Operative Treatment of Calcaneus Fractures Through a Sinus Tarsi Approach

Figure 10.1

Lateral radiograph (a), 30-degree semi-coronal (b), sagittal (c), and axial (d) CT showing an intra-articular joint depression type calcaneus fracture. There is flattening of the Böhler’s angle to 9° and joint depression with impaction on the lateral radiograph (a). The 30-degree semi-coronal plane view (b) allows for the Sander’s Classification as well as further defining the involvement of the posterior facet. The axial CT cut shows medial cortex overlap indicating varus alignment of the calcaneus (c). The sagittal cut demonstrates posterior facet depression (d)

Treatment and Timing of Surgery

The decision was made together with the patient to address his calcaneus fracture with open reduction internal fixation in an attempt to restore articular congruency and thus decrease the potential risk for post-traumatic arthritis of the subtalar joint. Historically, patients with similar calcaneus fractures were instructed to elevate their injured extremity for up to 3 weeks until soft tissue swelling had subsided and an extensile L-shaped approach could be performed safely without risking postoperative wound complications. Complication rates with the extensile approach reached from 1.5% in experienced hands to 30% in the general literature [1].

Recently, the limited incision sinus tarsi approach has gained traction and is now commonly used at our institution for the treatment of calcaneus fractures. Due to the shorter incision, and more proximal location of the incision, wound complications are less common [2]. However, because of the smaller surgical window, visualization is more difficult, often relying on indirect reduction techniques [3]. These indirect reduction maneuvers are easily performed within the first 7–10 days, after which fracture fragments become “sticky” and anatomic reduction is often more difficult to obtain [4]. In this case scenario, the soft tissue swelling was minimal and there was no blistering; therefore the patient was taken to the operating room on day seven after his injury.

Surgical Tact

Position

Lateral decubitus position with a beanbag on a radiolucent operating room table with the foot at the very distal aspect of the table. The operative leg is positioned on a bone foam positioner. Alternatively, a towel ramp can be built, creating a flat surface to rest the operative leg. The fluoroscopy unit is brought in obliquely from the contralateral side (Fig. 10.2a). A thigh tourniquet is placed.

Figure 10.2

Intraoperative setup demonstrates lateral decubitus positioning with the operative leg on a radiolucent bone foam positioner (a). Note that this allows for the fluoroscopy unit to be brought in from the contralateral side to help obtain a Harris heel view. A 4–6 cm incision is made over the sinus tarsi (b) using the inferior aspect of the fibula and the fourth metatarsal base as bony landmarks. Intraoperative image (c) and fluoroscopy (d) show the use of a periosteal elevator underneath the posterior facet to achieve reduction along with the use of a percutaneous Schanz pin in the tuberosity to reduce the varus deformity. Further intraoperative fluoroscopic views showing plate placement on the lateral aspect of the calcaneus 5 mm distal to the posterior facet joint line (e, f)

Approach

After exsanguination of the limb, a 4–6 cm incision is made over the sinus tarsi (Fig. 10.2b). Bony landmarks include the inferior aspect of the fibula and the fourth metatarsal base. If swelling or body habitus precludes palpation of bony prominence, a K-wire may be placed on the skin coursing from the inferior aspect of the fibula in line with the fourth metatarsal and position can be verified with fluoroscopy. Careful soft tissue dissection is carried down to the peroneal tendons and extensor digitorum brevis; very rarely will branches of the sural nerve come into the field [5–7]. The retinaculum over the peroneal tendons is incised and the tendons are retracted carefully out of the field, keeping the tendon sheath intact. The fascia and muscle of the extensor digitorum brevis are also incised and elevated distally. This allows access to the capsular structures, which are subsequently excised to visualize the articular surface of the posterior facet and the angle of Gissane.

Fracture Reduction Techniques and Fixation

After exposure of the subtalar joint, the amount of fracture comminution and lateral wall involvement was appreciated. Because the approach does not allow exposure of the tuberosity, a Steinmann pin was percutaneously placed into the posterior tuberosity and used to distract and reduce the tuberosity out of varus and restore length [5–7].

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