Minimally Invasive Operative Treatment of Displaced Intra-Articular Calcaneal Fractures via the Sinus Tarsi Approach

INDICATIONS

Displaced intra-articular calcaneal fractures are difficult to treat. Historically, operative intervention was abandoned secondary to wound healing complications and poor internal fixation techniques. With the advent of modern plating techniques in the 1980s, operative intervention regained popularity as it allows anatomic restoration of the subtalar joint and the height, width, and length of the bone. By doing so it increases the potential to provide improved functional outcome. Contemporary literature has demonstrated positive clinical and cost-effectiveness outcomes in most patient populations.¹^, ²^, ³

Several surgical approaches have been described, of which the extended lateral approach has been most reported upon.⁴^, ⁵^, ⁶^, ⁷^, ⁸^, ⁹^, ¹⁰ While this approach is very utilitarian, allowing direct reduction of the lateral wall, and with further dissection, visualization of the posterior facet and calcaneocuboid joints, it is plagued by wound complications which have reported rates as high as 30%.¹¹^, ¹²

Alternative limited lateral surgical approaches have been described. In 1948, Palmer described a curved incision below the lateral malleolus for direct exposure to the subtalar joint.¹³ Later, Essex-Lopresti adopted a similar sinus tarsi incision to elevate depressed joint fragments.¹⁴ Gupta, reported on a modification of Palmer’s approach, in which a straight incision was made 1 cm distal to the fibula in the direction of the fourth metatarsal base. Of 32 operatively treated fractures, there was only one case of postoperative wound complication related to the incision.¹⁵ Hospodar et al. described a similar approach using a 3- to 4-cm straight incision 1 to 1.5 cm distal to the tip of the fibula and roughly perpendicular to the fibula. Although there were only 16 patients in this series, there were no wound complications.¹⁶

Similarly, we advocate a limited sinus tarsi approach. This approach allows direct visualization of the posterior facet and angle of Gissane while minimizing damage to already traumatized soft tissues. This approach can be extended proximally to address peroneal tendon dislocations or tears, talus or fibular fractures, ligamentous or syndesmotic pathology or distally to visualize the calcaneocuboid joint. Direct reduction of the posterior facet is achieved and a lateral plate is placed subcutaneously that allows reduction of the calcaneal tuberosity to the posterior facet. Additional percutaneous screws can be placed as needed. The indications for using this approach are similar to the extended lateral approach. We employ the sinus tarsi approach on Sanders type II to IV fractures. Because of the limited dissection with this approach, we do not typically wait for swelling to subside before surgical intervention. Additionally, diabetes and smoking are not contraindications.

PATIENT POSITIONING

The patient is placed in the supine position on a radiolucent operating table. We routinely use a deflatable “beanbag” positioning device to achieve a partial or full lateral position. The down-leg should be padded to protect bony prominences and the common and superficial peroneal nerves. A thigh tourniquet or lower leg Esmarch is used at the surgeon’s discretion (Fig. 27-1).

SURGICAL APPROACH

A standard approach to the sinus tarsi is performed. The incision is made along a line connecting the tip of the fibula to the base of the fourth metatarsal and just dorsal to the peroneal tendons. The length of the incision is based on the surgeon’s familiarity with this technique and the need for exposure of the various components of the injury. Typically, the incision is 5 to 8 cm in length. We recommend a slightly longer incision early in the learning curve (Fig. 27-2, Fig. 27-3). Sharp dissection is carried through the skin (Fig. 27-3). Dissecting scissors should be used to navigate through the connective tissues. Insert deep retractors early to avoid skin damage. Occasionally a dorsal communicating branch of the sural nerve is identified in the wound. This should be dissected, retracted plantarly, and protected throughout the procedure. Incise the capsule to the subtalar joint in line with the incision and dorsal to the peroneal tendon sheath. A stack of folded towels is placed under the medial ankle to suspend the calcaneus off the OR table. This facilitates disimpaction of the talus from the calcaneus.
The sinus tarsi is entered and the fracture hematoma is evacuated. A small laminar spreader with teeth is then inserted between the head-body junction of the talus and the calcaneus at Gissane angle (Fig. 27-4). At times there is too much comminution to effectively push on the calcaneus. In these cases, sharply cut fibers of the inferior extensor retinaculum, anterior capsule of the posterior facet, and even a portion of the interosseous ligament. This will allow a deeper insertion of the laminar spreader which greatly improves the ability to visualize the posterior facet. Carefully insert a wide periosteal of Cobb elevator along the lateral wall of the calcaneus, deep to the peroneal tendons and superficial to all lateral wall fragments. Maneuver the elevator in a posterior and plantar direction. Occasionally, the peroneal tendon sheath is opened and the peroneal tendons are retracted plantarly. Mobile peroneal tendons allow for better tissue protection throughout the case and provide better access to the far posterior aspect of the posterior facet during “rafting” screw placement (discussed later). If there is anterior comminution, carry the dissection anteriorly until the calcaneocuboid joint is visualized by lifting off the extensor digitorum brevis from the bone.

Figure 27-1. Positioning for calcaneal fracture fixation using the sinus tarsi approach. The patient is positioned in the lateral decubitus position with the down-leg common peroneal nerve padded to prevent compression neuropathy.

Figure 27-2. Skin incision for sinus tarsi approach. Dotted yellow line indicates location of incision. White lines indicate the sural nerve and its potential branches.

Figure 27-3. Skin incision with surface anatomy features demarcated. The incision extends from just distal to the tip of the fibula toward the base of the fourth metatarsal.

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