Hi there, my name is Neb and I am a PGY-4 resident at the University of Saskatchewan. This is our study on calcaneus fracture fixation using the sinus tarsae approach. The calcaneus is the most commonly fractured tarsal bone and inter-articular in upwards of three quarters of cases. These fractures are devastating and life-changing for patients. Historically, there's been much debate surrounding how best to treat these fractures. Operatively, our goal in orthopedics is always to make things look as close to normal as possible. Many different incision types exist, as seen by the list below. Traditionally, the most common used is a large lateral extensile incision. This incision is plagued with soft tissue complications, so new less invasive approaches have been established with the practical goal of dissecting less, subsequently reducing wound complications, and hopefully achieving equivalent and adequate joint reductions. One of these approaches is the limited sinus tarsae approach. Our study came to be with our surgeons wondering just how well they were actually reducing these fractures using the sinus tarsae approach, where the eye cannot see. A radiographic assessment of joint reduction was therefore our primary outcome. We then also took a stab at tracking clinical outcome measures as secondary assessments. We identified cases done over roughly three years using hospital billing codes. The most important inclusion criteria were that they had pre- and post-operative x-rays and CT scans. Radiographically, on x-ray we measured in standard fashion, Bowler's angle and the angle of Jezan. On CT scan, we measured the single maximum step deformity of the posterior facet in each of the coronal, axial, and sagittal views. Post-operatively, these same measurements were taken on equivalent post-operative images. All in all, we were able to look through the charts and radiographs of 50 patients. Unfortunately, 20 had to be excluded from the study, the majority due to lacking a post-operative CT. We only had one patient to whom bilateral calcaneus fractures belonged to. The average age was just about 49, 80% were in males, and most as a result of a fall. Fractures are rarely simple patterned, adding to the complexity of surgical fixation. We have the luxury at our center of getting at these fractures quick before excessive swelling ensues, so our days to fixation are relatively low compared to the literature out there. Radiographically, our study demonstrates the competency of our fine surgeons to fix broken bones. Boller's angle was restored to within normal limits, and the cumulative joint step deformities were on average corrected to what is considered more or less anatomic in the trauma world. Interestingly, little change was noted measuring the angle of Jezan. Segregating groups by Sanders classification, we can see that with Sanders 4 fractures, Boller's angles were the most improved, while simultaneously the cumulative joint step improvements were probably the least improved. Fall of duration was determined from the date of procedure to the last clinic note. When it comes to infection, two patients were deemed to have some degree of superficial infection and prescribed some Keflex. Incision problems were found in only one patient at her two-week follow-up, where she was seen to have a loosely closed incision. Interestingly, she also had a screw in the subtalar joint, raising suspicions of non-compliance with non-weed bearing. Tallying up additional procedures, the most common occurrence was that a fifth of patients requested to have hardware removed, the mean time of removal being about 500 days from the initial ORIF. Our results suggest that the Sinus Tarsae approach can be used to achieve what is considered a good joint reduction. The literature describes fairly undisplaced fractures in this area to be of less than 2 mm displacement, and these are initial fracture characteristics that may sway a surgeon to offer non-operative management to begin with. So achieving this level of reduction, I feel, can be considered a success. Additional takeaways can include that Boller's angle is a useful judge of gross reduction, while the angle of Jezan less so. Important to note within this outcome is that the worse the fracture pattern, tremendous improvements can be made with surgery when we look at only x-ray images, but what is left in the joint as seen on CT scan certainly is not perfectly anatomic. This translates clinically into the importance of setting expectations with our patients, and that a wonderful looking x-ray will not mean the end of their troubles at the subtalar joint. In the literature, and practically, the biggest advantage of a small incision is a reduced frequency of soft tissue problems. Our study is small, but that, at an approximate 10% wound complication rate, when there are quoted rates of upwards of 15-22% with traditional incisions, it isn't something to be ignored. Larger studies with more patients, and studies that could maybe be randomized, may further add to this observation. The outcome of reoperation rate in our study mirrored that of other published literature at about 20% for calcaneus ORIF, however the majority of our reoperations were solely for hardware removal rather than irrigation and debridement or definitive arthrodesis. When it comes to treatment of subtalar joint arthritis, I imagine the need is to some degree proportional to the length of follow-up. Our study term was short and only managed to capture early symptomatic patients that were irritated by hardware rather than arthritis. For interest sake, subtalar fusion rates post calcaneus ORIF are much, much higher in patients with a bowler's angle of less than 0 degrees on presentation, a sanders 4 fracture, and or if they are a workplace injury patient. Limitations to our study include that only one reviewer scrutinized the images, me, which of course could be subject to bias. Our CT scans provided us with standard views of the foot and ankle, however the literature often describes slight variations to these to best view the posterior facet, such as the 30 degree semi-cronal cut. We also did not include in our analysis 5 patients who were only missing some clinical data but could have been included in the radiographic component of the study. In conclusion, the experience at our centre complements the literature in that using a smaller surgical incision such as the sinus-tarsae approach yields satisfactory joint reduction and has few immediate post-operative complications. Unfortunately, and ultimately, regardless of the management method, it seems that the clock begins to tick with these patients until post-traumatic arthritis ensues. The use of a minimally invasive surgical technique is appropriate to avoid additional morbidity with an already devastating injury. Thank you for your time.

calcaneus fracture fixation

sinus tarsae approach

radiographic joint reduction

clinical outcomes

post-traumatic arthritis