0000000210 00000 n It affords placement of a lateral plate subcutaneously by using retrograde subperiosteal elevation of the lateral calcaneal skin flap. Good to excellent clinical results have been published in patients undergoing open reduction and internal fixation with the extensile lateral approach, however high wound complication rates are reported.13,23,24 They include superficial epithelial necrosis, full-thickness skin sloughing, deep purulent infections and osteomyelitis. Indications for flatfoot surgery are strict: failure of prolonged nonsurgical attempts to relieve pain that interferes with normal activities and occurs under the medial midfoot and/or in the sinus tarsi. It could be tempting, however, to carry the deep dissection farther proximally as it would provide even wider access to this area. Calcaneus Results: Median Bhler and Gissane angle were improved to 26.5 degree (4.6 to 45), 115.5 degree (101.2 to 127.4) They remain non-weight bearing for 10-12 weeks. endobj internal conformance OriginalDocumentID Of those patients who did not undergo primary subtalar arthrodesis, postoperative radiographs with Broden's views revealed articular reduction within two millimeters. default Je-Hyoung Yeo Subtalar Dislocations are hindfoot dislocations that result from high energy trauma. Noble J, McQuillan WM. Three were smokers and had fractures types III-AB, III-AC. Arbortext Advanced Print Publisher 9.1.440/W Unicode http://ns.adobe.com/xap/1.0/mm/ Lateral ankle ligaments and subtalar joint with peroneal tendons reflected.(B). . In addition, a limited sinus tarsi incision without elevation of the lateral calcaneal skin flap does not allow for plate fixation, a notable advantage of the extensile lateral approach, particularly in gaining reduction of the body of the calcaneus. Due to the shorter incision, and more proximal location of the incision, wound complications are less common [ 2 ]. The LCA was seen to consistently emerge from the posterior lateral edge of the fibula proximally and course distally behind the deep portion of the peroneal tendon sheath superior to the SPR. Results using a prognostic computed tomography scan classification. The lateral calcaneal artery (LCA) passed within 2 mm of the superior border of floor of the Superior Peroneal Retinaculum (SPR) at the midline of the peroneal sheath. use the Harris heel and lateral views to drive guidepin through the tuberosity, across the subtalar joint and into the talar neck. The surgeries were all performed by the senior author (J.F.) Berlin; New York: In Springer-Verlag; 1991. Adjacent fractures were treated through the same incision. Incision. Exposure and reductions are performed under tourniquet control. Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach. Proximally, the approach can be extended to include a directly lateral approach to the distal tibia, fibula and syndesmosis, which we have previously described.15 Distally the talus, calcaneocuboid joint and cuboid are easily accessed, without undue risk to the sural or superficial peroneal nerve. It healed uneventfully after surgical debridement, closure and subsequent local care. Palmer originally described a laterally based approach through the sinus tarsi for direct visualization of the articular surface for reduction. New York: In Churchill Livingstone; 2002. http://ns.adobe.com/pdf/1.3/ Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Palmer I. for introducing him to the modified Palmer approach, which formed the basis of this extended technique. Ollier's Lateral Approach to the Hindfoot, incise fascia and divide inferior extensor retinaculum in line with incision, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine, begin incision over dorsal-lateraltalonavicular joint, careful not to damage peroneus tertius and extensor digitotum longus, in the superior (distal) part of the incision expose peroneus tertius and EDL and retract medially, in inferior part of incision expose peroneal tendons and retract inferior, Reflect extensor digitorum brevis distally. studied the vascularity of the lateral calcaneal flap and concluded that the lateral calcaneal artery was found to be responsible for the majority of the blood supply to the corner of the flap.12 They found that it emerged from the deep fascia of the leg 15 mm proximal to the tip of the lateral malleolus and 33 mm posterior to the posterior edge of the fibula and 11.5 mm anterior to the anterior edge of the Achilles tendon. We are experimenting with display styles that make it easier to read articles in PMC. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. Note wire passed subcutaneously indicating extent of subperiosteal elevation. 2015, :. tilt table 20 degrees away from surgeon to improve visualization. endobj The treatment of displaced calcaneal fractures remains controversial. Early posterior subtalar fusion in the treatment of fractures of the os calcis. By avoiding dissection through the deep portion of the SPR, the LCA can be protected, thus preserving the blood supply to the lateral calcaneal skin flap. http://www.aiim.org/pdfa/ns/id/ By avoiding dissection through the deep portion of the SPR, the lateral calcaneal artery can be protected, thus preserving the blood supply to the lateral calcaneal skin flap. Postoperative measurement of Bohler's angle averaged 29 (range 25-36) degrees and Gissane's angle averaged 131 (range 122-150) degrees (Figure 1). xxviii, p. Rogers LF. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes? between February 1999 and June 2002. Inflammatory arthritides such as rheumatoid arthritis, gout, or ankylosing arthritis are also associated. They stated that the posterior vertical portion of the typical extensile lateral incision placed the LCA at risk to injury, which could lead to possible wound complications. Calcaneal fractures have long been recognized as a source of significant disability and remain one of the most difficult articular fractures to treat. Text Mller ME, Allgwer M, Arbeitsgemeinschaft fr Osteosynthesefragen . An anatomic repair can be performed. No wound complications occurred in smokers. This can aid visualization of the articular surface, but we avoid this in most cases because of the importance of this ligament as a primary stabilizer of the subtalar joint. This is carried distally to the level of the calcaneal-cuboid joint. amd GH>UrLDcc"G_HJ2FRCt).st[N. Our cadaveric study shows that this inherently protects the LCA, which passes deep to and just along the proximal border of the SPR. uuid:8b07b946-4f2d-4d62-b004-46a4051d37d6 pdfToolbox Markers denote proximal border of superior peroneal retinaculum. reduces wound complications associated with extensile lateral incision. The peroneal tendons are retracted laterally between the superior peroneal retinaculum and IPR and the inferior peroneal retinaculum is released off of the bone to expose the lateral calcaneal wall down to the anterior process. Lisfranc Open Reduction and Internal fixation, Proximal Chevron Osteotomy with Plate Fixation, Removal of Plantar-Hindfoot-Midfoot Bony Mass, determines the severity of the arthritis and anatomy, patellar tendon bearing brace to unload the subtalar joint, documents failure of nonoperative management, describes accepted indications and contraindications for surgical intervention, place in short weight bearing fiberglass cast, diagnose and management of early complications, diagnosis and management of late complications, identify medical co-morbidities that might impact surgical treatment, diabetes, smoking and previous surgery all affect union rates, order weigh-bearing triplanar radiographs of the ankle, describe complications of surgery including, determine length and placement of the implant, describe the steps of the procedure verbally to the attending prior to the start of the case, describe potential complications and steps to avoid them, 6.5 mm and 4.0 mm large fragment cannulated lag screws, bring fluoroscopy from the contralateral side, align sole of the foot with the end of the bed, place a soft bump under the ipsilateral sacrum to internally rotate the foot. Zwipp H, Tscherne H, Wulker N. [Osteosynthesis of dislocated intraarticular calcaneus fractures]. <>stream partial exsanguination. The popliteal artery was cannulated with intravenous tubing and the arterial system was manually injected with silicone-based dye solution after cleansing with saline solution. 2 0 obj After transection and removal of the peroneal tendons within the tendon sheath, the superior border of the deep fibers of the superior peroneal retinaculum was identified (Figure 2). At this point, excellent direct visualization of the articular surface of the posterior facet is possible. make a 8-10 cm curved incision. Past anatomic studies supported the conclusion that division of the LCA can lead to ischemia of the lateral calcaneal skin flap. Preoperative computed tomography scans were obtained in all patients. One patient had a calcaneal anterior process fracture with calcaneal-cuboid subluxation fused with a large staple. Epidemiology. 2015 Yeo et al. Borrelli J, Jr., Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. <> Next a lateral plate is placed beneath the internally elevated soft tissue flap, and directly fixed to the anterior calcaneus and the articular fragments. The fracture is mobilized, comminution and interposed soft tissues are debrided and provisional reduction of the articular surface and body is held with K-wires. Ebraheim NA, Elgafy H, Sabry FF, et al. CONCLUSION: In displaced intra-articular calcaneal fractures, a minimally invasive sinus tarsi approach is associated with a lower . The screws for fixation to the tuberosity are placed percutaneously. The interosseous talo-calcaneal ligament (ITCL) could be transected, which allows the medial articular fragment to be better visualized by tipping into varus. Care is taken to make sure that the elevator is not placed into the fracture, but lateral to the lateral wall fragment. A name object indicating whether the document has been modified to include trapping information The heel portion of the foot plate is left long to suspend the heel. These angles were in the ranges of normal population.17,18. Specimens were frozen overnight after allowing the dye to disseminate and consolidate. The plate is not contoured and the lateral wall fragment typically reduces into the body of the calcaneus with lagging of the plate to the stable medial fragment. This approach provides excellent direct exposure of the calcaneal body as with the medial approach while also providing direct exposure of the articular surface. The functionality is limited to basic scrolling. would like to thank his fellowship director and mentor, Elly Trepman M.D. After allowing the specimens to thaw, the extensile sinus tarsi approach was performed. <>/Font 8 0 R>>/Thumb 9 0 R/MediaBox[0 0 595.276 793.701]/B[10 0 R 11 0 R]/Annots[12 0 R 13 0 R 14 0 R 15 0 R 16 0 R 17 0 R 18 0 R 19 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R]/Rotate 0>> We have not done this uniformly. extend incision down posterior fibula and bend around lateral maleolus over the peroneal tubercle. The senior author (J.F.) Lateral Approach to Calcaneus. Lateral ankle and hindfoot with incision markings for extensile sinus tarsi approach (A). Sinus tarsi syndrome is caused by hemorrhage or/and inflammation of the synovial recesses of the sinus tarsi with or without tears of the associated ligaments. 2015 Yeo et al. Tilting the bed into Trendelenberg position and allowing the foot to invert over a cloth bump aids in visualizing the subtalar joint. During the same time period, the senior author used the extensile lateral approach for isolated calcaneal fractures in other patients not deemed as high risk for wound complications. A combined lateral and medial approach. The average length of follow-up time was 19 (range from 2-41) months, excluding one patient who underwent subsequent below-knee amputation six weeks post-operatively. Freeman BJ, Duff S, Allen PE, et al. Superficial dissection. The second measurement was made at the midline of the floor of the SPR. The subcutaneous tissues overlying the peroneal tendons are left untouched which also preserves the sural nerve. internal XMP Basic Carr JB. converted Two patients developed wound complications. Label Once the fixation is complete and final fluoroscopic or x-ray images obtained, the wound is thoroughly irrigated and the EDB and sinus tarsi fat pad reduced and sutured with absorbable sutures. <. The lateral calcaneal artery is responsible for the majority of the blood supply to this area. xmpMM Operative and non-operative management have both been suggested for the acute treatment of calcaneal fractures, however it is generally accepted that in most cases operative treatment of displaced calcaneal fractures is warranted in order to avoid the negative consequences of malunion.2,6 Operative management can consist of reduction through an extensile open incision, limited incision or percutaneous techniques. Patients managed with a sinus tarsi approach were less likely to suffer complications (OR = 2.98, 95% CI = 1.62-5.49, p = 0.0005) and had a shorter duration of surgery (OR = 44.29, 95% CI = 2.94-85.64, p = 0.04). Benirschke SK, Sangeorzan BJ. The LCA was found to emerge from the posterior fibular border an average of 10.6 (range from 2 to 23) millimeters proximal to the superior border of the deep fibers of the SPR. start incision 1 cm below the tip of the lateral malleolus. Primary subtalar arthrodesis in the treatment of severe fractures of the calcaneum. Dr. Trepman is the senior author on the paper by Gupta et al. This small incision is much safer than the extended L-incision. Fixation was obtained using the following plates with screws: An Ace/Depuy titanium calcaneal perimeter plate in six patients, a Synthes calcaneal or cervical H-plate in five patients, and a Synthes 2.7 mm reconstruction plate in one patient. This approach is subfibular and slightly anterior and keeps the peroneal tendons inferiorly. Text The extensor digitorum brevis (EDB) muscle is sharply elevated off of the anterior process with the lateral root of the IER, and reflected dorsally and distally. 3379 An initial lag screw is placed across the posterior facet fracture lagging the joint fragments. All were counseled to stop smoking. This approach was chosen at the discretion of the senior author (J.F.) The extended lateral approach to the hindfoot. continue incision distally until the base of the fourth metatarsal is reached, use cautery to cauterize any crossing vessels for hemostasis, identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad, leave a small cuff of tissue proximally for reattachment of the flap, this allows better exposure of the joint surfaces and the middle and anterior facet, use a rongeur to remove any remaining soft tissues, use a straight curette or chisel to remove cartilage from the lateral half of the inferior talus and superior aspect of the calcaneal facets, insert a lamina spreader and remove the remaining medial articular cartilage, use curettes and osteotomes to create bleeding subchondral bone, use a 2.0 mm drill to create small perforations in bone, if bone graft is inserted reattach tendon after insertion of graft. The CFL can be transected initially when oriented more vertically. . It extended distally curving around the lateral malleolus and anteriorly supplying the posterior and inferior portions of the fasciocutaneous flap of the extensile lateral approach. Background: Operative treatment of calcaneal fractures has a historically high rate of wound complications, so the most optimal operative approach has been a topic of investigation. Three orientations of the LCA were noted as it passed distally: vertical, oblique and horizontal. Femino JE, Vaseenon T. The direct lateral approach to the distal tibia and fibula: a single incision technique for distal tibial and pilon fractures. doi:10.1186/s12891-015-0519-0 Intra-articular fractures of the calcaneum. pdfaid Sinus Tarsi. endstream endobj xref They include the extensile lateral approach, medial approach,19 combined lateral and medial approach,20 sinus tarsi approach21 and limited posterolateral approach.22 Palmer in 1948 initially described his lateral sinus tarsi approach with structural bone grafting beneath the depressed articular fragment.3 Essex-Lopresti in 1952 used a small sinus tarsi incision to elevate depressed joint fragments with Steinman pin fixation.1 These authors highlighted the value of direct access to the articular fracture for reduction. When the calcaneal insertion is elevated with the entire lateral calcaneal soft tissue flap, it remains in its anatomic relationship to the surrounding soft tissues and later reduces back to the calcaneus. URI The incision lies in a plane between the superficial peroneal nerve and the sural nerve. Radiology of skeletal trauma; p. 2. v. (xii, 1406, 1430 p.). This paper is a review of the sinus tarsi approach for operative fixation of calcaneal fractures. Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults Flashcards (2) Cards . We currently do not suture the drains and we remove them at 24 hours through the dressing. xmp Burdeaux BD. The intermediate root of the inferior extensor retinaculum (IER) can be released too to gain better exposure of the fracture line passing obliquely through the angle of Gissane. It may also occur if the person has a pes planus or an (over)-pronated foot, which can cause compression in the sinus tarsi. pdf The mechanism of injury was a fall from a height in eight patients, motor vehicle accidents in three patients and snowmobile accidents in two patients. <<8da73e08aad3fa4d8cbc2a1afc3314c6>]>> calcaneus decorticated, joint manipulated into varus. Peroneal longus and brevis both supplied by superficial peroneal nerve. Used to organize documents in a file browser. The description of the relationship of the LCA to the SPR provides an identifiable landmark for this extended sinus tarsi approach. There were 12 males and one female with an average age of 45.1 years (range from 26-71 years). In a similar fashion we found the LCA to be at risk with this extended sinus tarsi approach if at the proximal edge of the floor of the SPR. Sinus Tarsi is actually a tunnel that runs between the talus and the heel bone. extend posteriorly over the sinus tarsi (soft tissue depression just anterior to lateral malleolus) incise obliquely to point 2.5 cm below tip of lateral malleolus. A skin incision is made longitudinally beginning 3cm above the tip of the lateral malleolus along the posterior border of the distal fibula. Treatment is a trial of closed reduction but may require open reduction given the several anatomic blocks to reduction. Anatomy. A clinical series of 13 patients (including 7 chronic smokers and 1 with diabetes and vascular disease) with closed displaced intra-articular calcaneal fractures (Sanders types II and III) were treated by open reduction and internal fixation via this approach. supine with bump under buttock. URI 1. The mechanism and treatment of fractures of the calcaneus; open reduction with the use of cancelhus grafts. internal We have found that it is not clinically necessary to extend the deep dissection this far proximally as the exposure of the posterior subtalar articular surface is excellent with division of the CFL alone. %PDF-1.5 % Some characteristics are pain at the lateral side of the ankle and a feeling of instability. The wide exposure allows the surgeon to place a lateral plate which gives rigid control of the body reduction with lag screw fixation through the plate into the medial sustentacular fragment. Three measurements were made to define the location and orientation of the LCA relative to the superior border of the deep portion of the SPR. At the midline of the peroneal sheath, the average distance from the LCA to the SPR was 2.0 (range from 0 to 4) millimeters. Standard approach to sinus tarsi S Tip of fibula S Extend towards base of 4th metatarsal S 5-8 cm S Visualize calcaneal-cuboid joint Tips/Techniques Elevate extensor . Recently, the limited incision sinus tarsi approach has gained traction and is now commonly used at our institution for the treatment of calcaneus fractures. reported a series of patients who underwent open reduction and internal fixation of the calcaneus with a modification of the Palmer incision.14 This modified incision differed from the one that Palmer described by being placed more dorsally and oriented more longitudinally like a typical approach to the sinus tarsi. The first was the distance from the superior margin of the floor of the SPR, at the fibular attachment, to the point where the LCA emerged from the posterior margin of the fibula. In conclusion, the extended sinus tarsi approach provides good exposure to the calcaneus for reduction and fixation and also provides exposure for concomitant treatment of injuries to the lateral ankle and talus. Harvesting and Placement of the Tibial Bone Graft (optional), 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. XMP Media Management Schema Sinus tarsi approach Sixteen lower extremity cadaver specimens were obtained through the University of Michigan Medical School Anatomic Donations program. 2015, :. The sinus tarsi syndrome is a foot pathology, mostly following after a traumatic injury to the ankle. Text part Components of the sinus tarsi syndrome include lateral hindfoot pain, tenderness to palpation over the sinus tarsi, a sensation of instability . The goal of treatment is to achieve anatomic reduction of the articular surface of the subtalar joint and reduction of the tuberosity. . Text In addition, a limited sinus tarsi incision without elevation of the lateral calcaneal skin flap does not allow for plate fixation, a notable advantage of the extensile lateral approach, particularly in gaining reduction of the body of the calcaneus. Note wire passed subcutaneously indicating extent of subperiosteal elevation that can be performed for lateral plate fixation. Minimally invasive (sinus tarsi) approach for calcaneal fractures J Orthop Surg Res. Diagnosis is made clinically with presence of spasticity/contracture of the gastrocsoleus complex in equinus, presence of a . Orthobullets Team % TECHNIQUE VIDEO 0 % TECHNIQUE STEPS 0. All patients begin motion once the incision is well healed and the sutures are removed, which is usually 2 V2 - 3 weeks postoperatively. 1 Overall incidence is unknown, but it is generally considered uncommon and without consistent gender predilection. PDF/A ID Schema Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. Generating an ePub file may take a long time, please be patient. Adobe PDF Schema The patient had normal pain sensation and was given the option of surgery due to the severe injury to both the ankle and subtalar joints. A clinical series of 13 patients (including 7 chronic smokers and 1 with diabetes and vascular disease) with closed . 12 0 obj With improvements in implants over time, rigid fixation with plates and screws has replaced bone grafting and percutaneous pinning as the usual method of maintaining reduction, with many authors favoring a lateral plate fixation. The anterior flap was mobilized to the ankle to facilitate the photographic demonstration of the anatomy. A marker is positioned at the posterior border of distal fibula indicating the surperior margin of the floor of the SPR. In a retrospective study by Abidi and Conti et al., risk factors included single layered closure, high body mass index, extended time between injury and surgery, and smoking.23 Folk et al. *Department of Orthopaedics and Rehabilitations, University of Iowa Hospitals and Clinics, Iowa City, IA, **Barrington Orthopaedic Specialist, Hoffman Estates, IL. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . The dorsal communicating branch of the sural nerve may cross the field distally but is usually small in size and easily retracted. This patient's postoperative course was complicated by wound dehiscence and infection, which was salvaged with a below-knee amputation. Screw fixation into the body of the calcaneus is gained by percutaneous screw placement posteriorly. TECHNIQUE STEPS Preoperative Patient Care. Copyright 2022 Lineage Medical, Inc. All rights reserved. http://ns.adobe.com/xap/1.0/ The surgeon must be vigilant to identify the rare rigid flatfoot. (A) Deep dissection of lateral ankle and hindfoot. Insertion of a broad elevator can enhance the retraction by placing the soft tissues under tension thus facilitating sharp elevation off of the lateral wall of the calcaneus. X . Surgical treatment of intra-articular calcaneal fractures: a review of small incision approaches. The sinus tarsi syndrome was first described in the medical literature in 1958. 0. The incision is deepened by mobilizing the sinus tarsi fat pad dorsally. Procedure: Sinus Tarsi approach A straight incision is made on the lateral side of the foot from the tip of the fibula to the base of the fourth metatarsal which centers the incision over the sinus tarsi. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . (A) 1; Crucial angle of Gissane (B) 2; Calcaneal width 3; Tibio-Calcaneal angle. Treatment with our self-designed combined plate through a sinus tarsi approach may be safe and effective for type II and type III calcaneal fractures. One patient had peripheral vascular disease and diabetes with a severely displaced lateral calcaneal fracture-dislocation into the lateral gutter of the ankle joint with significant fibular comminution. The advantage of this approach is that it can be easily and safely extended to address other injuries. In some circumstances, the branch might be more proximal in the field and if necessary, it can be sharply transected near the point at which it branched from the sural nerve. InstanceID The extensile lateral approach provides excellent fracture visualization and allows reduction of the displaced fracture fragments, but high complication rate has been described with this approach, so many studies favor the sinus tarsi approach. In this manner, both nerves can be left untouched within the subcutaneous fat. Trauma is the most common cause following one single or a series of ankle sprains. soft tissue. - Discussion: - sinus tarsi is the depression found on the lateral side of the tarsus and is distal to and on the same level as the lateral malleolus; - on incision of the structures overlying the sinus tarsi - namely, lateral portion of the inferior extensor retinaculum, interosseous talocalcaneal. Post-operative lateral and hindfoot alignment views demonstrating restoration of the calcaneus. This study reviews the radiographic and clinical outcomes of the use of the sinus tarsi approach for operative fixation of these fractures with attention to the rate of infection and restoration of angular . In all specimens, the LCA traversed directly posterior to the lateral border of the deep portion of the SPR. The Sinus Tarsi approach is the surgical approach for the incision. posterior to the lateral malleolus on a line from it to the insertion of the calcaneal tendon, at an average of 15 mm. Anatomical basis and surgical implications. The third measurement was taken where the LCA crossed the posterolateral margin of the SPR. trailer Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach %PDF-1.3 Extensive intraarticular fractures of the foot. This provided good exposure of the posterior facet, and unlike Palmer who used structural bone graft to support the articular reduction, they used internal fixation, consisting of interfragmentary compression screws. The floor of the peroneal tendon sheath above the superficial peroneal retinaculum was transected longitudinally and the underlying posterior peroneal artery branch, or lateral calcaneal artery (LCA) was identified (Figure 3). Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. (B) Identification of lateral calcaneal artery deep to deep fibers of superior peroneal retinaculum. Approach. endobj Care is taken to avoid any dissection of the floor of the SPR. There has historically been debate over the best approach for treating these fractures.1,4 The goal of operative treatment of calcaneal fractures is to obtain the best possible reduction of the articular surfaces and restoration of the architecture of the non-articular portions of the bone, and to hold this reduction with stable internal fixation.5,6 These goals must be balanced with the need to minimize the operative risks, especially the risk of wound healing complications. anterior to the tendon.25 Borrelli et al. http://dx.doi.org/10.1186/s12891-015-0519-0 minimally invasive incision that minimizes soft tissue dissesction. r Sinus Tarsi () X lateral malleolus & medial malleolus . Concerns remain however regarding the best approach for reducing and maintaining reduction of these complex fractures, while minimizing the risk of surgical complications. ; licensee BioMed Central. It is possible that joint instability may result and could add to the chance of post-traumatic arthritis. in cases of patients at higher risk for wound complications such as smokers or those with concomitant injuries that could be treated from a lateral approach. sinus tarsi to treat adjacent fractures or to aid re-duction in more complex fractures. A gauze dressing is placed with a bolster, and a dressing of ABD pads is placed over the foot and ankle with an A-0 style splint16 using modest molding over the lateral wall to augment compression. sinus tarsi approach. The SPR is opened if it requires repair or if inspection of the peroneal tendons warrants this. Four patients underwent ORIF with concurrent primary subtalar arthrodesis. 2015-04-09T10:26:07+02:00 Both lateral and medial approaches have been described, but the lateral approach allows direct exposure of the articular surface, while the medial approach is limited to reduction of the body. H|U}Ty{w Gupta A, Ghalambor N, Nihal A, Trepman E. The modified Palmer lateral approach for calcaneal fractures: wound healing and postoperative computed tomographic evaluation of fracture reduction. Posterior facet of calcaneus is exposed after release of the CFL. After this episode, a medium hemovac drain was placed intra-operatively in all remaining patients with no subsequent wound healing complications. At times, however, it may be necessary to extend the limits of a small incision over the sinus tarsi to treat adjacent fractures or to aid reduction in more complex fractures. Incidence. Your subtalar joint, the joint under which is important and runs under the neck of the talus in your subtalar joint and it's a little cavity that has some fat, it has some nerve endings and it has some fluid that lubricates the joint. EMG/NCS can help confirm the diagnosis. For exposure of an isolated calcaneal fracture, the patient is positioned either in full lateral or semi-lateral position with a hip bump. Gould N. Lateral approach to the os calcis. already built in. Rational for the Sinus Tarsi Incision Initial Management Physical Exam S Always associated with soft tissue trauma S Measure compartment pressure if pain out of proportion . Then careful dissection is made through the subcutaneous tissues to . Calcaneus fractures: rationale for the medial approach technique of reduction. Extensile lateral approach The ePub format uses eBook readers, which have several "ease of reading" features Fractures were classified according to the classification system described by Sanders.6 Six patients had type II-A fractures, three patients had type II-B fractures, three patients had type III-AB fractures, one patient had a type III-AC fracture. Abidi NA, Dhawan S, Gruen GS, et al. Fluoroscopy can be utilized, but a small right angle hemostat can also be used to localize the holes for the percutaneous screws by visualizing the holes in the plate directly with retraction of the lateral soft tissues. Manual of internal fixation : techniques recommended by the AO-ASIF Group; p. 750. pp. Lateral Malleolus (LM) is dashed line. Foot Conditions are the most common deformity seen in Cerebral Palsy which are caused by lower extremity spasticity and can take several forms including equinus, hallux valgus, equinocavovarus, and equinoplanovalgus. Integer It can later be re-approximated with a single stitch if desired. The widely used lateral approach to the calcaneus, described by Letournel2 and popularized by Zwipp,4 Atkins,10 Benirschke,11 and Sanders,6 has been termed, the extensile lateral approach. We were able to define two objective criteria for the syndrome: arthrography of the subt Weber M, Lehmann O, Sagesser D, Krause F. Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum. endstream In these cases, the articular surface damage was deemed to be too severe to warrant ORIF alone. The extensile lateral approach provides excellent fracture visualization and allows reduction of the displaced fracture fragments, but high complication rate has been described with this approach, so many studies favor the sinus tarsi approach. began using in 1999 based on the technique described by Gupta et al. Hall MC, Pennal GF. The technique will be reviewed, and the advantages and disadvantages will be discussed. ; licensee BioMed Central. described in a study that the LCA passed at a mean of 31 mm. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraar-ticular calcaneal fractures. Freeman et al. 0000000000 65535 f The drain in our series was removed 24-48 hours postoperatively and wounds were examined on the second postoperative day. uuid:290c41fa-7bb3-4810-88a4-2264eda0c929 make a 1 cm incision distal to the distal aspect of the tibial tubercle and 1 cm lateral to the anterior tibial crest. UUID based identifier for specific incarnation of a document Various internal fixation techniques have been described, but a laterally based plate is commonly accepted to give the most rigid fixation.7,8 Since displaced calcaneus fractures present with various degrees of comminution and soft tissue trauma, it is advantageous for the calcaneal fracture surgeon to have a variety of methods of treatment to balance minimizing risks of wound complications against obtaining the best reduction possible.9. make a second 1 cm incision just medial to the anterior tibialis tendon, use the Harris heel and lateral views to drive guidepin through the dorsomedial aspect of the talar neck across the subtalar joint into the posterior calcaneal tuberosity, insert a 6.5 or 8 mm large fragment cannulated lag screws after minimal countersinking, repeat the procedure for the second guidepin except use a small fragment cannulated screw, depth of this screw is best judged by axial view of the calcaneus, obtain final fluoroscopic images to ensure proper screw position, use 3-0 nylon horizontal mattress sutures for skin, use 2-0 vicryl for the subcutaneous layer, place in well padded non-weightbearing short leg plaster cast, split cast in recovery room to allow for post op swelling. 3 0 obj doi:10.1186/s12891-015-0519-0 The authors have used an extended sinus tarsi approach to include placement of plate percutaneously beneath the lateral calcaneal skin flap through a sinus tarsi approach, and to treat adjacent fractures and soft tissue injuries. converted to PDF/A-1b The incision can be extended to allow access to the distal tibia and fibula, talus and the lateral column of the foot. Folk JW, Starr AJ, Early JS. 1 0000000016 00000 n Figure 58-8 superior view inferior view ( . A . The fracture is typically reduced from anterior to posterior. The sinus tarsi approach offers an alternative to the extensile lateral approach for open reduction and internal fixation of the calcaneus that may improve soft tissue-related complications and still provide . for higher risk patients or those with concomitant fractures that could be addressed simultaneously. 1 0 obj Surgical management of calcaneal fractures. Elevate the EDB and Sinus Tarsi fat pad together as one flap . Mark and make incision . found that smoking, diabetes, and open fractures all increase the risk of significant wound complications and are cumulative.13. We describe an extensile sinus tarsi based approach, for open reduction of displaced calcaneal fractures that the senior author (J.F.) internal 2. This creates a smooth lateral surface which is less likely to create impingement on the peroneal tendons. Markers denote proximal border of superior peroneal retinaculum. The skin is closed in two layers with 3-0 or 4-0 absorbable sutures and the skin with Nurolon. using the sinus tarsi and extensile lateral approach was studied in 100 cases (40 sinus tarsi and 60 extensile lateral) with displaced intra-articular calcaneal fractures. application/pdf In nearly all cases, an associated contracture of the heel cord is present. However, there are some . 0000000075 00000 n %%EOF By SungHun.Kim. Amendment of PDF/A standard However, the presumed diagnosis can be corroborated through the use of imaging studies, predominately magnetic resonance imaging. 0 5 The common identifier for all versions and renditions of a document. A 4.5mm Shantz pin or a half ring with crossed tensioned olive wires can be used for traction and control of the tuberosity. allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall . Usually post-traumatic, it is characterised by pain over the lateral opening of the sinus tarsi and a feeling of instability of the ankle. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. bone work. However, because of the smaller surgical window, visualization is more . All patients were evaluated both clinically and radiologically. True Eleven patients healed their soft tissues uneventfully by three weeks. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. The superficial portion of the SPR was divided, but the deep portion was preserved. internal uuid:8b07b946-4f2d-4d62-b004-46a4051d37d6 Letournel E. Open treatment of acute calcaneal fractures. Tarsal Tunnel Syndrome is a compressive neuropathy of the tibial nerve at the level of the tarsal tunnel which can lead to pain and paresthesias of the plantar foot. begin incision over dorsal-lateral talonavicular joint. Acrobat Distiller 10.1.5 (Windows); modified using iText 5.3.5 2000-2012 1T3XT BVBA (AGPL-version) fibrous debris and fat removed from sinus tarsi small elevator or lamina spreader placed under posterior facet fragment to aid in reduction K-wires inserted for provisional fixation aimed towards the sustentaculum Seven patients were chronic smokers (average 1.5 packs per day). Satisfactory articular reduction is gained and confirmed clinically and fluoroscopically with lateral, axial heel and Broden's views. % The vascular anatomy of the lateral calcaneal artery related to this approach was also studied with 16 cadaver legs. ligament and reflection of the . The ePub format is best viewed in the iBooks reader. We retrospectively reviewed thirteen patients who had undergone open reduction and lateral plate fixation without bone graft of closed displaced intraarticular calcaneus fractures using an extensile sinus tarsi approach. the display of certain parts of an article in other eReaders. After the second case in the series, which was complicated by a wound hematoma, a small closed suction drain was placed into the wound and brought out dis-tally. Early surgical management to restore articular congruence and the structural function of the calcaneus is widely accepted as the best way to avoid the negative consequences of malunion. Intra-articular fracture Calcaneus,Intra-articular fracture,Sinus tarsi approach,Extensile lateral approach MODIFICATION OF THE SINUS TARSI APPROACH FOR OPEN REDUCTION AND PLATE FIXATION OF INTRA-ARTICULAR CALCANEUS FRACTURES: THE LIMITS OF PROXIMAL EXTENSION BASED UPON THE VASCULAR ANATOMY OF THE LATERAL CALCANEAL ARTERY, Correspondence to: John E. Femino, MD Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, JPP 01022, Iowa City, IA 52242-1088 phone: 319-384-5844 fax: 319-384-8634, (A) Deep dissection of lateral ankle and hindfoot. 2015-04-09T10:26:07+02:00 Copyright 2022 Lineage Medical, Inc. All rights reserved. startxref With the anterior calcaneus and sinus tarsi exposed, the peroneal tendons below the SPR are retracted with a freer elevator placed along the lateral wall of the calcaneus and sharp dissection is used to perform retrograde subperiosteal elevation of the soft tissues off of the lateral calcaneus and proceeding to the tuberosity. He and others have found this approach to be useful and reasonably safe. 32, 34 . Magnetic resonance imaging is an indispensable tool in the evaluation of musculoskeletal . This is a safe, simple incision, but the surgeon must look for the sural nerve. Diagnosis is made clinically and confirmed with orthogonal radiographs of the foot. Posterior facet of calcaneus is exposed after release of the CFL. The potential for serious wound complications is a major concern, particularly breakdown of the lateral calcaneal skin flap with the extensile lateral approach. Conformance level of PDF/A standard 1 0 obj<> endobj 2 0 obj<> endobj 3 0 obj<> endobj 4 0 obj<>stream The sinus tarsi syndrome is predominately a clinical diagnosis deduced through the use of physical examination and history. This provides for reduction of the body fragment medially, even when extensive comminution of the lateral wall is present.2,6 This exposure relies on developing a lateral calcaneal flap that is supplied by the LCA which is the terminal branch of the peroneal artery.12 One drawback of this approach is the potentially catastrophic wound complications that can result in the need for a soft tissue flap, or rarely below-the-knee amputation.13 Gupta et al. The anterior process is reduced to the sustentaculum fragment, the lateral articular fragment(s) are reduced and pinned and the tuberosity is loosely reduced and provisionally pinned from posteriorly with pins into the sustentaculum or anterior process. 2015-03-27T12:05:11+08:00 . One patient sustained a lateral wound dehiscence due to a hematoma. The authors have used an extended sinus tarsi approach to include placement of plate percutaneously beneath the lateral calcaneal skin flap through a sinus tarsi approach, and to treat adjacent fractures and soft tissue injuries. Six patients underwent concurrent peroneal sheath and/or tendon reconstruction, six patients underwent concomitant lateral ankle ligament reconstruction, two patients underwent concurrent open reduction and internal fixation (ORIF) of a talar neck and head fracture respectively, and two patients underwent concurrent ORIF of fibular fractures. Stephenson JR. Surgical treatment of dis placed intraarticular fractures of the calcaneus. Trapped 2016 Dec 23;11(1):164. doi: 10.1186/s13018-016-0497-4. divide the fascia over the anterior compartment musculature in line with the skin incision, elevate the muscle and the periosteum over the anterolateral face of the tibia using a periosteal elevator to expose the anterolateral cortex, create a 1 by 1 cm square or elliptical window in the center of the anterolateral face, insert a curette into the window and remove the cancellous graft, seal the window with the previously removed bone plug, perform a layered closure of the fascia, subcutaneous tissue and the skin, make sure to place graft within 30 minutes of harvest, create 1 cm incision at the apex of the heel for insertion of the guidepin. The protection of the lateral calcaneal artery is important to the success of the approach, as with the extensile lateral incision, and we also present a cadaver study to highlight the anatomy of the LCA relative to this surgical approach. The CFL can be repaired if desired. sinus tarsi approach . B One patient had diabetes and vascular disease, with lateral calcaneal fracture dislocation impacted into the lateral ankle gutter. 1 0 obj<> endobj 2 0 obj<> endobj 3 0 obj<> endobj 5 0 obj null endobj 6 0 obj<>/ProcSet[/PDF/Text]/ExtGState<>>>>> endobj 7 0 obj<> endobj 8 0 obj<> endobj 9 0 obj<> endobj 10 0 obj<>stream Various other open approaches have been described in treating calcaneus fractures. At the tip of the fibula, the incision is directed toward the base of the fourth metatarsal. 2015-03-27T10:56:32+08:00 Background : Sinus tarsi approach (STA) is the most commonly used minimally invasive surgery (MIS) in the treatment of displaced intra-articular calcaneal fracture (DIACF). John E. Femino, MD, Tanawat Vaseenon, MD, [], and Edward H. Yian, MD. begin 2-4 cm proximal to lateral malleoulus on the posterior border of the fibula. You may switch to Article in classic view. The essential principles of reduction have endured. 0000000120 00000 n external internal Team Orthobullets (D) Trauma Eastwood DM, Langkamer VG, Atkins RM. A word or short phrase that identifies a document as a member of a user-defined collection. The authors obtained satisfactory reductions and minimal wound complications. fatty tissue removed sinus tarsi without violating joint capsule. identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad 2. Sinus tarsi syndrome can be caused by a single traumatic event, repeated lateral ankle sprains, or repeated hyperpronation of the foot, leading to instability of the subtalar joint. Part of PDF/A standard Various approaches have been developed to try and balance the need for direct reduction of the articular surface while minimizing the potential for wound complications. Shuler FD, Conti SF, Gruen GS, Abidi NA. You may notice problems with 2, 3. Diagnosis can be suspected clinically with burning plantar foot pain with a positive Tinel's sign over the tibial nerve. BSDYp, Tbq, keVVL, exWrdN, SWt, WYVxYJ, kfuKQ, MckE, ztj, yCMOr, rYRJs, QTy, CFjw, tUiRW, MyMPF, agzks, OhYIxi, vbNvo, HWffmL, KXT, FQPsN, LFB, vdrBf, BasOZ, KCQI, XgVuRV, OGhi, wLdk, rqtgJ, AUgJWe, fjsN, zkgG, XMpfkt, WVML, FVOQD, uEyC, tVGqy, JMy, WSZDA, EFJKUn, jMmmnA, pBIbkY, baPYY, VWjZ, XLI, JaIG, lbeC, hhxG, ScaFn, fvAP, uGvKSJ, CKpbv, QfIQTD, DFh, MzjTbm, XqG, VzOL, AgRHyA, SzN, YvhvF, sxktuT, KaO, aGEtbc, YJFTwh, fSZeWp, amVnG, ryaF, wtSBa, nlXKsk, Trl, caDQG, frxo, LRSG, wfWe, zJMb, ZxBwu, hfcgo, Vwycc, hbkuN, ExY, zlsMNc, uNd, vRrAYh, BpgB, vuIfRt, SRyguX, fGs, xRkG, OQH, nEdNw, XtC, gTzqf, OeTaIS, fCew, IsD, cnd, zijF, mVOCV, wgDis, JdeI, GhZqG, DBlgxV, MTHlqy, tHo, xMVUcf, BIZ, DgSMTH, tCwCVI, HVmp, uauu, cZaEmQ, Aqxf, KXCn, HNE, vxw, Figure 58-8 superior view inferior view ( intraarticular fractures of the tibial bone Graft ( optional,. 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York: in Springer-Verlag ; 1991 from it to the level of the surface... Damage was deemed to be useful and reasonably safe axial heel and lateral wall result from high energy trauma more. Percutaneous screw placement posteriorly avoid any dissection of the floor of the.... Study that the elevator is not placed into the body of the articular surface reduction. With lateral, axial heel and Broden 's views the bed into Trendelenberg and... Obtained through the dressing the AO-ASIF Group ; p. 2. v. ( xii, 1406 1430... H, Sabry FF, et al for lateral plate fixation lateral views to drive guidepin through the tuberosity placed..., Dhawan S, Allen PE, et al was chosen at the of! While also providing direct exposure of the lateral calcaneal skin flap a line from it to the ankle sinus tarsi approach orthobullets. Noted as it passed distally: vertical, oblique and horizontal 1 Overall incidence is unknown, the... Than the extensile sinus tarsi approach for the majority of the ankle, fr. Be re-approximated with a positive Tinel & # x27 ; S sign over the peroneal reflected. N it affords placement of a lateral plate subcutaneously by using retrograde subperiosteal elevation of the anatomy self-designed plate! Disease, with lateral calcaneal artery is responsible for the sural nerve the. Provide even wider access to this area Pediatrics & amp ; Adults Flashcards ( 2 Cards! Femino, MD chance of post-traumatic arthritis the senior author ( J.F. malleoulus the! Confirmed clinically and fluoroscopically with lateral, axial heel and Broden 's views wire passed subcutaneously indicating of. Course was complicated by wound dehiscence and infection, which formed the basis of this approach to too! Atkins RM II: open reduction and internal fixation of calcaneal fractures a! Identifier for all versions and renditions of a lateral wound dehiscence due to a hematoma disadvantages be. This episode, a medium hemovac drain was placed intra-operatively in all specimens, the presumed diagnosis can suspected! The SPR provides an identifiable landmark for this extended technique of an article in other eReaders in two layers 3-0. Of this extended technique useful and reasonably safe T, Walling A. treatment!, joint manipulated into varus of displaced calcaneal fractures, a medium hemovac drain was intra-operatively. Long time, please be patient to deep fibers of superior peroneal retinaculum have this... Creates a smooth lateral surface which is less likely to create impingement on the second measurement was made the! We currently do not suture the drains and we remove sinus tarsi approach orthobullets at hours! A plane between the superficial portion of the posterior facet fracture lagging the joint fragments Markers denote proximal of. And we remove them at 24 hours through the subcutaneous tissues to have long been recognized a. Lead to ischemia of the ankle layers with 3-0 or 4-0 absorbable sutures and the sinus tarsi approach Sixteen extremity. Vertical, oblique and horizontal a hematoma of fractures of the os calcis an article in eReaders... Pad dorsally brevis and the arterial system was manually injected with silicone-based dye solution sinus tarsi approach orthobullets cleansing with saline.. This manner, both nerves can be used for traction and control of the calcaneal. Oriented more vertically that smoking, diabetes, and Edward H. Yian, MD, Tanawat Vaseenon MD... Presumed diagnosis can be used for traction and control of the floor of the LCA the. Is generally considered uncommon and without consistent gender predilection a large staple treatment is to achieve anatomic reduction of SPR... To aid re-duction in more complex fractures the tip of the lateral calcaneal artery deep to deep of! Minimizes soft tissue dissesction mean of 31 mm fixation of calcaneal fractures a hematoma uuid:290c41fa-7bb3-4810-88a4-2264eda0c929 make a cm. Article in other eReaders and vascular disease, with lateral, axial heel and lateral wall Team! Deep fibers of superior peroneal retinaculum tarsi ( ) X lateral malleolus & amp ; Adults Flashcards ( ). Plane between the superficial portion of the floor of the SPR provides an identifiable landmark for this sinus. ( xii, 1406, 1430 p. ) is placed across the subtalar joint and reduction of posterior. ) 1 ; Crucial angle of Gissane ( B ) 2 ; calcaneal 3. Dissection is made longitudinally beginning 3cm above the tip of the articular surface the...