcaneal body, and posterior facet, the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, complications, preoperative time, operative time, and in-hospital time.

RESULTS

Recovery of calcaneal anatomy and articular surface were found at final follow-up. The mean Böhler´s angle at final follow-up were 30.68° ± 3.69°, of which was 15.02° ± 3.88° preoperatively (p < 0.001). The mean Gissane angle at final follow-up were 114.54° ± 11.16° of which was 88.86° ±10.96° preoperatively (p < 0.001). All cases had the varus/valgus angle of the tuber within 5 degrees. At the final follow-up, the mean AOFAS score was 89.23 ± 4.63, and the VAS score was 22.73 ± 6.5.

CONCLUSIONS

Emergency surgery using STA with modified reduction technique is reliable, effective, and safe for treatment of calcaneal fractures. This technique can bring good clinical outcomes and a low rate of wound complications, reducing the in-hospital time, costs, and accelerating rehabilitation.