KEYSTONE, Colo. – Although a limited
sinus tarsi approach for
calcaneal fracture fixation showed fewer wound healing
problems and postoperative infections than the standard extensile lateral
approach, a recently presented study showed that both methods had similar
radiographic and clinical outcomes.
“There is controversy regarding whether we should really abandon
the classical open techniques and this study does not dispel that controversy,
but it does provide data to show that further investigation is both ethical and
appropriate,” Wade R. Smith, MD, senior author of the study, told
His colleague, Patrick J. Maloney, MD, presented the results of the
retrospective study led by principal investigator Gerard J. Cush, MD, at the
2011 Annual Meeting of the American Orthopaedic Foot and Ankle
The investigators compared 26 patients who underwent the sinus tarsi
approach with a group of 52 patients who underwent the extensile lateral
approach for calcaneus fractures. Age, gender ratio, fracture classification
distribution and injury mechanism were similar between the groups.
An intraoperative image of exposure with retraction of the
peroneal tendons is shown.
inserts a small plate through the sinus tarsi incision.
postoperative X-ray shows a calcaneus fracture fixed via the sinus tarsi
approach with independent screw fixation.
Images: Maloney PJ
The team analyzed outcomes using AOFAS hindfoot scores and angles of
Bohler and Gissane on plain radiographs. Average follow-up was 24 months for
extensile lateral group and 15 months for sinus tarsi group.
Postoperative AOFAS hindfoot scores and angles of Bohler and Gissane
were similar between the cohorts, but the sinus tarsi group demonstrated fewer
complications and wound healing problems. Complications in the extensile
lateral group included wound necrosis, deep infection, sural neuritis, chronic
serious drainage, superficial infection and re-operations for arthrodesis or
wound healing problems.
“The sinus tarsi group had lower rates of wound edge necrosis, deep
infection and chronic serous drainage,” Maloney said. “They had
equivalent rates of superficial infection and sural neuritis compared to the
The researchers plan to conduct further prospective studies to evaluate
joint mechanics, prevention of osteoarthritis and preservation of gait with the
sinus tarsi approach. They also recommend paying close attention to location of
the sural nerve for either approach, according to the study abstract. –
by Renee Blisard
- Maloney PJ, Cush GJ, Smith WR, Widmaier JC, et al. Calcaneal
fixation: extensile lateral versus sinus tarsi mini-incision approach –
early outcome evaluation. Presented at the 2011 Annual Meeting of the American
Orthopaedic Foot and Ankle Society. July 13-15. Keystone, Colo.
- Patrick J. Maloney, MD, can be reached at Geisinger Medical Center,
100 N. Academy Ave., Danville, PA 17822; 800-275-6401; email:
- Wade R. Smith, MD, can be reached at Swedish Hospital, 701 E.
Hampden Ave., Ste. 515, Englewood, CO 80113; 303-209-2503; email:
- Disclosures: Maloney has no relevant financial disclosures.
Smith is a consultant to Synthes and Medtronic.
The approach to treating calcaneal fractures has changed over time.
Early on, these fractures were treated conservatively with a cast. Improved
surgical techniques and understanding of proper soft-tissue handling led to
open reduction and internal fixation through an extensile lateral approach.
Unfortunately, these procedures are fraught with potential complications; most
notably delayed wound healing and infections. To potentially reduce
complications, an attempt has been made in recent years to develop alternative
approaches to fixation of calcaneal fractures.
This study compared a group of calcaneal fractures treated with an
extended lateral approach to a similar group treated via an alternative sinus
tarsi incision approach. I was surprised by their high rate of severe
complications in the extended lateral approach. A 17% incidence of deep
infections, 17% incidence of wound necrosis and 17% incidence of sural neuritis
is higher than one would expect to see with this method. I agree with their
findings of lower complication rates utilizing a sinus tarsi approach and would
encourage its use in the appropriate fracture pattern. Their population did not
include the more severe calcaneal fractures (Sanders type 4), which I believe
are more difficult to reduce utilizing a sinus tarsi approach. Those comminuted
fractures, I feel, warrant the extended lateral approach in order to better
visualize and reduce the fragments.
— Steven Neufeld, MD
The Orthopaedic Foot
and Ankle Center
Disclosure: Neufeld has no
relevant financial disclosures.