Open Treatment and Internal Fixation of Displaced Intraarticular Calcaneal Fractures in High-Risk Patients Utilizing the Sinus Tarsi Approach

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1 Open Treatment and Internal Fixation of Displaced Intraarticular Calcaneal Fractures in High-Risk Patients Utilizing the Sinus Tarsi Approach W. Bret Smith, DO Steve Steinlauf, MD Greg E. Gaski, MD

2 Disclosure Open Treatment and Internal Fixation of Displaced Intra-articular Calcaneal Fractures in High-Risk Patients Utilizing the Sinus Tarsi Approach W. Bret Smith, DO Steven Steinlauf, MD Our disclosure is in the Final AOFAS Program Book. We have a potential conflict with this presentation due to: Greg E. Gaski, MD: Nothing to Disclose Smith/Nephew

3 Overview Evaluate results utilizing a sinus tarsi approach for intraarticular calcaneal fractures in a population of patients considered at high risk for wound issues High-risk patients: smokers, diabetics, immunocompromised patients, patients with open fractures, or any combination of these factors Comparison of wound complication and infection rates with the traditional lateral extensile approach

4 Methods 76 patients, who sustained a displaced intra-articular calcaneal fracture, were treated at two centers. 41 patients were included in the high-risk group. A sinus tarsi approach was used on all patients Dry arthroscopy was used to assist with reduction All patients were followed for an average of 8.1 months postop. Wound healing problems and infections were assessed. Any additional surgeries or post-operative complications were recorded.

5 Pre-Op Imaging

6 Intra-Op imaging

7 Post-Op Imaging

8 Sinus Tarsi Approach Approach Closure

9 The lateral extensile approach Basic Facts: Most common approach utilized to fix intraarticular calcaneal fractures Requires development of a large soft tissue flap Usually requires a lengthy time between injury and surgery secondary to swelling Concerns: Review of the literature reveals a wound complication rate of 6-33%. The tenuous soft tissue envelope leaves few options if wound complications occur

10 Results of sinus tarsi approach in high-risk group Data: 41 patients Defined as highrisk Sinus Tarsi approach used in all cases Follow-up - average of 8.1 months post operative Complications: 3 patients had delayed wound healing All healed with local care 8 patients required hardware removal 1 wound complication / Deep Infection: Patient with a history of an open fracture treated initially with an external fixator prior to plating Required surgical debridement, hardware removal, long-term antibiotics Healed with a wound VAC, Infection resolved, adequate function at long term follow-up

11 Selected References Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma Jun- Jul;13(5): Benirschke SA, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J.Orthop Trauma Jan;.18(1):1-6. Rak V, Ira D, Masek M. Operative treatment of intra-articular calcaneal fractures with calcaneal plates and its complications. Indian J Orthop Jul;43(3): Levine DS, Helfet DL. An introduction to the minimally invasive osteosynthesis of intraarticular calcaneal fractures. Injury May;32 Suppl 1:SA51-4. Schepers T. The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop May;35(5): Epub 2011 Feb 19. Femino JE, Vaseenon T, Levin DA, Yian EH. 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. Iowa Orthop J. 2010;30: 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. Foot Ankle Int Oct;24(10):