SINUS TARSI APPROACH FOR TREATMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2018 vol. 122, no. 2 SURGERY ORIGINAL PAPERS SINUS TARSI APPROACH FOR TREATMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES B. Veliceasa 1, B. Puha 1*, D. Popescu 1, Mihaela Pertea 2, Roxana Pinzaru 1, O. Alexa 1 Grigore T. Popa University of Medicine and Pharmacy Iasi Faculty of Medicine 1. Department of Surgery (II) 2. Department of Surgery (I) *Corresponding author. puhab@yahoo.com SINUS TARSI APPROACH FOR TREATMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES (Abstract): The optimal treatment for displaced calcaneal fractures involving the posterior facet is surgical. Several minimally invasive techniques have been developed in recent years. Aim: We evaluated the results of calcaneal posterior facet reduction by a limited sinus tarsi approach combined with percutaneous reduction and screw fixation. Material and methods: Twenty-three consecutive patients (mean age 41 years) with 27 intraarticular calcaneal fractures were treated. After reduction and fixation of the posterior calcaneal facet, the final fixation of the calcaneal fractures was performed percutaneously with two or three 6.5 mm, fully threaded cancellous screws. Patient follow-up was on average 1.4 years. Results: Superficial wound edge necrosis was observed in one case (0.27%) which has healed within one week with local wound care. The Bohler angle has improved from an average of o preoperatively to o postoperatively. Median AOFAS score was 89 points and median MES score was 87 points at the final follow-up. Conclusions: Minimally invasive open reduction and percutaneous screw fixation of selected displaced intra-articular calcaneal fractures can achieve good to excellent functional and radiological outcomes. Sinus tarsi approach appears to be an effective and reliable method for the treatment of these fractures being associated with fewer wound complications and a shorter waiting time before surgery. Keywords: DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES, SINUS TARSI AP- PROACH, CALCANEAL POSTERIOR FACET, MINIMALLY INVASIVE. Calcaneal fractures account for 1-2% of all fractures and are the most common fractures of the tarsal bones, representing 65% of all tarsal fractures (1). Seventy percent of these fractures are intra-articular (2). Nonsurgical treatment of displaced intra-articular calcaneal fractures is associated in general with poor results due to secondary subtalar arthrosis and modification of hindfoot morphology. For these reasons more and more surgeons advocate in favor of surgical over conservative treatment of displaced intra-articular calcaneal fractures (3-5). The optimal treatment for displaced calcaneus fractures involving the posterior facet is surgical and, for an extended period, the gold standard in the treatment of these fractures was represented by open reduction and internal fixation (ORIF) via an extended L-shaped lateral approach. However, this approach was frequently associated with major wound healing com- 318

2 Sinus tarsi approach for treatment of displaced intra-articular calcaneal fractures plications, from 5.8% to 43%, such as skin edge necrosis, hematoma, and deep wound infection (6). To minimize these risks, several minimally invasive techniques have been developed in recent years: closed reduction and percutaneous screw fixation (7, 8), open reduction of the posterior facet via sinus tarsi lateral approach (9, 10), limited posterior approach and arthroscopic-assisted fixation (11, 12). In this prospective study we evaluated the results of calcaneal posterior facet reduction by a limited sinus tarsi lateral approach combined with percutaneous reduction and screw fixation of displaced intraarticular calcaneal fractures. MATERIAL AND METHODS Study design. Twenty-three consecutive patients, 18 (78.3%) males and 5 (21.7%) females, with 27 intra-articular calcaneal fractures were treated in the interval The age of patients ranged from 24 to 78 years (mean age 41 years). The mechanism of injury was fall from height in most cases - 17 (73.9%) fractures, car accidents in 5 (21.7%) patients and direct trauma (a weight falling directly on the hindfoot) in one (4.4%) patient. Right foot was affected in 14 (60.8%) patients, left foot in 5 (21.7%) patients and four (17.4%) patients had bilateral calcaneal fractures. Two of the fractures were open: one type I and the other type IIIA according to Gustilo- Anderson classification. Plain X-ray films were obtained for all the patients including lateral view, axial heel view (Harris view) and Broden s oblique views. Bohler s angle was measured in all patients pre- and postoperatively. Computer Tomography (CT) scan was performed in all patients to assed the fracture patterns and for classification. Fractures were classified according to Sanders classification: 19 (70.3%) fractures Sanders type II and 8 (29.7%) fractures Sanders type III. After the reduction and fixation of the posterior calcaneal facet, the final fixation of the calcaneal fractures was performed percutaneously with two or three 6.5 mm, fully threaded cancellous screws. The average time till surgery was 4 days (range 1-8 days) depending in general on the availability of surgical theater, and in older, active patients on comorbidity assessment (the oldest patient was 78 years old). Seven (30.4%) patients were chronic smokers (on average more than 1.5 packs per day), 3 (13%) patients had diabetes and 1 (4.3%) patient had associated vascular disease. Postoperative CT scan was performed in 17 (73.9%) patients to evaluate the reduction of calcaneal posterior facet. All patients were assessed clinically and radiologically. Patients follow-up was on average 1.4 years (9 months to 1.8 years), two (8.7%) patients were excluded because were lost to after one-year follow-up. For clinical assessment we used The American Orthopedic Foot and Ankle Score (AO- FAS) and Maryland Foot Score (MES). Surgical technique. For exposure the patient is positioned in full lateral decubitus on the radiolucent operating table (fig. 1A). High tourniquet was used in all patients. The involved extremity is positioned on a cylindrical pillow and the other extremity is bent from the knee not to interfere during fluoroscopy. Sinus tarsi approach consists in a small incision of about 3-4 cm under the tip of the lateral malleolus in the direction of the base of the fifth metatarsal bone (fig. 1B). This small incision is situated in the plane be- 319

3 B. Veliceasa et al. tween the superficial peroneal nerve and the sural nerve and protects the lateral calcaneal artery which is responsible for most of the blood supply to the lateral calcaneal area. By sharp dissection care must be taken not to damage the peroneal tendons which are retracted laterally (fig. 1C). The incision is deepened by mobilizing the sinus tarsi fat pad dorsally. Sometimes the intermediate root of the inferior extensor retinaculum can be released to have better access to the fracture line. By now excellent visualization of the posterior facet is obtained (fig. 1D). In some cases, for better visualization of the medial articular fragment the interosseous talocalcaneal ligament could be transected, but this is not recommended because it creates subtalar instability. A B C D Fig. 1. A position of the patient on the table, B sinus tarsi approach, C position of the peroneal tendons in the surgical field, D visualization of the fractured calcaneal posterior facet. A Shantz screw or a Steinman pin is used for traction and reduction of the tuberosity. After the fracture is mobilized and the interposed soft tissue is debrided, the posterior facet is reduced and fixed temporally with two, Ø 2mm, Kirschner (K) wires. The fractured fragments are reduced to the constant sustentacular fragment. Reduction of posterior facet fragments can be performed in an outside-in or inside-out-inside manner in case of a dislocated intermediate fragment. Accurate articular surface reduction is assisted either by direct visualization or dry arthroscopy and fluoroscopically with lateral, axial heel and Broden's views. After confirming the anatomic reduction of the posterior facet, the two K-wires are replaced successively with two Ø 3.5 mm cancellous screws. The last step is the fixation of the calcaneal fracture. Once the fixation is complete and final fluoroscopic or X-ray images are obtained, the wound is thoroughly irrigated, and the soft tissues are sutured in layers. A small closed suction drain is placed into the wound which is removed after hours postoperatively. All patients begun active and passive 320

4 Sinus tarsi approach for treatment of displaced intra-articular calcaneal fractures range of motion exercises the second day after surgery. RESULTS No intraoperative complications occurred. The patient with open type IIIA calcaneal fracture needed plastic surgery reconstruction for skin closure. All the fractures had healed radiologically within three months (fig. 2). A B C D E F G H I Fig. 2. Patient HA, 31-years-old: A, B preoperative X-ray: Bohler type 2 calcaneal fracture; C preoperative CT scan: Sanders type IIb calcaneal fracture; D, E, F postoperative X-rays (lateral, Broden s and Harris views); G postoperative CT scan: anatomic reduction of the posterior facet; H, I 3D postoperative CT scans. 321

5 B. Veliceasa et al. Active and passive range of motions exercises were initiated from postoperative day 2. Non-weight bearing for thirty days was recommended followed by partial weight bearing (15-20 kg) for two weeks. Superficial wound edge necrosis was observed in two cases (0.54%) which had healed within one week with local wound care. No superficial or deep infections developed in our series. In one patient we noticed, at three months follow-up, a lost in calcaneal varus reduction, without major clinical implication, probably due to intense anterior process comminution. The Bohler angle has improved from an average of o preoperatively (range from o to o ) to o postoperatively (range from o to o ). Postoperative CT scan showed a posterior facet step-off less than 1 mm in 12 patients, 1-2 mm in 4 patients and more than 2 mm in 1 patient. Median AOFAS score was 89 points (range from 74 to 96) and median MES score was 87 points (range from 76 to 94) at the final follow-up. DISCUSSION Closed reduction and percutaneous K- wire or screw fixation have frequently been reported and can effectively reduce the risk of surgical wound complications because of the small incision (8). Open reduction of the posterior facet using a less invasive sinus tarsi approach and percutaneous screw fixation seems to be a better option (13). In his study, Tornetta (14) was the first to report satisfactory results of percutaneous treatment of calcaneal fractures. He found a mean Maryland Foot Score of 87 in 22 patients with Sanders type IIc fractures at a mean follow-up of 2.9 years. In 2004, Rammelt et al. (15) found that percutaneous fixation of displaced calcaneal fractures had good to excellent results in patients with less severe fracture patterns, with a mean AOFAS ankle-hindfoot score of In their study, Beltran and Collinge (16) including high-grade open calcaneal fractures treated with percutaneous screw fixation found good results in 17 patients, with an average AOFAS ankle-hindfoot score of 77, 1 patient developed a deep infection (6%) and 1 patient wound dehiscence (6%). Van Hoeve et al. (17), in a 2016 review of the published data regarding minimally invasive treatment of intra-articular calcaneal fractures found that open and percutaneous reduction and screw osteosynthesis techniques have been used with increased frequency as an alternative to ORIF. Also, their review indicates that techniques using percutaneous reduction and screw osteosynthesis and minimally invasive open approaches result in significantly better outcomes in terms of the AOFAS anklehindfoot score and increased Bohler angle after treatment compared with external fixation and other techniques such as Kirschner wire fixation. No significant difference in the incidence of infection was found between these techniques. Only a few studies reported the congruency of the posterior facet of the subtalar joint as an outcome parameter. Comparable results were found in our study, and it seems that excellent results are in close correlation with the restoration of Bohler angle and posterior facet step-out. Open, less invasive, sinus tarsi approach with the application of the common calcaneal plate is limited to specially designed plates, which have not undergone biomechanical testing. Another option for osteosynthesis through sinus tarsi approach 322

6 Sinus tarsi approach for treatment of displaced intra-articular calcaneal fractures are nails (18-20) which seem to offer better stability than the plates (21). Another crucial element is that the lateral extensile incision requires delay in surgical treatment until swelling has improved, usually an average of two weeks. The current trend and interest is in small incision approaches which allow earlier operative fixation (22). The average time till surgery was 4 days in our series and this is due to prolonged preoperative period in some older patients (two patients were older than 70 years) who needed complex health assessment due to their frailty (23). In our country, older patients are sometimes self-neglected, and these conditions require a complex preoperative management in such cases (24). CONCLUSIONS We believe that minimally invasive open reduction and percutaneous screw fixation of selected displaced intra-articular calcaneal fractures can achieve good to excellent functional and radiological outcomes. Sinus tarsi approach appears to be an effective and reliable method for the treatment of these fractures being associated with fewer wound complications and a shorter waiting time for surgery. REFERENCES 1. Zwipp H, Rammelt S, Barthel S et al. Fracture of the calcaneus. Unfallchirurg 2005; 108: Buckley RE, Tough S. Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg 2004; 12: Bruce J, Sutherland A. Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database Syst Rev 2013; (1): CD Luo X, Li Q, He S, He S. Operative Versus Nonoperative Treatment for Displaced Intra-Articular Calcaneal Fractures: A Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg 2016; 55(4): Wei N, Yuwen P, Liu W et al. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: A meta-analysis of current evidence base. Medicine (Baltimore) 2017; 96(49): e Wu J, Zhou F, Yang L, Tan J. Percutaneous reduction and fixation with Kirschner wires versus open reduction internal fixation for the management of calcaneal fractures: a meta-analysis. Sci Rep 2016; 6: Lamichhane A, Mahara D. Management of intra-articular fracture of calcaneus by combined percutaneous and minimal internal fixation. J Nepal Health Res Counc 2013; 11: Hsu AR, Anderson RB, Cohen BE. Advances in surgical management of intraarticular calcaneus fractures. J Am Acad Orthop Surg 2015; 23: Yeo JH, Cho HJ, Lee KB. Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach. BMC Musculoskelet Disord 2015; 16: Park CH, Lee DY. Surgical Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach. Indian J Orthop 2017; 51(4): Pastides PS, Milnes L, Rosenfeld PF. Percutaneous arthroscopic calcaneal osteosynthesis: a minimally invasive technique for displaced intra-articular calcaneal fractures. J Foot Ankle Surg 2015; 54: Park CH, Yoon DH. Role of Subtalar Arthroscopy in Operative Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach. Foot Ankle Int 2018; 39(4):

7 B. Veliceasa et al. 13. Nosewicz T, Knupp M, Barg A et al. Mini-open sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography-based study. Foot Ankle Int 2012; 33(11): Tornetta P. Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res 2000; 375: Rammelt S, Amlang M, Barthel S, Zwipp H. Minimally-invasive treatment of calcaneal fractures. Injury 2004; 35: Beltran MJ, Collinge CA. Outcomes of high-grade open calcaneus fractures managed with open reduction via the medial wound and percutaneous screw fixation. J Orthop Traumatol 2012; 26: van Hoeve S, Poeze M. Outcome of Minimally Invasive Open and Percutaneous Techniques for Repair of Calcaneal Fractures: A Systematic Review. J Foot Ankle Surg 2016; 55(6): Falis M, Pyszel K. Treatment of Displaced Intra-articular Calcaneal Fractures by Intramedullary Nail. Preliminary Report. Ortop Traumatol Rehabil 2016; 18(2): Pompach M, Carda M, Amlang M, Zwipp H. [Treatment of calcaneal fractures with a locking nail (C- Nail)]. Oper Orthop Traumatol 2016; 28(3): Zwipp H, Paša L, Žilka L, Amlang M, Rammelt S, Pompach M. Introduction of a New Locking Nail for Treatment of Intraarticular Calcaneal Fractures. J Orthop Trauma 2016; 30(3): e Reinhardt S, Martin H, Ulmar B et al. Interlocking Nailing Versus Interlocking Plating in Intraarticular Calcaneal Fractures: A Biomechanical Study. Foot Ankle Int 2016; 37(8): Swords MP, Penny P. Early Fixation of Calcaneus Fractures. Foot Ankle Clin 2017; 22(1): Pîslaru AI, Ilie AC, Pancu AG, Sandu IA, Alexa ID. Detection and prevention of frailty in independently living pre-elderly and elderly in Northeastern Romania. Rev Med Chir Soc Med Nat Iaşi 2016; 120(4): Alexa ID, Ilie CA, Morosanu A, Papaioannou Emmanouil Stamos, Ismo Räihä: Auto-neglijarea la varstnici: o problema globala neglijata in Romania. Revista Romana de Bioetica 2012; 10(1): NOUTĂȚI NEWS GHRELIN PLAYS AN IMPORTANT ROLE IN METABOLIC DISEASES Changes in ghrelin levels can directly affect immune responses and tissue homeostasis. Le u- kocytes, such as adipose tissue macrophages, express GHS-R and detect changes in energy status. Thus, ghrelin actions on ATMs may play a role in the maintenance of the tissue homeostasis, suggesting a link between the immune system and systemic metabolism in response to different physiological and pathological conditions such as obesity and insulin r e- sistance. Immunoregulatory role of acyl-ghrelin and its beneficial effects to treat chronic inflammatory syndromes, especially acyl-ghrelin immunoprotected properties during endotoxic shock has been demonstrated. Ghrelin is not only a gastric peptide with CNS actions, but it is also an important hormone/cytokine with important pleiotropic functions. The wide distribution of GHS-R1a in different cell types, including immune cells, indicates that ghrelin acts as a potent immunomodulator with powerful anti-inflammatory roles. Ghrelin mainly acts on the innate and adaptive immune systems to suppress inflammation and induce an anti-inflammatory profile. (Jéssica Aparecida da Silva Pereira, Felipe Corrêa da Silva, Pedro Manoel Mendes de Moraes-Vieira, The Impact of Ghrelin in Metabolic Diseases: An Immune Perspective, J Diabetes Res Volume 2017:1-15) Iustina-Silvia Crețu-Silivestru 324