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

Approach

Tao Zhang et alDept Of Orthopaedic Surgery, Third hosp of Hebei Med University, Hebei,

ChinaJournal of Bone and Joint Surgery

| FEB 2014 | Vol. 96-A | Number 4

Level of evidence I

PRESENTER : Dr SAUMYA AGARWAL

Junior resident Dept of Orthopaedics J.N. Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum

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%

• 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

• 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

AIM

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

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

Preoperative Management

• Calcaneal lateral and axial radiographs

• CT Scan foot

• Injury severity – Sanders classification

• Surgery done when swelling subsided and wrinkles appeared on hindfoot

Surgical Procedure

• Epidural / spinal

• Lateral decubitus position

• 3.5cm longitudinal incision – posterior part of lateral aspect of hindfoot along lateral border of achilles tendon

• 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

• Sinus tarsi approach - direct exposure for reduction of posterior facet

• Anatomical plates and compression bolts -inserted subcutaneously

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

• 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

Functional outcome evaluation

• American Orthopaedic Foot and Ankle Society AOFAS Hindfoot scores at 2 year follow up

Statistical Analysis

4 factors selected for evaluation :

• Age

• Surgical technique

• Sanders classification

• Time of start of weight bearing activity

RESULTS

• 130 Patients ( 114 men and 16 women )

• Injury mechanism : fall from height, motor vehicle collision and twisting injury

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

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

• For sanders type II and III fractures , articularrestoration between 2 groups was not significant

• Patients with Type IV fractures in STA group had better restoration of posterior articularsurface

• 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

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

• 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

• 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

• 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

• 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

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

THANK YOU

GOOD DAY