Sinus Tarsi Approach for Calcaneal Fracture Treatment: Our Experience with 36 Consecutive Cases
Corresponding Author: Diwakar Mishra, Department of Orthopedic, Yash Orthopedic Hospital, Ankleshwar, Gujarat, India, Phone: +91 8511027088, e-mail: firstname.lastname@example.org
A total of 35 patients with 36 Sanders type 2 and 3 calcaneal fractures were treated with open reduction and internal fixation using the sinus tarsi approach. Wires, screws, plates, and combinations of these were used for the fixation of fractures. The patients were followed for 10-44 months and evaluated for radiological and clinical outcomes. Bohler angle was corrected from a preoperative mean of 0.68 degrees (range: 34.7-23.4 degrees) to postoperative mean of 23.5 degrees (range: 16-40 degrees). Gissane angle was corrected from a preoperative mean of 94.7 degrees (range: 41.8-123.8 degrees) to 110 degrees postoperatively (range: 87.7-135.8 degrees). Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) scoring. The score, at last follow-up was 62-90 with an average of 82. We conclude that the sinus tarsi approach can be used for earlier intervention and permits adequate access for satisfactory reduction of Sanders type 2 and 3 calcaneal fractures and optimum implant placement. The approach is associated with a low incidence of soft tissue complications.
How to cite this article: Soni M, Mishra D. Sinus Tarsi Approach for Calcaneal Fracture Treatment: Our Experience with 36 Consecutive Cases. J Foot Ankle Surg (Asia Pacific) 2022;9(2):75-80.
Source of support: Nil
Conflict of interest: None
Keywords: Calcaneus fractures, Displaced intra-articular calcaneal fractures, Sinus tarsi approach
Although relatively rare, calcaneal fractures comprise about 1-2% of all fractures.1 and are the most common fractures of the tarsal bones. The fractures occur in relatively young patients.2 About 75% of the fractures are intra-articular3,4 and have been associated with long-term morbidity. Even in the 21st century, the treatment of displaced intra-articular calcaneal fractures (DIACFs) remains controversial.5 Operative interventions are becoming more common for displaced fractures, but soft tissue complications are also commonly documented in fractures treated with extensile approaches nearing 31%.6,7 Minimally invasive approaches have thus evolved, with lesser incidence of wound complications.8 We present our experience of limited sinus tarsi approach in a prospective cohort of DIACFs (Figs 1 to 6).
MATERIALS AND METHODS
A total of 46 consecutive patients with displaced intra-articular calcaneal fractures presenting to our hospital between January 2018 and December 2020 were evaluated for inclusion in this study. Of these 35 patients with 36 Sanders type 2 and 3 calcaneal fractures that met the inclusion criteria were included in the study. We excluded open fractures, Sanders type 1 and 4 fractures, those with medical comorbidities like diabetes mellitus, peripheral vascular insufficiency, and refusal to accept the treatment plan.
The fractures were evaluated by standard radiographic views—axial, lateral, anteroposterior (AP) view of the foot, and ankle-mortise views. The fractures were further evaluated by computed tomographic (CT) scans. Classification of fractures into thalamic depression and tongue type was done on radiographic evaluation. Sanders classification was used to classify the fractures based on a CT scan.
The surgery was done with the patient in a lateral decubitus position after administration of spinal anesthesia. Tourniquet was used in all cases after exsanguination. Approximately 5-7 cm long incision was made starting from 1 cm below the tip of lateral malleolus extending anteriorly in the line of the fourth metatarsal. Subcutaneous tissue was dissected. Care was taken to avoid injury to the sural nerve. Sinus tarsi fat pad was mobilized, and the origin of extensor digitorum brevis was elevated sharply and reflected dorsally and distally along with an inferior attachment of the extensor retinaculum. The peroneal sheath was sharply dissected and tendons were retracted inferiorly. Subtalar joint was exposed by capsulotomy and the posterior facet of calcaneum was identified. In pure tongue depression type fractures, the facet was elevated using the Essex-Lopresti maneuver, while in thalamic depression fractures, a periosteal elevator was passed below the depressed fragment to elevate the posterior facet. Alternatively, a novel technique invented by the senior author was used in which multiple drill holes are made with 3.2 mm drill bit over tuberosity just below Tendoachilles (TA) insertion and a vertical slit was created to pass a Kirschner wire (k-wire) for use as a joystick, and the depressed thalamic fragment was elevated under fluoroscopy guidance (Figs 4A to C).
Then the reduction was assessed in axial view. If the medial wall was not reduced then a Schanz screw was passed from tuberosity anteriorly to exert valgus force and simultaneously a small bone spike was passed between the body and sustentaculum fragment and levered back to achieve reduction. We have found the Mixter forceps to be a useful tool in some cases which was passed medially to hook the sustentacular fragment and the fragment pulled laterally with a valgus force applied from the posteriorly placed Schanz pin (Fig. 4D). The reduction was held with a k-wire passed anteriorly from tuberosity toward the sustentaculum tali. Then the elevated facet fragment was temporarily fixed to a constant medial fragment with a 2 mm k-wire and the reduction was assessed under fluoroscopy. Another 1 mm k-wire was passed directed medially, anteriorly, and cephalad to caudate, exiting medially through the anterior part of the sustentaculum. A 4 mm cannulated drill was passed over this wire and a cannulated screw of appropriate size was inserted over the wire. The choice of the implant depended on the amount of communition and lateral wall blowout. We opted for low profile 2.7 mm or 1/3 tubular plate fixation for Sanders type 3 cases and/or with extensive lateral wall blowout. In other cases, multiple 4 mm cancellous screws were used. A “kickstand” screw is inserted to support the elevated facet. Two or three posteroanterior screws were inserted to maintain the length of the calcaneus. Small 2.7 mm screws were used to fix anterolateral fragments when required. The reduction was assessed by passing a periosteal elevator in the subtalar space to feel for any incongruity or articular step. Further, the reduction was assessed visually and on fluoroscopy by obtaining axial, lateral, and Broden’s views. Wound lavage was given and closure was done in layers. The posterior splint was applied.
The dressing was mostly done on 5th day. Sutures were removed on 12-14th day and the splint was discontinued. Mobilization was initiated at the visit for suture removal. Radiographic evaluation was done monthly for the first three months and then at 6 and 9 months. Partial weight-bearing was initiated at 4-6 weeks and full weight-bearing from 8-10 weeks.
Preoperative and postoperative radiographs (Fig. 4E) were evaluated. Bohler and Gissane angles were measured. Outcomes were measured with the AOFAS foot and ankle scoring system. The score at the last follow-up was 62-90 with an average of 82.
Observations and Analysis
The mean age was 33.84 years (range: 19-54). All patients were male; the mechanism of injury was a road traffic accident in 42% and fall from height in 58% of the cases. Fractures were left-sided in 16, right-sided in 18, and bilateral in one.
As per Sanders classification, there were 22 type 2, and 14 type 3 fractures. The mean time to surgery after injury was 6.7 days (range: 0-19 days). Patients were followed up for a minimum of 9 months (mean 14 months, range: 10-44 months). The details of the implants used are given in Table 1.
|Implant||Number of cases|
|Plate and screws||19|
|Plate, screws and wires||1|
|Plate and wires||2|
|Screws and wires||1|
Preoperative Bohler angle ranged from -34.7-23.4 degrees with a mean of -0.68 degrees while postoperatively the angle ranged from 16-40 degrees with a mean of 23.5 degrees. Gissane angle ranged from 41.8-123.8 degrees with a mean of 94.7 degrees preoperatively and was corrected to a mean of 110 degrees (range: 87.7-135.8 degrees) ( Table 2).
|Bohler angle||Gissane angle|
One case developed a deep infection, requiring the removal of implants. No nerve injury occurred in our series.
The treatment of calcaneal fractures is aimed at restoration of the posterior facet of the subtalar joint, restoration of the height of calcaneus (Bohler angle), reduction of the width of calcaneum, decompression of subfibular space available for peroneal tendons, realignment of tuberosity into a valgus position, and reduction of the calacaneocuboid joint if fractured.9
Surgical reduction of intra-articular calcaneal fractures should be pursued in patients with a joint step-off of more than 2 mm or fracture gap of more than 3 mm.5 Open reduction and internal fixation is currently considered the gold standard in the surgical treatment of displaced intra-articular fractures.10-11 Several open surgical techniques have been described in the past, of which the extended lateral approach has been applied most frequently. Advantages of the extensile lateral approach include wide exposure of the subtalar joint allowing more accurate reduction of the facet fragments, ability to decompress the lateral wall, exposure of the calcaneocuboid joint, and sufficient area laterally for plate fixation.9 However extensile approach is associated with increased risk of complications like delayed wound healing, wound dehiscence, infection, etc. in up to 31% of the cases.6,11 Soft tissue covering the lateral wall of the calcaneum is supplied by the lateral calcaneal artery which is thin and vulnerable, making the extensile lateral approach prone to wound complications.6 Risk factors for complications in the wound after calcaneal open reduction and internal fixation include single-layered closure, high body mass index, extended time between injury and surgery, smoking, diabetes, and open fractures.7,12 Therefore less extensive approaches were described including the approaches described by Palmer,13 modified obtuse-angled approach,14 limited lateral approaches,15 posterolateral approach16 modified lateral Palmer approach,17 etc
Many studies have shown that the clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach.8 However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries.8 Sinus tarsi approach permits good visualization of the fracture and allows anatomic reduction of articular surfaces.4
On the other hand, Nathaniel et al. report a higher incidence of deep infection in cases treated with sinus tarsi (17.6%).18 This was not the case in our experience, as we found only 1/34 cases developed deep infection. No specific factor could be attributed to the occurrence of this infection.
Sural nerve injury has been reported as complications of sinus tarsi approach. We did not see any such case; the incidence of sural nerve injury increases if the incision extends posterior to the lateral malleolus,19 and we ensure adequate visualization of the nerve with careful retraction whenever possible. Jeong-Hyun Park et al. have described distance ratios to localize and avoid sural nerve injury during sinus tarsi approach.20 Medial plantar nerve has also been reported as a complication of this approach,4 but we did not have any problem in this regard.
Painful hardware needing removal is the most common complication of sinus tarsi approach (STA) in long term.21 Fixation of the fracture has thus to be done with care. A variety of implants have been used, with various authors using only Kirschener pins,22 pins and screws,23 screws only,24 subcutaneously delivered plates25 We used pins, screws, plates, or a combination of these.
Changjun et al., in their study, found no difference in radiographic, clinical, and cost parameters while comparing fixation with plates to fixation with screw construct only.26 Chuagang Peng et al. in their meta-analysis concluded that, compared with extensile lateral approach (ELA), STA is superior for treating calcaneal fractures as we can get an adequate reduction of the calcaneus, incision complications are minimized and operative time and postoperative stay both shortened.27 STA is also more favorable due to less postoperative pain, less expense of analgesia as well as cost of internal fixation materials.28
In our study, satisfactory reduction of the fracture was obtained through limited sinus tarsi approach in all 34 calcaneum cases. Incidence of complications was 2.7% which is quite less compared to the studies with extensile lateral approach. The results were good with average AOFAS score of 82. In all patients Bohler angle, Gissane’s angle were corrected to normal value with valgus correction which were satisfactory.
Good results correlate with restoration of Bohler angle.30 There is significant correlation between preoperative Bohler angle and the injury severity of the fracture but postoperative Bohler angle parameters have a significant correlation with the functional recovery.31 We found no difficulty in fracture reduction, and were able to restore both Bohler and Gissane angles to acceptable or better levels.
From the supportive evidence in the literature, and our experience of 34 cases, we would recommend considering the sinus tarsi approach to be the new gold standard for the treatment of DIACFs.29
Sinus tarsi approach can be done early and permits adequate access for satisfactory reduction of the fractures and implant placement. The incidence of soft tissue complications is low. We conclude that it should be the recommended approach for treatment of most DIACFs.
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