Comparison of Sinus Tarsi Approach with screws vs Lateral Extensile Approach with plates in Sanders Type Two and Three Calcaneal Fractures: A Non-Randomized Study
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Abstract
Background. Intra-articular calcaneal fractures, particularly of the joint depression type, present significant surgical challenges. The traditional lateral extensile approach (LEA), although providing excellent exposure, is associated with notable soft tissue complications, such as wound necrosis and infection. The sinus tarsi approach (STA), a minimally invasive technique, aims to minimize these complications while maintaining comparable outcomes. This study aimed to compare the functional, radiological outcomes, and complications of STA with cannulated cancellous (CC) screw fixation versus LEA with plating in the management of joint depression-type intra-articular Sanders Type 2 and 3 calcaneal fractures.
Methodology. A prospective, non-randomized comparative study was conducted at a tertiary care center (BSTRH and MIMER Medical College, Talegaon Dabhade), involving 56 adult patients (aged >18 years) with acute (<three weeks) intra-articular joint depression (Sanders Type 2 and 3) calcaneal fractures, diagnosed via radiographs and CT scan. All surgeries were performed by a senior orthopaedic trauma surgeon with more than 10 years of experience. Patients were allocated into two groups of 28 each: Group A underwent STA with CC screw fixation, while Group B received LEA with plate fixation. Surgical intervention was performed after soft tissue readiness, followed by standard postoperative care. Patients were evaluated at one, three, six, nine, and 12 months postoperatively using the American Orthopaedic Foot and Ankle Society hindfoot score (AOFAS), Visual Analogue Scale (VAS), and radiological parameters including Bohler’s angle, Gissane angle, and calcaneal height and width. Complication rates, operative time, and hospital stay were also analyzed.
Results. STA resulted in significantly shorter operative times (59.1 vs. 98.4 minutes, p < 0.001) and hospital stays (4.7 vs. 7.42 days, p < 0.001). AOFAS scores at 12 months were comparable between STA (mean 80.57) and LEA (mean 77.33). Postoperative VAS scores were significantly better in the STA group (1.67 vs. 2.04; p = 0.044). Radiographic outcomes were similar between groups. STA demonstrated fewer complications, including superficial infection (3 vs. 5), deep infection (0 vs. 2), and sural nerve injury (0 vs. 1).
Conclusion. The sinus tarsi approach with cannulated screw fixation offers equivalent functional and radiological outcomes to the lateral
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References
Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Foot. 2009;19(4):197–200. https://pubmed.ncbi.nlm.nih.gov/20307476 https://doi.org/10.1016/j.foot.2009.05.001
Bajammal S, Tornetta P III, Sanders D, Bhandari M. Displaced intra-articular calcaneal fractures. J Orthop Trauma. 2005;19(5):360–4. https://pubmed.ncbi.nlm.nih.gov/15891550
Richter M, Thermann H, Wippermann B, Otte D, Schratt HE, Tscherne H. Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years. J Orthop Trauma. 2001;15(4):287–93. https://pubmed.ncbi.nlm.nih.gov/11371795 https://doi.org/10.1097/00005131-200105000-00009
Al-Ashhab ME. Treatment for calcaneal malunion. Eur J Orthop Surg Traumatol. 2013;23(8):961–6. https://pubmed.ncbi.nlm.nih.gov/23412236 https://doi.org/10.1007/s00590-012-1110-0
Aaron AD. Ankle fusion: a retrospective review. Orthopedics. 1990;13(11):1249–54. https://pubmed.ncbi.nlm.nih.gov/2259662 https://doi.org/10.3928/0147-7447-19901101-11
Maskill JD, Bohay DR, Anderson JG. Calcaneus fractures: a review article. Foot Ankle Clin. 2005;10(3):463–89. https://pubmed.ncbi.nlm.nih.gov/16081015 https://doi.org/10.1016/j.fcl.2005.03.002
McBride DJ, Ramamurthy C, Laing P. The hindfoot: calcaneal and talar fractures and dislocations—Part I: fractures of the calcaneum. Curr Orthop. 2005;19(2):101-7. https://doi.org/10.1016/j.cuor.2005.03.005
Buzzi R, Sermi N, Soviero F, Bianco S, Campanacci DA. Displaced intra-articular fractures of the calcaneus: ORIF through an extended lateral approach. Injury. 2019;50(Suppl 2):S2–7. https://pubmed.ncbi.nlm.nih.gov/30770121 https://doi.org/10.1016/j.injury.2019.01.037
Al-Mudhaffar M, Prasad CV, Mofidi A. Wound complications following operative fixation of calcaneal fractures. Injury. 2000;31(6):461–4. https://pubmed.ncbi.nlm.nih.gov/10831747 https://doi.org/10.1016/s0020-1383(00)00026-7
Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma. 1999;13(5):369–72. https://pubmed.ncbi.nlm.nih.gov/10406705 https://doi.org/10.1097/00005131-199906000-00008
Harvey EJ, Grujic L, Early JS, Benirschke SK, Sangeorzan BJ. Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int. 2001;22(11):868–73. https://pubmed.ncbi.nlm.nih.gov/11722137 https://doi.org/10.1177/107110070102201102
Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18(1):1–6. https://pubmed.ncbi.nlm.nih.gov/14676549 https://doi.org/10.1097/00005131-200401000-00001
Shuler FD, Conti SF, Gruen GS, Abidi NA. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes? Orthop Clin North Am. 2001;32(1):187–92. https://pubmed.ncbi.nlm.nih.gov/11465128 https://doi.org/10.1016/s0030-5898(05)70202-9
Bai L, Hou YL, Lin GH, Zhang X, Liu GQ, Yu B. Sinus tarsi approach versus extensile lateral approach for treatment of closed displaced intra-articular calcaneal fractures: a meta-analysis. Orthop Traumatol Surg Res. 2018;104(2):239–44. https://pubmed.ncbi.nlm.nih.gov/29410159 https://doi.org/10.1016/j.otsr.2017.12.015
Abdelgaid SM. Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures. Foot Ankle Surg. 2012;18(3):164–79. https://pubmed.ncbi.nlm.nih.gov/22857958 https://doi.org/10.1016/j.fas.2011.07.005
Pitts CC, Almaguer A, Wilson JT, Quade JH, Johnson MD. Radiographic and postoperative outcomes of plate versus screw constructs in open reduction and internal fixation of calcaneus fractures via the sinus tarsi. Foot Ankle Int. 2019;40(8):929-35. https://pubmed.ncbi.nlm.nih.gov/31088171 https://doi.org/10.1177/1071100719848063
Nosewicz T, Knupp M, Barg A, et al. Mini-open sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography-based study. Foot Ankle Int. 2012;33(11):925-33. https://pubmed.ncbi.nlm.nih.gov/23131437 https://doi.org/10.3113/FAI.2012.0925
Li S. Wound and sural nerve complications of the sinus tarsi approach for calcaneus fractures. Foot Ankle Int. 2018;39(9):1106–12. https://pubmed.ncbi.nlm.nih.gov/29766742 https://doi.org/10.1177/1071100718774808
Bedigrew KM, Blair JA, Possley DR, Kirk KL, Hsu JR. Comparison of calcaneal exposure through the extensile lateral and sinus tarsi approaches. Foot Ankle Spec. 2018;11(2):142–7. https://pubmed.ncbi.nlm.nih.gov/28597687 https://doi.org/10.1177/1938640017713616
Biggi F, Di Fabio S, D’Antimo C, Isoni F, Salfi C, Trevisani S. Percutaneous calcaneoplasty in displaced intraarticular calcaneal fractures. J Orthop Traumatol. 2013;14(4):307–10. https://pubmed.ncbi.nlm.nih.gov/23744105 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828486 https://doi.org/10.1007/s10195-013-0249-8
Carr JB. Surgical treatment of intra-articular calcaneal fractures: a review of small incision approaches. J Orthop Trauma. 2005;19(2):109–17. https://pubmed.ncbi.nlm.nih.gov/15677927 https://doi.org/10.1097/00005131-200502000-00007
Seat A, Seat C. Lateral extensile approach versus minimal incision approach for open reduction and internal fixation of displaced intra-articular calcaneal fractures: a meta-analysis. J Foot Ankle Surg. 2020;59(2):356-66. https://pubmed.ncbi.nlm.nih.gov/32131003 https://doi.org/10.1053/j.jfas.2019.08.007
Xu J, He Z, Zhang G, et al. An experimental study on the digital precision of internal fixation via the sinus tarsi approach for calcaneal fractures. J Orthop Surg (Hong Kong). 2019;27(1):2309499019834072. https://pubmed.ncbi.nlm.nih.gov/30866744 https://doi.org/10.1177/2309499019834072
Bedigrew KM, Blair JA, Possley DR, Kirk KL, Hsu JR. Comparison of calcaneal exposure through the extensile lateral and sinus tarsi approaches. Foot Ankle Spec. 2018;11(2):142–7. https://pubmed.ncbi.nlm.nih.gov/28597687 https://doi.org/10.1177/1938640017713616
Kwon JY, Guss D, Lin DE, et al. Effect of delay to definitive surgical fixation on wound complications in the treatment of closed, intra-articular calcaneus fractures. Foot Ankle Int. 2015;36(5):508-17. https://pubmed.ncbi.nlm.nih.gov/25589541 https://doi.org/10.1177/1071100714565178
Basile A, Albo F, Via AG. Comparison between sinus tarsi approach and extensile lateral approach for treatment of closed displaced intra-articular calcaneal fractures: a multicenter prospective study. J Foot Ankle Surg. 2016;55(3):513-21. https://pubmed.ncbi.nlm.nih.gov/26810127 https://doi.org/10.1053/j.jfas.2015.11.008
Zeng Z, Yuan L, Zheng S, Sun Y, Huang F. Minimally invasive versus extensile lateral approach for Sanders type II and III calcaneal fractures: a meta-analysis of randomized controlled trials. Int J Surg. 2018;50:146-53. https://pubmed.ncbi.nlm.nih.gov/29337175 https://doi.org/10.1016/j.ijsu.2017.12.034
Ma C, Zhao J, Zhang Y, et al. Comparison of the modified sinus tarsi approach versus the extensile lateral approach for displaced intra-articular calcaneal fractures. Ann Transl Med. 2021;9(8):695. https://pubmed.ncbi.nlm.nih.gov/33987393 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106015 https://doi.org/10.21037/atm-21-1226
Ebraheim NA, Elgafy H, Sabry FF, Freih M, Abou-Chakra IS. Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. Foot Ankle Int. 2000;21(2):105-13. https://pubmed.ncbi.nlm.nih.gov/10694021 https://doi.org/10.1177/107110070002100203
Yeo JH, Cho HJ, Lee KB. Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach. BMC Musculoskelet Disord. 2015;16:63. https://pubmed.ncbi.nlm.nih.gov/25886471 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4391481 https://doi.org/10.1186/s12891-015-0519-0
Zhang T, Su Y, Chen W, Zhang Q, Wu Z, Zhang Y. Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach. J Bone Joint Surg Am. 2014;96(4):302-9. https://pubmed.ncbi.nlm.nih.gov/24553886 https://doi.org/10.2106/JBJS.L.01215
Lin J, Xie C, Chen K, et al. Comparison of sinus tarsi approach versus extensile lateral approach for displaced intra-articular calcaneal fractures Sanders type IV. Int Orthop. 2019;43(9):2141-9. https://pubmed.ncbi.nlm.nih.gov/30903254 https://doi.org/10.1007/s00264-019-04318-w