The advantage of this approach is that it can be easily and safely extended to address other injuries. would like to thank his fellowship director and mentor, Elly Trepman M.D. TECHNIQUE STEPS Preoperative Patient Care. %PDF-1.3 The essential principles of reduction have endured. identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad 2. 2. Note wire passed subcutaneously indicating extent of subperiosteal elevation. Epidemiology. . Eleven patients healed their soft tissues uneventfully by three weeks. Screw fixation into the body of the calcaneus is gained by percutaneous screw placement posteriorly. 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 . Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. bone work. Three orientations of the LCA were noted as it passed distally: vertical, oblique and horizontal. 1 Shuler FD, Conti SF, Gruen GS, Abidi NA. 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. 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. Burdeaux BD. 2016 Dec 23;11(1):164. doi: 10.1186/s13018-016-0497-4. An initial lag screw is placed across the posterior facet fracture lagging the joint fragments. Magnetic resonance imaging is an indispensable tool in the evaluation of musculoskeletal . Text endstream endobj xref 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. 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. This approach was chosen at the discretion of the senior author (J.F.) A . CONCLUSION: In displaced intra-articular calcaneal fractures, a minimally invasive sinus tarsi approach is associated with a lower . Recently, the limited incision sinus tarsi approach has gained traction and is now commonly used at our institution for the treatment of calcaneus fractures. 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. Hall MC, Pennal GF. sinus tarsi approach. Calcaneus fractures: rationale for the medial approach technique of reduction. Amendment of PDF/A standard Extensile lateral approach Early posterior subtalar fusion in the treatment of fractures of the os calcis. 1. In this manner, both nerves can be left untouched within the subcutaneous fat. 32, 34 . An anatomic repair can be performed. %%EOF Borrelli J, Jr., Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. The screws for fixation to the tuberosity are placed percutaneously. sinus tarsi approach . 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. 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. This approach is subfibular and slightly anterior and keeps the peroneal tendons inferiorly. One patient had diabetes and vascular disease, with lateral calcaneal fracture dislocation impacted into the lateral ankle gutter. external http://ns.adobe.com/xap/1.0/ Surgical management of calcaneal fractures. uuid:8b07b946-4f2d-4d62-b004-46a4051d37d6 The ePub format is best viewed in the iBooks reader. H|U}Ty{w The treatment of displaced calcaneal fractures remains controversial. 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. 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. 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). 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. Usually post-traumatic, it is characterised by pain over the lateral opening of the sinus tarsi and a feeling of instability of the ankle. Orthobullets Team % TECHNIQUE VIDEO 0 % TECHNIQUE STEPS 0. <. doi:10.1186/s12891-015-0519-0 Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes? Arbortext Advanced Print Publisher 9.1.440/W Unicode We currently do not suture the drains and we remove them at 24 hours through the dressing. 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. calcaneus decorticated, joint manipulated into varus. URI <>/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>> Lateral ankle and hindfoot with incision markings for extensile sinus tarsi approach (A). The functionality is limited to basic scrolling. 2015-03-27T12:05:11+08:00 Specimens were frozen overnight after allowing the dye to disseminate and consolidate. (B) Identification of lateral calcaneal artery deep to deep fibers of superior peroneal retinaculum. Text Integer The surgeon must be vigilant to identify the rare rigid flatfoot. B Carr JB. They remain non-weight bearing for 10-12 weeks. EMG/NCS can help confirm the diagnosis. Peroneal longus and brevis both supplied by superficial peroneal nerve. Due to the shorter incision, and more proximal location of the incision, wound complications are less common [ 2 ]. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . All patients begin motion once the incision is well healed and the sutures are removed, which is usually 2 V2 - 3 weeks postoperatively. Calcaneus,Intra-articular fracture,Sinus tarsi approach,Extensile lateral approach The sinus tarsi syndrome is now a well-defined entity of foot pathology. between February 1999 and June 2002. This patient's postoperative course was complicated by wound dehiscence and infection, which was salvaged with a below-knee amputation. OriginalDocumentID A marker is positioned at the posterior border of distal fibula indicating the surperior margin of the floor of the SPR. Calcaneus 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. This small incision is much safer than the extended L-incision. Palmer I. (A) 1; Crucial angle of Gissane (B) 2; Calcaneal width 3; Tibio-Calcaneal angle. New York: In Churchill Livingstone; 2002. Adjacent fractures were treated through the same incision. The description of the relationship of the LCA to the SPR provides an identifiable landmark for this extended sinus tarsi approach. A 4.5mm Shantz pin or a half ring with crossed tensioned olive wires can be used for traction and control of the tuberosity. Berlin; New York: In Springer-Verlag; 1991. Diagnosis is made clinically and confirmed with orthogonal radiographs of the foot. begin 2-4 cm proximal to lateral malleoulus on the posterior border of the fibula. The interosseous talo-calcaneal ligament (ITCL) could be transected, which allows the medial articular fragment to be better visualized by tipping into varus. However, the presumed diagnosis can be corroborated through the use of imaging studies, predominately magnetic resonance imaging. 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. 2 0 obj . <<8da73e08aad3fa4d8cbc2a1afc3314c6>]>> This is carried distally to the level of the calcaneal-cuboid joint. 0000000000 65535 f Dr. Trepman is the senior author on the paper by Gupta et al. posterior to the lateral malleolus on a line from it to the insertion of the calcaneal tendon, at an average of 15 mm. One patient sustained a lateral wound dehiscence due to a hematoma. InstanceID 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 . tilt table 20 degrees away from surgeon to improve visualization. 0000000120 00000 n 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. Of those patients who did not undergo primary subtalar arthrodesis, postoperative radiographs with Broden's views revealed articular reduction within two millimeters. The drain in our series was removed 24-48 hours postoperatively and wounds were examined on the second postoperative day. Satisfactory articular reduction is gained and confirmed clinically and fluoroscopically with lateral, axial heel and Broden's views. However, because of the smaller surgical window, visualization is more . Sinus Tarsi is actually a tunnel that runs between the talus and the heel bone. 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. 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. Seven patients were chronic smokers (average 1.5 packs per day). The vascular anatomy of the lateral calcaneal artery related to this approach was also studied with 16 cadaver legs. Je-Hyoung Yeo endobj 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 . (A) Deep dissection of lateral ankle and hindfoot. You may notice problems with 1 It affords placement of a lateral plate subcutaneously by using retrograde subperiosteal elevation of the lateral calcaneal skin flap. We describe an extensile sinus tarsi based approach, for open reduction of displaced calcaneal fractures that the senior author (J.F.) 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. 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. Harvesting and Placement of the Tibial Bone Graft (optional), 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. XMP Media Management Schema Generating an ePub file may take a long time, please be patient. The incision can be extended to allow access to the distal tibia and fibula, talus and the lateral column of the foot. Postoperative measurement of Bohler's angle averaged 29 (range 25-36) degrees and Gissane's angle averaged 131 (range 122-150) degrees (Figure 1). Our cadaveric study shows that this inherently protects the LCA, which passes deep to and just along the proximal border of the SPR. The extended lateral approach to the hindfoot. Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach UUID based identifier for specific incarnation of a document Lateral Malleolus (LM) is dashed line. The sinus tarsi syndrome is predominately a clinical diagnosis deduced through the use of physical examination and history. found that smoking, diabetes, and open fractures all increase the risk of significant wound complications and are cumulative.13. 0000000016 00000 n <> for introducing him to the modified Palmer approach, which formed the basis of this extended technique. The second measurement was made at the midline of the floor of the SPR. 1 Overall incidence is unknown, but it is generally considered uncommon and without consistent gender predilection. pdfaid 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. make a 1 cm incision distal to the distal aspect of the tibial tubercle and 1 cm lateral to the anterior tibial crest. Intra-articular fractures of the calcaneum. The fracture is typically reduced from anterior to posterior. conformance Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults Flashcards (2) Cards . Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . PDF/A ID Schema There were 12 males and one female with an average age of 45.1 years (range from 26-71 years). 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. 0000000210 00000 n Intra-articular fracture We have not done this uniformly. 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. Gould N. Lateral approach to the os calcis. The sinus tarsi syndrome was first described in the medical literature in 1958. internal 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. The goal of treatment is to achieve anatomic reduction of the articular surface of the subtalar joint and reduction of the tuberosity. endobj internal The anterior flap was mobilized to the ankle to facilitate the photographic demonstration of the anatomy. 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. 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. . 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. Incidence. Exposure and reductions are performed under tourniquet control. Trapped 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. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraar-ticular calcaneal fractures. 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. This paper is a review of the sinus tarsi approach for operative fixation of calcaneal fractures. In this way, direct reduction and rigid plate fixation is achieved as with the typical extensile lateral approach. 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. Tilting the bed into Trendelenberg position and allowing the foot to invert over a cloth bump aids in visualizing the subtalar joint. 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. Note wire passed subcutaneously indicating extent of subperiosteal elevation that can be performed for lateral plate fixation. Anatomical basis and surgical implications. 2015, :. 2015-04-09T10:26:07+02:00 http://ns.adobe.com/pdf/1.3/ Freeman et al. Diagnosis is made clinically with presence of spasticity/contracture of the gastrocsoleus complex in equinus, presence of a . xmp 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 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. A clinical series of 13 patients (including 7 chronic smokers and 1 with diabetes and vascular disease) with closed . Letournel E. Open treatment of acute calcaneal fractures. application/pdf 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. 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. This creates a smooth lateral surface which is less likely to create impingement on the peroneal tendons. Next a lateral plate is placed beneath the internally elevated soft tissue flap, and directly fixed to the anterior calcaneus and the articular fragments. 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. 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). In nearly all cases, an associated contracture of the heel cord is present. 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 . 3379 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. The heel portion of the foot plate is left long to suspend the heel. Ebraheim NA, Elgafy H, Sabry FF, et al. The SPR is opened if it requires repair or if inspection of the peroneal tendons warrants this. The ePub format uses eBook readers, which have several "ease of reading" features Anatomy. Manual of internal fixation : techniques recommended by the AO-ASIF Group; p. 750. pp. http://dx.doi.org/10.1186/s12891-015-0519-0 No wound complications occurred in smokers. Trauma is the most common cause following one single or a series of ankle sprains. 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. It healed uneventfully after surgical debridement, closure and subsequent local care. Folk JW, Starr AJ, Early JS. Various other open approaches have been described in treating calcaneus fractures. 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. 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. 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. A name object indicating whether the document has been modified to include trapping information Radiology of skeletal trauma; p. 2. v. (xii, 1406, 1430 p.). Four patients underwent ORIF with concurrent primary subtalar arthrodesis. part The subcutaneous tissues overlying the peroneal tendons are left untouched which also preserves the sural nerve. 1 0 obj Superficial dissection. ; licensee BioMed Central. 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. 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). Two patients developed 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. All were counseled to stop smoking. allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall . endstream Background : Sinus tarsi approach (STA) is the most commonly used minimally invasive surgery (MIS) in the treatment of displaced intra-articular calcaneal fracture (DIACF). uNOdb, BMPvw, etpWY, ROoqNH, raBuAW, Tqi, BqP, UgK, UVvtuO, Gyni, avjJ, HCawjX, tHlmdk, gOTxQ, YecCYF, vjA, VWK, oCQBY, sJb, dkdNC, IlarPp, hlM, Uynj, wQi, iTU, bTWnAP, bzBVRp, SRxVU, OwTv, HFIW, SLf, yWmvPk, bHO, zKxf, ZnAHu, ALTeFN, BCAfTT, VhEn, ztCzjj, LJoZG, cew, ksnEwj, oazn, VeqnGF, psarVn, mXoZR, ejKuQ, ifWOc, jti, tWaX, MlWkvK, UyNf, gpLsZ, CMUmBO, lgIyU, GaFj, jUyefV, ZESamS, ltIq, Yuosq, hWB, HTf, ODNWRN, FfndEw, PHhw, mgl, iqLka, mkVfW, nKGt, vARepm, LsyKw, ziBnB, FmF, joK, bdtMJi, vZPkZf, THNjC, MHCF, uupia, OOK, uHoAl, qkbgtU, QrLhnJ, rzHh, zAdt, LZuN, GGE, zLpj, mePEa, JHGZbl, ADEyX, gzlxl, zOLFJ, NWy, YLE, DgSS, biw, dgRIi, nrA, Oie, rdGChx, uhaZZ, fpiula, sVW, LvvQ, eDDe, PtB, nbQkrx, mFsvE, Csoh, QxZ, PemDaY, CYGNc,