Sage Journals: Discover world-class research

Abstract

Background

The purpose of this study was to evaluate the optimal timing and measures of the sinus tarsi approach for calcaneus fractures to avoid iatrogenic injury of the sural nerve and to assess for wound complications.

Methods:

A case series of 53 patients with calcaneus fractures treated by a single surgeon with the sinus tarsi approach was retrospectively analyzed. On the basis of the delay time from injury to surgery, patients were classified into 4 groups: immediate (0–3 days), early (4–6 days), intermediate (7–14 days), and late (14–18 days). All patients were followed for at least 1 year to observe wound conditions. The rate of wound complications and iatrogenic sural nerve injury was described. Incisions were classified into 2 groups: group A included patients with incisions extending posterior to the lateral malleolus, and group B included patients with incisions confined anterior to the lateral malleolus. The rates of nerve injury were compared between both groups. Forty-three patients with 52 Sanders type II fractures were included.

Results:

The average time to surgery from injury was 8.8 days (range, 0–18 days). The overall postoperative rate of wound complications was 5.8% (3 of 52). In the immediate group, deep infections and wound necrosis were found in 2 of 8 fractures (25%). In the early group, 1 of 15 fractures developed superficial infection (6.7%). In the intermediate and late groups, no wound complication was identified. Iatrogenic sural nerve injury was recorded in 5 of 52 patients (9.6%). Group A had 33% (4 of 12) nerve injuries and group B had 2.5% (1 of 40) (P = .009). In 70% of cases, a main branch of the sural nerve was directly under the incision.

Conclusions:

The sinus tarsi approach was generally effective and safe for calcaneus fractures. However, it was relatively risky to perform open reduction and internal fixation by the sinus tarsi approach within 6 days of injury. Because the sural nerve is in the vicinity of the approach, iatrogenic injury should be avoided by the use of careful planning and meticulous manipulations.

Level of Evidence

Therapeutic; Level III, comparative study.

Keywords

calcaneus fracture sinus tarsi approach complication sural nerve

Get full access to this article

View all access options for this article.

References

Abidi

Dhawan

Gruen

et al . Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int. 1998;19(12):856-861.

Agren

Wretenberg

Sayed-Noor

AS.

Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2013;95(15):1351-1357.

Andermahr

Helling

Rehm

Koebke

The vascularization of the os calcaneum and the clinical consequences. Clin Orthop. 1999; 363:212-218.

Borrelli

Lashgari

Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma. 1999;13(2):73-77.

Bruce

Sutherland

Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database Syst Rev. 2013;(1):CD008628.

Court-Brown

Schmidt

Schutte

. Factors affecting infection after calcaneal fracture fixation. Injury. 2009;40(12):1313-1315.

Ebraheim

Elgafy

Sabry

et al . Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. Foot Ankle Int. 2000;21(2):105-113.

Epstein

Chandran

Chou

Current concepts review: intra-articular fractures of the calcaneus. Foot Ankle Int. 2012;33(1):79-86.

Femino

Vaseenon

Levin

et al . Modification of the sinus tarsi approach for open reduction and plate fixation of intra-articular calcaneus fractures: the limits of proximal extension based upon the vascular anatomy of the lateral calcaneal artery. Iowa Orthop J. 2010;30:161-167.

10.

Gardner

Nork

Barei

et al . Secondary soft tissue compromise in tongue-type calcaneus fractures. J Orthop Trauma. 2008;22(7):439-445.

11.

Gougoulias

Khanna

McBride

et al . Management of calcaneal fractures: systematic review of randomized trials. Br Med Bull. 2009;92:153-167.

12.

Harvey

Grujic

Early

et al . Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int. 2001;22(11):868-873.

13.

Hospodar

Guzman

Johnson

et al . Treatment of displaced calcaneus fractures using a minimally invasive sinus tarsi approach. Orthopedics. 2008;31(11):1112.

14.

Ibrahim

Rowsell

Rennie

et al . Displaced intra-articular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury. 2007;38(7):848-855.

15.

Kikuchi

Charlton

Thordarson

DB.

Limited sinus tarsi approach for intraarticular calcaneus fractures. Foot Ankle Int. 2013;34(12):1689-1694.

16.

Kline

Anderson

Davis

et al . Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. Foot Ankle Int. 2013;34(6):773-780.

17.

Kwon

Guss

Lin

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):508-517.

18.

Loucks

Buckley

Bohler’s angle: correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma. 1999;13(8):554–558.

19.

Randle

Kreder

Stephen

et al . Should calcaneal fractures be treated surgically? A meta-analysis. Clin Orthop Relat Res. 2000;377:217-227.

20.

Sanders

Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992;6(2):252-265.

21.

Schepers

The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop. 2011;35(5):697-703.

22.

Schon

Jacob

et al . Minimally invasive plate fixation of calcaneus fractures. Tech Orthop. 2012;27(2):118-125.

23.

Spagnolo

Bonalumi

Pace

et al . Calcaneus fractures, results of the sinus tarsi approach: 4 years of experience. Eur J Orthop Surg Traumatol. 2010;20(1):37-42.

24.

Swanson

Clare

Sanders

RW.

Management of intra-articular fractures of the calcaneus. Foot Ankle Clin. 2008;13(4):659-678.

25.

Thordarson

Krieger

LE.

Operative

vs.

nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int. 1996;17(1):2-9.

26.

Xia

Wang

et al . Open reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fractures: a randomized controlled trial. Int J Surg. 2014;12(5):475-480.

27.

Zhang

Chen

et al . 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):302-309.

28.

Zwipp

Rammelt

Barthel

Calcaneal fractures—open reduction and internal fixation (ORIF). Injury. 2004;35(Suppl 2):SB46–SB54.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.05 MB

Wound and Sural Nerve Complications of the Sinus Tarsi Approach for Calcaneus Fractures