Displaced Intra-Articular Calcaneal Fractures Treated in a Minimally Invasive Fashion- Longitudinal Appraoch versus Sinus Tarsi Approach

1. Displaced Intra-Articular Calcaneal Fractures
Treated in a Minimally Invasive Fashion-
Longitudinal Appraoch versus Sinus Tarsi
Approach
Tao Zhang et al
Dept Of Orthopaedic Surgery, Third hosp of Hebei Med University, Hebei,
China
Journal of Bone and Joint Surgery
| FEB 2014 | Vol. 96-A | Number 4
Level of evidence I
PRESENTER : Dr SAUMYAAGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College and
Dr. Prabhakar Kore Hospital and MRC, Belgaum

2. INTRODUCTION
• Surgical approach for accurate reduction of
displaced intra articular # of calcaneum with
minimum wound related complications remains
controversial
• Most common method extended lateral
approach
• Wound complications rate ~30%

3. • Soft tissue envelope over lateral wall of
hindfoot is thin and vulnerable
• Sinus tarsi approach - most frequently used
minimally invasive approach
• provides adequate exposure for posterior
facet, anterolateral fragment and lateral wall

4. • wound complications range - 0 to 15.4 %
• Study introduced minimally invasive approach
with small longitudinal lateral incision on
hindfoot and use of plates and compression
bolts

5. AIM
To compare the clinical outcomes of
widely used sinus tarsi approach with
those of minimally invasive longitudinal
approach

6. Materials and Methods
• 2 groups : MILA and STA from Sept 2009 to
April 2010
• Inclusion criteria :
displaced intra articular fracture of calcaneum
> 18 yrs
No polytrauma of ipsilateral lower limb
• Both groups were fixed with same implants

7. Preoperative Management
• Calcaneal lateral and axial radiographs
• CT Scan foot
• Injury severity – Sanders classification
• Surgery done when swelling subsided and
wrinkles appeared on hindfoot

9. Surgical Procedure
• Epidural / spinal
• Lateral decubitus position
• 3.5cm longitudinal incision – posterior part of
lateral aspect of hindfoot along lateral border
of achilles tendon

10. • Bohlers angle restored – steinmann pins
• Posterior articular facet – percutaneous leverage
• Fracture fixed with anatomical plate and 2,3,4
compression bolts
• C-arm was used

12. • Sinus tarsi approach - direct exposure for
reduction of posterior facet
• Anatomical plates and compression bolts -
inserted subcutaneously

15. Postoperative Management & Follow Up
• Radiographs and CT Scan
• Non Weight Bearing exercises – extension and
plantar flexion of toes and ankle – as soon as
pain is tolerated
• Partial weight bearing – 4 weeks
• Full weight bearing – radiological osseous
union

16. • Follow up – 6 wks & 3,6,12 months and then yearly
• Physical examination
• Lateral and axial radiographs
• Bohler angle measured on lateral radiograph
• CT Scan at 3 months
• Removal at 12 months

17. Functional outcome evaluation
• American Orthopaedic Foot and Ankle Society
AOFAS Hindfoot scores at 2 year follow up

18. Statistical Analysis
4 factors selected for evaluation :
• Age
• Surgical technique
• Sanders classification
• Time of start of weight bearing activity

19. RESULTS
• 130 Patients ( 114 men and 16 women )
• Injury mechanism : fall from height, motor
vehicle collision and twisting injury

20. General information MILA group STA group
Age 39.8 41.7
Sex
Male 56 58
Female 7 9
Sanders classification
Type II 32 29
Type III 23 27
Type IV 14 16
Operative time 45.9 61.9

21. Complications MILA
No of feet
MILA
%
STA
No of feet
STA
%
Wound healing complications 2 2.9 9 12.5
Superficial infection 2 5
Deep infection 0 2
Sural nerve injury 1 1.5 3 4.2
Median plantar nerve injury 4 5.8 3 4.2
Severe defect with removal 2 2.9 3 4.2
Total 7 10.1 13 18.1

22. • For sanders type II and III fractures , articular
restoration between 2 groups was not
significant
• Patients with Type IV fractures in STA group
had better restoration of posterior articular
surface

23. • The mean AOFAS score was 86.2 in MILA
group and 88.8 in STA group
• Patients with Sanders type II or III fractures in
both groups had similar function outcomes
• Sanders type IV – good to excellent rate in STA
group was significantly higher

24. DISCUSSION
• Calcaneal # account for 2% of all #
• 80 – 90% involve young adults
• Patients treated nonoperatively for displaced
intra articular calcaneal fractures are unable
to return to original occupation or have severe
residual disability

25. • Prevalence of wound complications post-op
ranges from 7.57% to 32.8%
• Prevalence of Neurovascular injury ranges from
9.1% to 25%
• Among various approaches – sinus tarsi
approach – most popular – direct visualization
of posterior articular facet and fewer soft tissue
related complications

26. • Schepers reported – wound complication rate
of 4.8% with STA
• In 2004, MILA was developed and proved to be
quite effective when compared with open
technique
• Buckley suggested comminuted # were
associated with higher risk of poor outcomes
regardless of treatment method

27. • Biomechanical studies revealed – even a
minor residual step-off of the posterior facet
may lead to significant load shift within
subtalar joint
• Clinical studies showed that patients with
early postoperative weight bearing activity
may have better functional outcomes

28. • In this study, anatomical plate and compression
bolts provided rigid fixation of calcaneal # which
enable partial weight bearing as early as 4
weeks post-op
• In contrast, other studies showed partial weight
bearing time from 8-10 weeks
• Pozo et al reported that weight bearing can lead
to molding of articular surface which will help to
restore congruity of subtalar joint

29. LIMITATIONS
• 22.2% patients were lost to follow up
• AOFAS has its own limitations
• Both limbs were considered independently
• Quantified data on fracture reduction not
specifically analyzed

30. THANK YOU
GOOD DAY