Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature

Abstract

Introduction: To analyze recent literature comparing clinical outcomes of displaced intra-articular calcaneal fractures (DIACF) treated with open reduction and internal fixation using the extensile lateral approach (ELA) vs the minimally invasive sinus tarsi approach (STA), with a focus on wound complications.

Materials and methods: A comprehensive literature search was conducted utilizing PubMed, EMBASE, and Cochrane Library databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 2013 and 2022, level of evidence (LOE) I-III, head-to-head comparative studies reporting on clinical outcomes after DIACFs treated with ORIF using ELA versus STA, and literature with full-text written in English were included. Data collection included: publication year, study design, number of surgeons, number of participants, demographic data (mean age at time of surgery, percent male, body mass index, medical co-morbidities), preoperative data (mechanism of injury, Sanders classification, time from injury to surgical fixation), intraoperative data, and postoperative clinical and radiographic outcomes (Böhler angle, angle of Gissane, calcaneal height/length/width).

Results: A total of 21 articles (4 randomized control trials, 17 cohort studies) comprising of 2086 patients with calcaneal fractures, treated with either ELA (n = 1129) or STA (n = 957) met inclusion criteria. The risk of postoperative wound-related complications (RR 2.82, 95 % CI: 2.00-3.98, I²=27 %) and the risk of reoperation (RR 1.85, 95 % CI: 0.69-5.00, I2=67 %) was higher in ELA patients comparted to STA patients. However, the increased risk of postoperative wound-related complications with an ELA vs. STA was shown to be trending downward in recent publications. The ELA group also experienced longer time to surgery, extended operative times, and prolonged hospital stays when compared to the STA group. Radiographic measurements at final follow-up, including Böhler angle, angle of Gissane, as well as calcaneal height, length, and width, showed no statistically significant differences between the two groups.

Conclusion: Surgical treatment of calcaneal fractures utilizing the ELA continues to have an increased rate of complications and reoperation when compared to the less invasive STA, yet recent trends in the literature show that this rate is decreasing. Operative treatment of calcaneal fractures via either an ELA or STA can both achieve comparable postoperative radiographic outcomes.

Level of evidence: Therapeutic Level III.

Keywords: Calcaneal fracture; Extensile lateral approach; Meta-analysis; Sinus tarsi approach; Wound complication.