Update on Calcaneus Fractures: Open vs Sinus Tarsi Gil R. Ortega, - - PowerPoint PPT Presentation

Update on Calcaneus Fractures: Open vs Sinus Tarsi

Gil R. Ortega, MD, MPH Sonoran Orthopaedic Trauma Surgeons Orthopaedic Trauma Director, Mayo Clinic Arizona Residency Program Vice Chair, Department of Surgery, Scottsdale Osborn Level 1 Trauma Center, Scottsdale, AZ, USA

Disclosures

• Founding Member, Orthopaedic Board of

Advisors: Carbofix

• Founding Member, Orthopaedic Board of

Advisors: Artross Nanobone

• Consultant: Smith and Nephew

Why I’ve Used Sinus Tarsi Approach for last 7 years

• 4-cm incision over sinus tarsi
• Allows for excellent visualization of posterior

facet, anterolateral fragment, CCJ, lateral wall, and peroneal tendons

• If need be, incision can be extended proxi-

mally to treat acute peroneal tendon dislocation

• If needed, same incision can be used at later

date should subtalar arthrodesis or tendon debridement be indicated

Remember This One Slide and Do the Right Thing for Your Patients…Use the Sinus Tarsi Approach for Most Calcaneus Fractures

• Less blood loss
• Decreased operative time
• Minimization of soft tissue disruption
• Fewer wound complications
• Higher patient satisfaction scores
• Better disability scores than extensile

approach

Show You the Evidence…

• Retrospective review of 112 operatively

treated calcaneus fractures

• 79 treated with lateral extensile approach
• 33 with sinus tarsi
• Significantly lower rate of wound complica-

tions

– Sinus tarsi group (6%) – Lateral extensile group (29%; P < .005)

Show You the Evidence…

• Patients undergoing ORIF via an

extensile lateral approach were also more likely to require secondary surgery within the 3-year study period

• Importantly, fracture severity was

relatively equally distributed among 2 groups

• Both groups had 100% union rate

Show You the Evidence…

• 2014 randomized, prospective trial by Xia and colleagues
• 117 calcaneal fractures were allocated randomly to ORIF

via lateral extensile approach versus sinus tarsi approach

• All surgeries were performed 8 to 12 days after injury
• Significantly decreased operative times in sinus tarsi

group compared with extensile group (62 vs 93 minutes)

• Lower rate of wound complication (0% vs 16.3%)
• Patients in minimally invasive group had significantly

higher Maryland foot scores at time of final follow-up

• Xia et al. Minimally invasive percutaneous osteosynthesis versus ORIF for Sanders type II and III

Show You the Evidence…

• Kwon and colleagues recently conducted a

retrospective review of 405 operatively treated calcaneus fractures

• Found a decreased overall risk of wound

complications with minimally invasive ap- proaches (percutaneous and sinus tarsi techniques) compared with extensile approach

• Kwon 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 May;36(5):508-17

Show You the Evidence…

• Increased risk of wound complication in Sanders types III

and IV fractures treated with minimally invasive approaches compared with Sanders types I and fractures II treated with similar approach (odds ratio, 3.5; 95% confidence interval, 1.3–10.3; P < .018)

• Increased risk of wound complication with operative delay

beyond 14 days when using minimally invasive approaches (odds ratio, 3.2; 95% confidence interval, 1.3– 9.5; P < .01)

• However, these outcomes are of 24 different surgeons

with varying degrees of operative experience

• Kwon et al. Effect of Delay to Definitive Surgical Fixation on Wound Complications in the Treatment
• f Closed, Intra-articular Calcaneus Fractures. Foot Ankle Int. 2015 May;36(5):508-17

Show You the Evidence…

• Investigate whether sinus tarsi approach (STA)

allows for a similar anatomical reduction of the posterior talocalcaneal facet as extended lateral approach (ELA) and compare rate of postoperative wound complications

• Incidence of wound complications, time to surgery,

postoperative duration of hospital admission, and number of hospital admissions because of wound complications were significantly different between the ELA group and STA group

• Tim Schepers, MD, PhD et al 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 Volume 31, Number 6, June 2017

Show You the Evidence…

• No significant difference in restoration of

calcaneal anatomy with either approach

• STA was performed in median duration of 105

minutes and ELA in median of 134 minutes, accounting for nearly half an hour difference in

• perating time (P < 0.001)
• Tim Schepers, MD, PhD et al 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 Volume 31, Number 6, June 2017

Show You the Evidence…

• Systematic review combining results of studies using

sinus tarsi approach

• Literature search in electronic databases of Cochrane

Library and Pubmed Medline, between January 1st 2000 to December 1st 2010, was conducted to identify studies for sinus tarsi approach or modified sinus tarsi approach

• Eight case series reporting on 256 patients with 271

calcaneal fractures were identified

• Overall good to excellent outcome was reached in three-

quarters of all patients

Show You the Evidence…

• Average complication rate of minor wound

complications of 4.1% was reported and major wound complications in 0.7%

• Need for a secondary subtalar arthrodesis
• ccurred at an average rate of 4.3%
• Functional outcome and complication rates,
• f sinus tarsi approach compare similarly
• r favourably to extended lateral approach
• Tim Schepers. International Orthopaedics (SICOT) (2011) 35:697–703

Remember This One Slide and do the right thing for your patients…Use the Sinus Tarsi Approach for Most Calcaneus Fractures

• Less blood loss
• Decreased operative time
• Minimization of soft tissue disruption
• Fewer wound complications
• Higher patient satisfaction scores
• Better disability scores than extensile

approach

Thank You