Limited sinus tarsi approach versus extended lateral L-shaped approach for the open reduction and internal fixation of Sanders type III calcaneal fractures: a retrospective study

doi:10.21203/rs.3.rs-2080679/v1

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Limited sinus tarsi approach versus extended lateral L-shaped approach for the open reduction and internal fixation of Sanders type III calcaneal fractures: a retrospective study

https://doi.org/10.21203/rs.3.rs-2080679/v1

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Purpose

Controversy still exists regarding whether the sinus tarsi approach is able to effectively manage the Sanders type III fractures. The objective of this retrospective study was to describe and evaluate the clinical applications of the minimally invasive sinus tarsi approach and the extended lateral L-shaped approach for treating Sanders type III calcaneal fractures.

Methods

Between January 2012 and February 2015, 35 patients with calcaneal fractures(Sanders type III)treated in our trauma center were enrolled in this retrospective study. Surgeries were performed after improvement of soft tissue conditions. Either limited ORIF via sinus tarsi approach (minimally invasive group) or traditional ORIF via extended lateral L - shaped approach (traditional group) was performed on these patients. Clinical evaluation indicators including time to surgery, time for surgery, complications, subtalar joint stiffness, traumatic arthritis, SF-36, VAS, AOFAS score, Böhler's angle as well as Gissane's angle were recorded and compared between these two groups.

Results

The waiting time before surgery in minimally invasive group was significantly shorter than that in the traditional group. The mean operative time was significantly higher than that in the traditional group. No significant difference with respect to the AOFAS score, VAS score and SF-36 score between the groups was manifested. Subtalar stiffness occurred in 3 cases in the minimally invasive group, while 7 cases in the traditional group. 2 cases in traditional group and one case in the minimally invasive group presented with subtalar traumatic arthritis and the symptoms subsided after treatment. The difference regarding the Böhler angle and Gissane angle between groups were not statistically significant.

Conclusion

With the lower incidence of soft tissue complications and subtalar joint stiffness, minimally invasive treatment of calcaneal Sanders III fracture through the trans-tarsal sinus incision can be performed as one of the routine options.

Limited sinus tarsi approach

Extended lateral L-shaped approach

Open reduction and internal fixation

Sanders type III calcaneal fracture

Calcaneal fractures are common types of foot fractures, accounting for 2.1% of all fractures [1]. As the standard approach for managing calcaneal fractures, the lateral L-shaped incision (traditional method) is associated with complications which brings a major concern to orthopaedic surgeons [2]. The study performed by Zwipp et al. indicated that its infection rate was 1.9%, wound edge necrosis rate was 8.3% and hematoma incidence was 2.5% [3]. Veltman et al. reported a total of 1181 patients in 17 studies, of which 240 (nearly 20%) had wound complications [4].

In order to avoid the complications, especially the wound problems, a variety of minimally invasive techniques have been performed for the treatment of calcaneal fractures. The closed reduction, percutaneous Kirschner wire fixation as well as the limited open reduction and internal fixation (ORIF) have all achieved good results [5–7]. Among them, limited ORIF via sinus tarsi approach is the most widely applied technique, especially for treating Sanders type II calcaneus fractures and certain Sanders type III fractures with soft tissue problems or peripheral vascular disease. For Sanders type III calcaneal fracture, there is still a great controversy about whether limited open reduction and internal fixation through the tarsus approach can achieve the same clinical effect. The exposure and reduction of intra calcaneal fragments, especially for sustentaculum tail fragments, are difficult because there are two fracture lines at the posterior facet in Sanders type III fractures. Regarding the Sanders type III calcaneal fractures Besides, the calcaneal body of Sanders type III is usually comminuted and displaced, it is challenging to correct the alignment and maintain the reduction. As there are numerous ways of internal fixation with the limited sinus tarsi approach, finding a reliable and reproducible one is imperative and worthwhile. To this end, we designed a scheme for posterior facet rafting fixation as well as two cannulated screws acting as a buttress for medial and lateral column fixation (Fig. 1).

This study was designed to validate this internal fixation method's efficacy and compare the clinical results of this minimally invasive method with the traditional ORIF in treating Sanders III calcaneus fractures.

General information

From January 2012 to February 2015, 35 patients with calcaneal fractures treated in our trauma center were enrolled. Ethics Committee of Shanghai General Hospital reviewed and approved the study. Each patient signed informed consent. All of them underwent lateral and axial view X-ray and three-dimensional CT examination pre-operatively so as to be able to classify the fracture according to the Sanders classification. The inclusion criteria were as follows: age > 18 years and < 65 years; Sanders type III fractures; unilateral closed fractures; no ipsilateral foot and ankle fractures; no diabetes or lower limb vascular disease; no obvious soft tissue infections or skin diseases. A total of 35 patients (25 males and 10 females) were included in this study. The patients were randomly divided into two groups, which were either treated with limited ORIF via sinus tarsi approach (minimally invasive group) or traditional ORIF via extended lateral L - shaped approach (traditional group). Of the 35 cases, 19 were fixed via the sinus tarsi incision (minimally invasive group): 13 males (68.4%), 6 females (31.5%) with an average age of 42.0 ± 11.4 years. Other 16 cases were treated via extended L shape incision (traditional group):12 males (75%) and 4 females (25%), mean age of 39.1 ± 14.2 years. In the traditional group, one case was lost to follow-up. The general information of the cases is shown in Table 1.

Surgeries were performed after the improvement of soft tissue conditions (vesicle dissolution and formation of wrinkles). The waiting period ranged from 2 days to 10 days preoperatively. In the minimally invasive group, the timing of surgery can be relaxed, and the patients were operated 2 to 3 days before as compared with the traditional group.

Surgical procedures

Minimally invasive group:

After general anesthesia or spinal anesthesia was given, the patient was placed in a lateral position with the healthy side down. A 4 to 5 cm incision is made 5mm from the tip of the lateral malleolus towards the base of the fourth metatarsal (Fig. 1a). After the articular surface was revealed and the hematoma was removed, the distribution of the main fracture line of the posterior articular surface was observed with the three-dimensional CT. The reduction was achieved as follows: 1) under normal circumstances, we used elevation techniques to reduce the three major fracture fragments and achieve posterior articular surface congruency. 2) a 3.5mm K-wire is drilled into the posterior aspect of the calcaneus and was used to exert traction and correct the calcaneal varus. 3) Precontouring 7-hole L-type High-flex F3 fragment plating system (Biomet, Miami, Germany) was used. The F3 plate was placed at the lateral wall of the calcaneus. The proximal part of the plate was placed along the inferior edge of the articular cartilage surface. Three locking screws were used to fix the inferior articular surface, a plate bridging fixation from the subtalar articular surface to the anterior calcaneal bone was performed. 4) two 4.0mm diameter cannulated screws were placed from the calcaneal tubercle towards the calcaneal articular surface and tarsal joint to provide calcaneus mediolateral column support as shown in Fig. 2c and 2d.

Traditional group:

Anesthesia and positioning of the patient were the same as for the minimally invasive group. A single L-shaped incision on the lateral side of the calcaneus was used. The incision began 3 ~ 5cm proximal to the lateral malleolus, 1/3 distance from the posterior edge of the fibula and the posterior edge of the Achilles tendon extending distally towards the lateral and plantar skin junction, and then finishing at 1cm proximal to the head of the base of the fifth metatarsal. The incision is made directly to the bone surface, a whole thickness flap is made and lifted, the fibular muscle is retracted superiorly, soft tissue blunt dissection is carried out to avoid electrocautery. For the retraction of the flap, three Kirschner wires are drilled into the talus, and the Kirschner wire is bentbent and used to expose the subtalar joint. Under direct vision using bone stripping or Kirschner wires temporary fixation techniques were used restore the subtalar joint congruency and the height and width of the calcaneus. The calcaneus was fixed with a calcaneal locking plate. Wound closure was done using a two-tier suture technique, and an indwelling drainage tube was placed.

Postoperative treatment

Post-operatively, antibiotics were prescribed routinely for 3 days, and it was discontinued if the wound was dry and there was no exudate. Otherwise it was appropriately extended for a few days. In the traditional group, the drain was pulled out after two days, and compression bandage was continued. If the amount of fluid in the drain is continuously elevated, the drain can be kept for an additional 1–3 days before it is removed. In the traditional group, the stitches were removed three weeks after the operation, and in the minimally invasive group, they were removed two weeks after the operation. Two days post-operatively, under the proper analgesic conditions (parecoxib 40mg + normal saline 10ml intravenous injection, two times a day), the patients were encouraged to actively flex and extend their toes, as well as exercise subtalar joint functions with sub-circular movements. For the traditional group, post-operatively, functional exercise was started after the removal of the drain. Wound exudate would subside after the start of exercises. Three months after the surgery, the patients were allowed to start weight-bearing exercises.

Postoperative follow-up and efficacy evaluation

The patients were followed up for at least 2 years after the operation. The wound condition and complications were recorded. The Böhler and Gissane angles were measured before surgery and 3 months after surgery, and then again at 2 years post-operatively. This work was carried out via using the Picture Archiving and Communication Systems, PACS. The efficacy of the treatment was evaluated using AOFAS Ankle Hindfoot Scale [8, 9] and SF-36 (the MOS item short from health survey). The Visual analogue scale (VAS) was used to rate the pain experienced by the patient.

Statistical analysis

Data Statistics Data were processed by one of the study group members (K.W.) using SPSS 17.0 statistical software (SPSS, Chicago, USA). Inter-group time to surgery, time for surgery, change in Böhler and Gissane angles, AOFAS score, VAS score, and SF-36 score were analysed using the independent sample t-test, and the difference between the two groups was significant if P < 0.05. Intra-group Böhler and Gissane angles were compared by paired t-test. The chi-square test was used to compare the incidence of complications. P ≤ 0.05 was considered to be statistically significant.

Only one case in control group was lost. The remaining patients (34 feet) were followed up for more than 2 years. The follow-up period was 24 to 34 months (28.9 ± 3.91 months). As shown in Table 2, in minimally invasive group, the waiting time before surgery was 3.58 days which was slightly shorter than in traditional group, where the waiting time before surgery was 7.40 days, the difference between the two groups was statistically significant. The mean operative time was 80.9 ± 6.86 minutes (68–94 minutes) in minimally invasive group, which was significantly higher than that in traditional group (71.4 ± 7.19 minutes, 63–90 minutes). All cases achieved bony union at the 3 months follow-up. There was skin necrosis in one case (6.7%), and 1 case (6.7%) of deep infection. To treat deep infection, the internal fixation was removed prematurely 8 weeks after the operation. The scores of AOFAS, VAS and SF-36 were evaluated at 2-year follow-up. for minimally invasive group and traditional group were 84.6 ± 8.08, 2.05 ± 1.13, 89.2 ± 4.75 and 80.7 ± 11.0, 2.53 ± 1.64 and 86.1 ± 5.49, respectively. The difference in AOFAS score, VAS score and SF-36 score between the groups was not statistically significant. In minimally invasive group, there were 3 cases (15.8%) of subtalar stiffness, while there were 7 cases (46.7%) in conventional group. Although the difference was not statistically significant, 2 cases in traditional group (10.5%) and one case in minimally invasive group (6.7%) presented with subtalar traumatic arthritis in varying degrees, and the symptoms subsided after treatment with non-steroidal anti-inflammatory drugs. Analysis showed that the two kinds of surgical approach attained the same post-operative results. As far as the Böhler angle and Gissane angle were concerned in the timing of pre-operative, 3 months post-operative and 2 years post-operative, the difference between groups were not statistically significant as shown in Table 3. In addition, 3 months and 24 months postoperatively, the Böhler angle and Gissane angle changed between 0 to 2 degrees, suggesting that there was no significant change in fracture reduction.

Our study manifested that in the minimally invasive group, mini-plate fixation of the subtalar joint surface with medio-lateral column screw fixation can achieve the same clinical outcomes as the traditional group. However, the minimally invasive fixation has merits of lower incidence of postoperative subtalar stiffness and incision complications, although the difference was not statistically significant.

The minimally invasive treatment of Sanders III fractures has been controversial. Because the Sanders classification is based on the CT classification of the posterior articular surface and lacks a specific assessment of the overall shape of the calcaneus, Sanders III fractures contain more and more complex fracture subtypes. The previous literature for the minimally invasive treatment of Sanders III type is mainly for patients with soft tissue problems or other peripheral vascular neuropathy. The Abdelazeem study reported that there was no difference in the efficacy of Sanders type II and III calcaneal fractures with limited incision and screw fixation in the sinus tarsi [10]. Some authors have also achieved good results in the treatment of Sanders III calcaneal fractures by a modified sinus tarsi incision or by adding a vertical incision posterior to the calcaneus [11, 12]. How to balance good exposure with the potential risk of incision has always been a difficult decision.

This study also found that the posterior articular surface could be better reduced through the incision of the sinus tarsus, and combined with other pry techniques, the overall reduction effect was good, but the operation time would be relatively prolonged. It should also be recognized that reduction and fixation of fractures through the incision of the tarsal sinus has a long learning curve and often requires experienced orthopaedic surgeons to complete it. Another perplexing concern using this incision is the lack of unified internal fixation mode. Studies by different scholars often use different fixation methods, such as pure percutaneous screws, micro plates, plate combined with screws, et al, resulting in significant differences in biomechanical properties of the subjects and even a lack of comparability compared with the control group [6, 10, 12, 13]. The merits of this study were that the same fixation method was used in all the patients. Subtalar surface micro-plate screw fixation combined with medial and lateral column screw fixation were performed, reducing the samples’ heterogeneity. The F3 system (high flexibility type) has the characteristics of arbitrary shaping in three-dimensional space without plate fracture and locking hole deformation, which is very suitable for limited incision internal fixation of the calcaneus. In addition, subtalar articular surface fixation supported by plate row screws has mechanical advantages. Its collapse resistance is superior to external steel plate row screws, and large diameter cannulated screw fixation [14]. Besides, considering the lack of direct biomechanical evidence for microplates like the F3 system, the following measures were taken: 1) preoperative routine three-dimensional CT examination, to understand the three-dimensional spatial distribution of the main fracture fragments, and design the angle and placement position of the plate; 2) adding two screws for the medial and lateral columns; 3)the initial weight-bearing time of patients was strictly limited, generally three months after surgery. Bohler Angle and Gissane Angle were recovered in both groups after surgery, and the difference between the two groups was not statistically significant, indicating that the reduction of SandersIII fracture by prying through the sinus tarsi incision can achieve good reduction, and the difference is not significant from the traditional extended L-incision. At final follow-up, no significant difference regarding the Bohler Angle and Gissane Angle was found between the minimally invasive group and the conventional group at two years postoperatively, suggesting that the high-subtalar fixation technique combined with medial and lateral column screws can provide a similar fixation effect to conventional calcaneal locking plates. A literature review confirmed that bone grafting had no impact on the healing and function of calcaneal fracture and was only beneficial to earlier weight-bearing [1, 15]. Thus, no bone grafting was used in this study.

Incision problems have been plaguing calcaneal surgery, and the reported complication rate of traditional lateral L-shaped incisions is around 20% [4]. Recently, it has been reported in some anatomical literatures that the vertical part of the l-shaped incision is modified from the midpoint of the posterior edge of the fibula to the posterior edge of the Achilles tendon to the posterior 1/3 to avoid injury to the lateral calcaneal artery and thus reduce the risk of flap necrosis [16]. The high incidence of wound problems associated with lateral L-shaped incisions results from multiple factors, such as incision layout, surgical timing, intraoperative procedures, and drainage [17]. To reduce the incidence of incision problems by improving the lateral L-shaped incision of the vertical arm is still not supported by high-quality literature. In recent years, a series of reports on the treatment of intra-articular calcaneal fractures through sinus tarsi incision have been reported with the incision complications ranging from 0 to 15.4%, which is much lower than that of the classical extended L-shaped incision approach (10–25%). The efficacy of the two approaches was similar [4, 18–20]. In this study, no incision problems occurred in 19 sinus tarsi incision cases, while the incidence of incision problems was 13.3% in 15 cases of the traditional group (the control group). The advantages of using the tarsal sinus incision are as follows: 1) the subtalar articular surface can be fully exposed, the articular fracture fragments can be reduced and fixed under direct vision, and the Bohler Angle and Gissane Angle can be effectively restored. 2) The incision is on the upper edge of the peroneal tendon, which can not only avoid damage to the peroneal retinaculum but also can avoid the upper superficial peroneal nerve and the lower sural nerve branches; 3) The preoperative waiting time and hospital stay were shorter than those of traditional incision surgery. This study shows that minimally invasive incisions can appropriately relax the requirements for improving soft tissue conditions, and the timing of surgery in advance will not increase the risk of the incision. Excessive preoperative waiting time will lead to the formation of local fibrous callus, which will hinder the intraoperative prying reduction; 4) minor trauma, quick recovery, and conducive to earlier functional exercise.

The results of this study indicate that fixation of the posterior articular surface of the calcaneus using micro-plate row screws combined with internal and lateral screws through the limited tarsal sinus incision can achieve a similar effect as using locking calcaneus plate internal fixation through conventional extended lateral L-incision approach. However, there are still some concerns to be solved: 1) Whether the F3 plate has sufficient biomechanical resistance to load needs to be verified by further biomechanical experiments; 2) due to the limited number of cases in this study and the complex types of Sanders III fractures, data bias is inevitable when patients were enrolled, which will be solved by future large-sample and multi-center studies.

In conclusion, treating Sanders type III calcaneal fractures using a micro-plate to fix the posterior articular surface and the medial and lateral column screws fixation through the tarsal sinus approach can achieve satisfactory results. The incidence of soft tissue complications and subtalar joint stiffness was much lower than that of the conventional L incision approach. Therefore, as long as appropriate cases and adequate preoperative planning are selected, minimally invasive treatment of calcaneal Sanders III fracture through the trans-tarsal sinus incision can be performed as one of the routine options.

Ethics approval and consent to participate
Shanghai General Hospital’s Ethics Committee reviewed and approved this retrospective study. Each participant signed the written informed consent.

Consent for publication
Written informed consent was obtained from individual participants.

Availability of data and materials
The datasets during and/or analyzed during the current study are available from the corresponding author on a reasonable request.

Conflict of interests
The authors declare that they have no conflicts of interests. There are no ethical/legal conflicts involved in the article

Funding
The current study was supported by grants from the National Natural Science Foundation of China (No.71432007).

Authors’ contributions
CB and KW performed the study design, analyzed the results, and contributed to the manuscript. QW and JL contributed to collecting the cases. JH and QW made some meaningful suggestions. HL and KW helped in the drafting and revising of the manuscript. All authors reviewed and approved the final submitted version.

Acknowledgements

Not applicable

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Table 1 to 3 are available in the Supplementary Files section.

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Editorial decision: Reject after review
30 Mar, 2023
Reviewers agreed at journal
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Editor invited by journal
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Editor assigned by journal
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You are reading this latest preprint version

Limited sinus tarsi approach versus extended lateral L-shaped approach for the open reduction and internal fixation of Sanders type III calcaneal fractures: a retrospective study

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