A combined lateral and medial approach. In all specimens, the LCA traversed directly posterior to the lateral border of the deep portion of the SPR. 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. Sixteen lower extremity cadaver specimens were obtained through the University of Michigan Medical School Anatomic Donations program. began using in 1999 based on the technique described by Gupta et al. The superficial portion of the SPR was divided, but the deep portion was preserved. An initial lag screw is placed across the posterior facet fracture lagging the joint fragments. 2015 Yeo et al. reduces wound complications associated with extensile lateral incision. Magnetic resonance imaging is an indispensable tool in the evaluation of musculoskeletal . 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. 2015-03-27T12:05:11+08:00 The sinus tarsi syndrome was first described in the medical literature in 1958. In this manner, both nerves can be left untouched within the subcutaneous fat. We currently do not suture the drains and we remove them at 24 hours through the dressing. allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall . 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 patient had normal pain sensation and was given the option of surgery due to the severe injury to both the ankle and subtalar joints. 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. Text Lateral Malleolus (LM) is dashed line. Note wire passed subcutaneously indicating extent of subperiosteal elevation. B The skin is closed in two layers with 3-0 or 4-0 absorbable sutures and the skin with Nurolon. Results: Median Bhler and Gissane angle were improved to 26.5 degree (4.6 to 45), 115.5 degree (101.2 to 127.4) Surgical treatment of intra-articular calcaneal fractures: a review of small incision approaches. We describe an extensile sinus tarsi based approach, for open reduction of displaced calcaneal fractures that the senior author (J.F.) Je-Hyoung Yeo pdfaid %PDF-1.3 The description of the relationship of the LCA to the SPR provides an identifiable landmark for this extended sinus tarsi approach. Manual of internal fixation : techniques recommended by the AO-ASIF Group; p. 750. pp. The treatment of displaced calcaneal fractures remains controversial. calcaneus decorticated, joint manipulated into varus. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. Tilting the bed into Trendelenberg position and allowing the foot to invert over a cloth bump aids in visualizing the subtalar joint. 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. This is a safe, simple incision, but the surgeon must look for the sural nerve. Integer fatty tissue removed sinus tarsi without violating joint capsule. 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. This is carried distally to the level of the calcaneal-cuboid joint. Trapped pdfToolbox 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. <> 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. The vascular anatomy of the lateral calcaneal artery related to this approach was also studied with 16 cadaver legs. sinus tarsi approach. bone work. make a 1 cm incision distal to the distal aspect of the tibial tubercle and 1 cm lateral to the anterior tibial crest. At this point, excellent direct visualization of the articular surface of the posterior facet is possible. This approach is subfibular and slightly anterior and keeps the peroneal tendons inferiorly. startxref XMP Media Management Schema OriginalDocumentID 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). 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. 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. sinus tarsi to treat adjacent fractures or to aid re-duction in more complex fractures. Minimally invasive (sinus tarsi) approach for calcaneal fractures J Orthop Surg Res. The authors obtained satisfactory reductions and minimal wound complications. . 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. An anatomic repair can be performed. One patient had diabetes and vascular disease, with lateral calcaneal fracture dislocation impacted into the lateral ankle gutter. Anatomical basis and surgical implications. http://ns.adobe.com/pdf/1.3/ The surgeries were all performed by the senior author (J.F.) internal Epidemiology. 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. 3 0 obj The sinus tarsi syndrome is now a well-defined entity of foot pathology. uuid:8b07b946-4f2d-4d62-b004-46a4051d37d6 The SPR is opened if it requires repair or if inspection of the peroneal tendons warrants this. 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. Lateral Approach to Calcaneus. use the Harris heel and lateral views to drive guidepin through the tuberosity, across the subtalar joint and into the talar neck. Folk JW, Starr AJ, Early JS. Three were smokers and had fractures types III-AB, III-AC. %PDF-1.5 % One patient had a calcaneal anterior process fracture with calcaneal-cuboid subluxation fused with a large staple. Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. InstanceID Incision. 0000000120 00000 n Hall MC, Pennal GF. 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. doi:10.1186/s12891-015-0519-0 begin 2-4 cm proximal to lateral malleoulus on the posterior border of the fibula. Surgical management of calcaneal fractures. 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. The functionality is limited to basic scrolling. 1 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. 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). 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. Two patients developed wound complications. Then careful dissection is made through the subcutaneous tissues to . 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 . However, because of the smaller surgical window, visualization is more . This creates a smooth lateral surface which is less likely to create impingement on the peroneal tendons. GH>UrLDcc"G_HJ2FRCt).st[N. Calcaneal fractures have long been recognized as a source of significant disability and remain one of the most difficult articular fractures to treat. Shuler FD, Conti SF, Gruen GS, Abidi NA. Zwipp H, Tscherne H, Wulker N. [Osteosynthesis of dislocated intraarticular calcaneus fractures]. doi:10.1186/s12891-015-0519-0 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. Extensive intraarticular fractures of the foot. http://ns.adobe.com/xap/1.0/mm/ 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. 2 0 obj Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraar-ticular calcaneal fractures. 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. Primary subtalar arthrodesis in the treatment of severe fractures of the calcaneum. xxviii, p. Rogers LF. For exposure of an isolated calcaneal fracture, the patient is positioned either in full lateral or semi-lateral position with a hip bump. They remain non-weight bearing for 10-12 weeks. Adobe PDF Schema Results using a prognostic computed tomography scan classification. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . Harvesting and Placement of the Tibial Bone Graft (optional), 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. Arbortext Advanced Print Publisher 9.1.440/W Unicode Mark and make incision . Berlin; New York: In Springer-Verlag; 1991. True Diagnosis can be suspected clinically with burning plantar foot pain with a positive Tinel's sign over the tibial nerve. These angles were in the ranges of normal population.17,18. The anterior flap was mobilized to the ankle to facilitate the photographic demonstration of the anatomy. 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. You may notice problems with Concerns remain however regarding the best approach for reducing and maintaining reduction of these complex fractures, while minimizing the risk of surgical complications. 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. A skin incision is made longitudinally beginning 3cm above the tip of the lateral malleolus along the posterior border of the distal fibula. The ePub format is best viewed in the iBooks reader. Part of PDF/A standard The incision lies in a plane between the superficial peroneal nerve and the sural nerve. <>stream The mechanism and treatment of fractures of the calcaneus; open reduction with the use of cancelhus grafts. Various other open approaches have been described in treating calcaneus fractures. Team Orthobullets (D) Trauma Specimens were frozen overnight after allowing the dye to disseminate and consolidate. We are experimenting with display styles that make it easier to read articles in PMC. 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. New York: In Churchill Livingstone; 2002. Sinus tarsi approach Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. Noble J, McQuillan WM. The goal of treatment is to achieve anatomic reduction of the articular surface of the subtalar joint and reduction of the tuberosity. endobj Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Satisfactory articular reduction is gained and confirmed clinically and fluoroscopically with lateral, axial heel and Broden's views. start incision 1 cm below the tip of the lateral malleolus. A name object indicating whether the document has been modified to include trapping information Calcaneus,Intra-articular fracture,Sinus tarsi approach,Extensile lateral approach application/pdf The Sinus Tarsi approach is the surgical approach for the incision. Markers denote proximal border of superior peroneal retinaculum. The sinus tarsi syndrome is predominately a clinical diagnosis deduced through the use of physical examination and history. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes? All patients begin motion once the incision is well healed and the sutures are removed, which is usually 2 V2 - 3 weeks postoperatively. 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. 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 . Posterior facet of calcaneus is exposed after release of the CFL. It can later be re-approximated with a single stitch if desired. 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. 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. xmpMM for higher risk patients or those with concomitant fractures that could be addressed simultaneously. Abidi NA, Dhawan S, Gruen GS, et al. Freeman et al. The lateral calcaneal artery is responsible for the majority of the blood supply to this area. 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. soft tissue. Subtalar Dislocations are hindfoot dislocations that result from high energy trauma. Label This approach was chosen at the discretion of the senior author (J.F.) ligament and reflection of the . Elevate the EDB and Sinus Tarsi fat pad together as one flap . Eleven patients healed their soft tissues uneventfully by three weeks. It healed uneventfully after surgical debridement, closure and subsequent local care. The CFL can be repaired if desired. All patients were evaluated both clinically and radiologically. 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 . r Sinus Tarsi () X lateral malleolus & medial malleolus . One patient sustained a lateral wound dehiscence due to a hematoma. It affords placement of a lateral plate subcutaneously by using retrograde subperiosteal elevation of the lateral calcaneal skin flap. internal 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. <>/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>> pdf In this way, direct reduction and rigid plate fixation is achieved as with the typical extensile lateral approach. Of those patients who did not undergo primary subtalar arthrodesis, postoperative radiographs with Broden's views revealed articular reduction within two millimeters. 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