Fixation of displaced intra-articular calcaneus fractures is safe using either sinus tarsi or extensile lateral approach

Noah M Joseph; Margaret A Sinkler; Steven Magister; Abigail Bacharach; Aaron Pang; Kirsten Boes; Heather A Vallier; Adam G Hirschfeld; George Ochenjele

doi:10.1016/j.injury.2023.02.036

Fixation of displaced intra-articular calcaneus fractures is safe using either sinus tarsi or extensile lateral approach

Injury. 2023 Feb 23:S0020-1383(23)00168-7. doi: 10.1016/j.injury.2023.02.036. Online ahead of print.

Authors

Noah M Joseph¹, Margaret A Sinkler², Steven Magister², Abigail Bacharach², Aaron Pang², Kirsten Boes², Heather A Vallier³, Adam G Hirschfeld³, George Ochenjele²

Affiliations

¹ Department of Orthopaedics, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA. Electronic address: Noahjo18@gmail.com.
² Department of Orthopaedics, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
³ Department of Orthpaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.

PMID: 36878733
DOI: 10.1016/j.injury.2023.02.036

Abstract

Introduction: Management of displaced intra-articular calcaneus fractures continues to challenge surgeons. Use of the extensile lateral surgical approach (ELA) had been standard practice however wound necrosis and infection have become deterrents. The sinus tarsi approach (STA) has gained popularity as a less invasive technique to optimize articular reduction while minimizing soft tissue injury. Our aim was to compare wound complications and infections following calcaneus fractures treated using ELA versus STA.

Methods: Retrospective review of 139 displaced intra-articular calcaneus fractures (AO/OTA 82C; Sanders II-IV injuries) treated operatively at 2 level-I trauma centers using STA (n = 84) or ELA (n = 55) over a 3-year period with minimum 1-year follow up was performed. Demographic, injury, and treatment-related characteristics were collected. Primary outcomes of interest included wound complications, infection, reoperation, and American Orthopaedic Foot and Ankle Society ankle and hindfoot scores. Univariate comparisons between groups were conducted using Chi-Square, Mann-Whitney, and independent sample t-tests at the p < 0.05 significance level, where appropriate. Multivariable regression analysis was performed to identify risk factors for poor outcomes.

Results: Demographic characteristics were homogenous between cohorts. Most sustained falls from height (77%). Sanders III fractures were most common (42%). Patients treated with STA went to surgery earlier (6.0 days STA vs 13.2 ELA, p < 0.001). No differences were seen in restoration of Bohler's angle, varus/valgus angle, or calcaneal height, yet the ELA significantly improved calcaneal width (-2 mm STA vs -13.3 mm ELA, p < 0.001). There were no significant differences in wound necrosis or deep infection based on surgical approach (12% STA vs 22% ELA, p = 0.15). Seven patients underwent subtalar arthrodesis for arthrosis (4% STA vs 7% ELA). No differences in AOFAS scores were seen. Risk factors for reoperation included Sanders type IV patterns (OR = 6.6, p = 0.001), increasing BMI (OR = 1.2, p = 0.021), and advanced age (OR = 1.1, p = 0.005), not surgical approach.

Conclusion: Despite prior concerns, use of ELA versus STA for fixation of displaced intra-articular calcaneus fractures was not associated with more complication risk, illustrating both are safe when indicated and executed appropriately.

Keywords: Calcaneus fracture; Extensile lateral approach; Functional outcomes; Sinus tarsi approach; Wound complications.