Extensile lateral versus sinus tarsi approach for calcaneal fractures: A meta-analysis

Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature

INTRODUCTION

To analyze recent literature comparing clinical outcomes of displaced intra-articular calcaneal fractures (DIACF) treated with open reduction and internal fixation using the extensile lateral approach (ELA) vs the minimally invasive sinus tarsi approach (STA), with a focus on wound complications.

MATERIALS AND METHODS

A comprehensive literature search was conducted utilizing PubMed, EMBASE, and Cochrane Library databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 2013 and 2022, level of evidence (LOE) I-III, head-to-head comparative studies reporting on clinical outcomes after DIACFs treated with ORIF using ELA versus STA, and literature with full-text written in English were included. Data collection included: publication year, study design, number of surgeons, number of participants, demographic data (mean age at time of surgery, percent male, body mass index, medical co-morbidities), preoperative data (mechanism of injury, Sanders classification, time from injury to surgical fixation), intraoperative data, and postoperative clinical and radiographic outcomes (Böhler angle, angle of Gissane, calcaneal height/length/width).

RESULTS

A total of 21 articles (4 randomized control trials, 17 cohort studies) comprising of 2086 patients with calcaneal fractures, treated with either ELA (n = 1129) or STA (n = 957) met inclusion criteria. The risk of postoperative wound-related complications (RR 2.82, 95 % CI: 2.00-3.98, I2=27 %) and the risk of reoperation (RR 1.85, 95 % CI: 0.69-5.00, I2=67 %) was higher in ELA patients comparted to STA patients. However, the increased risk of postoperative wound-related complications with an ELA vs. STA was shown to be trending downward in recent publications. The ELA group also experienced longer time to surgery, extended operative times, and prolonged hospital stays when compared to the STA group. Radiographic measurements at final follow-up, including Böhler angle, angle of Gissane, as well as calcaneal height, length, and width, showed no statistically significant differences between the two groups.

CONCLUSION

Surgical treatment of calcaneal fractures utilizing the ELA continues to have an increased rate of complications and reoperation when compared to the less invasive STA, yet recent trends in the literature show that this rate is decreasing. Operative treatment of calcaneal fractures via either an ELA or STA can both achieve comparable postoperative radiographic outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III.

[Effectiveness of vertical compression of locking plate combined with hollow screws in treatment of Sanders type and calcaneal fractures]

Objective

To probe into the effectiveness of vertical compression of locking plate combined with hollow screws in the treatment of Sanders type Ⅱ and Ⅲ calcaneal fractures.

Methods

The clinical data of 128 patients with Sanders type Ⅱ and Ⅲ calcaneal fractures who were admitted between March 2019 and April 2022 and met the selection criteria were retrospectively analyzed. Among them, 65 patients were treated with locking plate combined with hollow screw vertical compression (study group), and 63 patients were treated with simple locking plate (control group). There was no significant difference in baseline data between the two groups ( P>0.05), such as gender, age, fracture side and Sanders classification, cause of injury, time from injury to operation. The operation time, intraoperative blood loss, hospital stay, and fracture healing time were recorded and compared between the two groups. Before operation and at 12 months after operation, the American Orthopaedic Foot and Ankle Association (AOFAS) score (including total score, pain score, functional score, and alignment score) was used to evaluate the recovery of foot function, and imaging indicators such as calcaneal width, calcaneal height, calcaneal length, Böhler angle, and Gissane angle were measured on X-ray films.

Results

All patients were followed up 12 months after operation. There was no significant difference in operation time, intraoperative blood loss, hospital stay, and fracture healing time between the two groups ( P>0.05). Poor wound healing occurred in 1 case in the study group and 2 cases in the control group. At 12 months after operation, there was no significant difference between the two groups in the pre- and post-operative difference of calcaneal length, calcaneal height, Gissane angle, and Böhler angle ( P>0.05). However, the pre- and post-operative difference in calcaneal width in the study group was significantly higher than that in the control group ( P<0.05). The pre- and post-operative difference of AOFAS total score in the study group was significantly higher than that in the control group ( P<0.05), and further analysis showed that the pre- and post-operative difference of pain and function scores in the study group were significantly higher than those in the control group ( P<0.05), while there was no significant difference in the pre- and post-operative difference of force score between the two groups ( P>0.05).

Conclusion

Compared with simple locking plate treatment, the treatment of Sanders type Ⅱ and Ⅲ calcaneal fractures with vertical compression of locking plate combined with hollow screws can more effectively improve the width of the subtalar calcaneal articular surface, avoid peroneal longus and brevis impingement, reduce pain, and increase the range of motion of the subtalar joint, and the effectiveness is better.

Treatment of displaced intra-articular calcaneal fractures using a sinus tarsi approach. Surgical technique

Calcaneal articular fractures are fractures classically associated with a high rate of complications and poor outcomes. Osteosynthesis of the calcaneus through a sinus tarsi approach has shown results equal to or superior to those of the extended approach, having become the new gold standard. The objective of this article is to detail step by step the surgical technique of osteosynthesis of intra-articular fractures of the calcaneus through a sinus tarsi approach, from the selection of the fracture, positioning of the patient, layout of the operating room and the fluoroscope, the entire surgical process until postoperative treatment. The surgical technique described below is described in 6 steps. Anatomical reduction of complex calcaneal fractures through an Sinus Tarsi Approach requires an understanding of the fracture and its associated deformities. Following the described sequence step by step will help to achieve a better reduction in order to achieve better functional results.

Geographical Differences in Wound Complication Rates Following the Sinus Tarsi Approach in Displaced Intra-articular Calcaneal Fractures: A Systematic Review of the Literature

Background

The sinus tarsi approach (STA) has gained popularity for the treatment of displaced intra-articular calcaneal fractures. No large studies comparing wound complications worldwide after STA surgery are available. The aim of this systematic review was to compare postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following STA surgery between continents and countries and their differences in climate.

Methods

A literature search was performed using the databases of PubMed, Embase, and the Cochrane Library. Studies published before January 1, 2000, including < 10 patients and written in a language other than English were excluded.

Results

In total, 86 studies containing 4,392 surgeries via STA from 20 different countries were included. The mean POWC was 5.9% and the mean POWI was 4.4%. The highest median POWC rate was in North America (8.5%) and the lowest in South America (2.0%). No significant differences were found in the POWC and POWI rates between countries (p = 0.178 and p = 0.570, respectively), but significant differences were found between the POWC and POWI rates between continents (p = 0.011 and p = 0.036, respectively). The number of surgeries per year and climate differences, as represented by mean local temperature, were not correlated with both the POWC/POWI rates and functional outcome scores.

Conclusions

Significant differences between the POWC and POWI rates were found between continents but not between individual countries. With a mean POWC of 5.9% and a mean POWI rate of 4.4%, STA has an intrinsic low risk for complications given the minimally invasive nature of the approach and is inevitably becoming the gold standard for calcaneal surgery.

[Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach]

OBJECTIVE

Surgical treatment of intra-articular calcaneus fractures via a minimally invasive approach.

INDICATIONS

Intra-articular dislocated calcaneus fractures.

CONTRAINDICATIONS

Fracture older than 14 days; poor soft tissue quality in the surgical area.

SURGICAL TECHNIQUE

Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsal IV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of a Schanz screw in the calcaneal tuberosity from lateral or posterior as a reduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing a cannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X‑rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath.

POSTOPERATIVE MANAGEMENT

Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8 weeks; subsequently increased load bearing.

RESULTS

Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Comparison of sinus tarsi approach versus extensile lateral approach in the management of displaced intra-articular calcaneal fractures: A single-center study

BACKGROUND

Controversy still exists for optimal treatment for displaced intra-articular calcaneal fractures (DIACFs). Conven-tionally, the extensile lateral approach (ELA) has been the most preferred approach. Although ELA provides excellent fracture access and direct evaluation of the depressed posterior facet, this approach has a high rate of serious complications, such as hematoma, superficial/deep infection, and wound healing issues. To overcome such complications, more minimally invasive techniques including external fixation, percutaneous fixation, arthroscopic assisted fixation, and sinus tarsi approach (STA) have been recently described. The primary aim of this study was to compare STA and LEA in the treatment of DIACFs.

METHODS

Patients who were operated for DIACFs in our clinic were included in the study. Patients with closed DIACFs of Sanders Type II, III, IV, and over 18 years of age were identified. Physical examinations and radiological evaluations of the patients were per-formed, and clinical scores were filled. Patients were divided into subgroups according to the Sander's classification and comparisons were made again according to these subgroups.

RESULTS

There were 37 patients (four female and 33 male) in STA group and 44 patients in LEA group (six female and 38 male). The mean age was 44.42±13.57 years (range, 18-61) for STA group and 37.32±11.09 years (range, 18-56) for the LEA group. In clinical outcomes, except for short-form survey (SF-12)/MCS-12 (Mental Score) and visual analog scale score, all the parameters were signifi-cantly better in STA group compared to LEA group. No significant difference was observed between the two groups in radiographic results, except for the Böhler angle. Significantly less infection occurred in the STA group compared to LEA group (P=0.021). According to Sander's classification, American Orthopedic Foot and Ankle Society, foot and ankle disability index, and SF-12/PCS-12 and foot function index scores, no significant differences were determined between STA and LEA groups for Sanders Type 2, whereas the values were considerably higher in STA group than in LEA group for Sanders Type 3 and 4.

CONCLUSION

In DIACFs, STA is considered a safe and effective method for restoring the width, height, and length of the calca-neus and reconstruction of joint alignment and has now become our standard technique for all calcaneal fractures requiring operative treatment.

Implant Choice and Outcomes of the Sinus Tarsi Approach for Displaced Intra-articular Calcaneal Fractures

BACKGROUND

Operative fixation of displaced intra-articular calcaneal fractures is considered the gold standard, for which multiple fixation methods are available. This study compares the (functional) outcome of screw fixation (SF), plate fixation (PF), and anatomical plate fixation (APF) via the sinus tarsi approach (STA).

METHODS

A total of 239 patients (265 fractured calcanei) who received surgical treatment of a displaced intra-articular calcaneal fracture via STA between 2011 and 2022 were included.

RESULTS

Böhler angle (BA) measured immediately postoperatively (BA post-OR) and the decrease in BA at 1 year (∆BA) differed significantly in favor of PF/APF compared with SF (BA post-OR: SF vs PF P = .010 and SF vs APF P = .001; ∆BA: SF vs PF P = .032 and SF vs APF P = .042). Implant removal surgery was performed significantly less in the APF group as compared to the SF/PF groups (APF vs SF/PF; 9.9% vs 22.9%/23.7%, P = .015). Surgical site infections and secondary arthrodesis of the subtalar joint occurred equally in the 3 groups. Furthermore, the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index score, and EuroQOL-5D-index / visual analog scale score, did not differ notably between SF, PF, and APF.

CONCLUSION

The results show that both PF and APF are favored over SF because of an improved correction of BA measured directly postoperatively, a lower secondary loss of BA and, for APF, a lower implant removal rate. There was no difference in the rate of surgical site infections, need for secondary arthrodesis, nor functional outcome scores between different implants using the STA.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Does the postoperative quality of reduction, regardless of the surgical method used in treating a calcaneal fracture, influence patients' functional outcomes?

BACKGROUND

The extensile lateral approach (ELA) and sinus tarsi approach (STA) are commonly utilized for surgically treating calcaneal fractures. This study compared the outcomes of ELA and STA in the management of calcaneal fractures and assessed the influence of postoperative quality of reduction on functional and pain scores.

METHODS

The study included 68 adults with Sanders type-II and type-III calcaneal fractures who underwent either ELA or STA surgery. Pre- and postoperative radiographs and computed tomography scans were analyzed, and functional and pain scores were evaluated using the Manchester Oxford Foot Questionnaire (MOXFQ), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and Visual Analogue Score (VAS) during follow-up visits.

RESULTS

Out of the total patients, 50 underwent ELA surgery while 18 underwent STA surgery. The anatomic (excellent) reduction was achieved in 33 (48.5%) patients. There were no significant differences between the ELA and STA groups concerning functional scores, pain scores, the proportion of excellent reduction, and complications. Additionally, anatomic reduction, compared to near or non-anatomic (good, fair, or poor) reduction, demonstrated a decrease in MOXFQ (unstandardized β coefficient: -13.83, 95% CI: -25.47 to -2.19, p = 0.021), an increase in AOFAS (unstandardized β coefficient: 8.35, 95% CI: 0.31 to 16.38, p = 0.042), and a reduction in VAS pain (unstandardized β coefficient: -0.89, 95% CI: -1.93 to -0.16, p = 0.095) scores.

CONCLUSION

In conclusion, we found no significant differences regarding complications, excellent reduction, and functional scores between STA and ELA surgeries. Therefore, STA may be an effective alternative for the treatment of calcaneal fractures in Sanders type II and type III calcaneal fractures. Furthermore, the anatomic reduction of the posterior facet correlated with improved functional scores, emphasizing the importance of achieving it for restoring foot function regardless of surgery type or time between injury and surgery.

Delayed Surgical Treatment of Displaced Intra-Articular Calcaneal Fractures in Major Trauma Is Safe and Effective

BACKGROUND

To assess whether delaying operative fixation through the sinus tarsi approach resulted in a decreased wound complications rate or could hinder the quality of reduction in subjects with Sanders type II and III displaced intra-articular calcaneus fractures.

METHODS

From January 2015 to December 2019, all polytrauma patients were screened for eligibility. We divided patients into two groups: Group A, treated within 21 days after injury; Group B, treated more than 21 days after injury. Wound infections were recorded. Radiographic assessment consisted of serial radiographs and CT scans: postoperatively (T0) and at 12 weeks (T1) and at 12 months after surgery (T2). The quality of reduction of the posterior subtalar joint facet and calcaneal cuboid joint (CCJ) was classified as anatomical and non-anatomical. A post hoc power calculation was performed.

RESULTS

A total of 54 subjects were enrolled. Four wound complications (three superficial, one deep) were identified in Group A; two wound complications (one superficial one deep) were identified in Group B. According to "mean interval between trauma and surgery" and "duration of intervention", there was a significant difference between the groups (p < 0.001). There were no significant differences between Groups A and B in terms of wound complications or quality of reduction.

CONCLUSIONS

The sinus tarsi approach is a valuable approach for the surgical treatment of closed displaced intra-articular calcaneus fractures in major trauma patients who need delayed surgery. The timing of surgery did not negatively influence the quality of the reduction and the wound complication rate.

LEVEL OF EVIDENCE

level II, prospective comparative study.

Fixation of displaced intra-articular calcaneus fractures is safe using either sinus tarsi or extensile lateral approach

INTRODUCTION

Management of displaced intra-articular calcaneus fractures continues to challenge surgeons. Use of the extensile lateral surgical approach (ELA) had been standard practice however wound necrosis and infection have become deterrents. The sinus tarsi approach (STA) has gained popularity as a less invasive technique to optimize articular reduction while minimizing soft tissue injury. Our aim was to compare wound complications and infections following calcaneus fractures treated using ELA versus STA.

METHODS

Retrospective review of 139 displaced intra-articular calcaneus fractures (AO/OTA 82C; Sanders II-IV injuries) treated operatively at 2 level-I trauma centers using STA (n = 84) or ELA (n = 55) over a 3-year period with minimum 1-year follow up was performed. Demographic, injury, and treatment-related characteristics were collected. Primary outcomes of interest included wound complications, infection, reoperation, and American Orthopaedic Foot and Ankle Society ankle and hindfoot scores. Univariate comparisons between groups were conducted using Chi-Square, Mann-Whitney, and independent sample t-tests at the p < 0.05 significance level, where appropriate. Multivariable regression analysis was performed to identify risk factors for poor outcomes.

RESULTS

Demographic characteristics were homogenous between cohorts. Most sustained falls from height (77%). Sanders III fractures were most common (42%). Patients treated with STA went to surgery earlier (6.0 days STA vs 13.2 ELA, p < 0.001). No differences were seen in restoration of Bohler's angle, varus/valgus angle, or calcaneal height, yet the ELA significantly improved calcaneal width (-2 mm STA vs -13.3 mm ELA, p < 0.001). There were no significant differences in wound necrosis or deep infection based on surgical approach (12% STA vs 22% ELA, p = 0.15). Seven patients underwent subtalar arthrodesis for arthrosis (4% STA vs 7% ELA). No differences in AOFAS scores were seen. Risk factors for reoperation included Sanders type IV patterns (OR = 6.6, p = 0.001), increasing BMI (OR = 1.2, p = 0.021), and advanced age (OR = 1.1, p = 0.005), not surgical approach.

CONCLUSION

Despite prior concerns, use of ELA versus STA for fixation of displaced intra-articular calcaneus fractures was not associated with more complication risk, illustrating both are safe when indicated and executed appropriately.

Comparison of Robot-Assisted Percutaneous Cannulated Screws Versus Open Reduction and Internal Fixation in Calcaneal Fractures

OBJECTIVE

Accurate placement of the screws is challenging in percutaneous cannulated screw fixation of calcaneal fractures, and robot-assisted (RA) surgery enhances the accuracy. We investigated the outcome of percutaneous cannulated screw fixation of Sander's type II and III calcaneal fractures.

METHODS

This retrospective study analyzed clinical data of 26 patients with fresh closed calcaneal fractures (28 fractures) who were admitted to our center from January 2022 to July 2022. All fractures were divided into the RA group and the open reduction and internal fixation (ORIF) group according to the surgeries performed. RA surgery was performed by closed reduction or open reduction combined with a tarsal sinus approach. Age, sex, operation time, preoperative waiting time, length of postoperative hospital stay, wound complications, and American Orthopaedic Foot and Ankle Society Ankle Hindfoot Scale (AOFAS) at 3 months postoperatively were compared. Preoperative and postoperative radiographic parameters (calcaneal length, width, height, Böhler angle, and fixation rate of the sustentaculum tali) were documented. The chi-square test, one-way analysis of variance, and Wilcoxon test were used for the comparison of categorical, normally distributed, and nonnormally distributed continuous variables, respectively.

RESULTS

The calcaneal width, height, and Böhler angle were significantly corrected postoperatively in both groups. The postoperative calcaneal lengths in both groups were also corrected. However, no significant difference was found. No significant differences in calcaneal length, width, height, and Böhler angle were observed between the two groups. The operation time (p < 0.001), preoperative waiting time (p < 0.001), and length of postoperative hospital stay (p = 0.003) in the RA surgery group were significantly shorter than those in the ORIF group. The fixation rate of the sustentaculum tali (p < 0.001) in the RA surgery group was significantly superior to that in the ORIF group. All wound complications occurred in the ORIF group. All fractures healed within 3 months. The AOFAS scores at 3 months postoperatively were not significantly different.

CONCLUSION

RA percutaneous screw fixation of the calcaneal fracture is a safe, effective, rapid, and minimally invasive surgical option for surgeons.

Complication Rates Are Similar Between Patients Aged <50 and >50 Years in Calcaneus Fractures Treated With the Sinus Tarsi Approach

Background:

The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years with an increased interest in shifting to less invasive approaches for calcaneal fracture fixation allowing for adequate fixation if complications do not arise. Although the ST approach has gained acceptance as standard for calcaneus fracture fixation, the literature surrounding early complications rates based on age differences for this specific approach and pathology is lacking. The objective of this study was to determine if rates of complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of closed calcaneus fractures using the ST approach.

Methods:

A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria were based on an age greater than 18 years, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative computed tomographic scan, and a minimum of 180 days’ follow-up. Patients were divided into 2 groups: those aged <50 years and those aged >50 years.

Results:

A total of 196 fractures were included with 114 fractures in the <50-year age group and 82 fractures in the >50-year age group. Mean age was 34.2 and 59.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.2% vs 4.4%, P = .204), superficial surgical site infection (1.2% vs 2.6%, P = .490), deep infection (9.8% vs 7.9%, P = .648), and nonunion (4.9% vs 3.5%, P = .633) compared with the younger group. Rates of 30-day readmission, unplanned reoperation, and symptomatic hardware were not significantly different. Postoperative Bohler and Gissane angles were not significantly different between both groups.

Conclusion:

Older patients with intraarticular calcaneus fractures treated via the ST approach maintain complication rates similar to those in younger individuals.

Level of Evidence:

Level III, retrospective study.

Predictors for wound healing complications and prolonged hospital stay in patients with isolated calcaneal fractures

Purpose

Surgically treated calcaneal fractures have a high risk of postoperative wound healing complications and a prolonged length of hospital stay (LOS). The aim of this study was to identify predictor variables of impaired wound healing (IWH) and LOS in surgically treated patients with isolated calcaneal fractures.

Methods

This retrospective cohort study analyzed data on patients aged 18 years or older who were admitted to a level I trauma center with isolated calcaneal fractures between 2008 and 2018. Multivariable regression models were used to identify predictor variables.

Results

In total, 89 patients (age: 45.4 years; SD: 15.1) were included. In 68 of these patients, low-profile locking plate osteosynthesis was performed, and a minimally invasive approach (MIA) (percutaneous single screws/K-wire or low-profile locking plating via a sinus tarsi approach) was applied in 21 patients. Multivariable regression analysis revealed that a higher preoperative Böhler’s angle (β = − 0.16 days/degree, 95% CI [− 0.25, − 0.08], p = 0.004) and MIA (β = − 5.04 days, 95% CI [− 8.52, − 1.56], p = 0.002) reduced the LOS. A longer time-to-surgery (β = 1.04 days/days, 95% CI [0.66, 1.42] p = 0.001) and IWH increased the LOS (β = 7.80 days, 95% CI [4.48, 11.12], p = 0.008). In a subsequent multivariable regression analysis, two variables, open fractures (OR: 14.6, 95% CI [1.19, 180.2], p = 0.030) and overweight (BMI > 24) (OR: 3.65, 95% CI [1.11, 12.00], p = 0.019), increased the risk of IWH.

Conclusion

Advanced treatment algorithms for open fractures are needed to reduce the risk of IWH.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01863-1.