Review Question - QID 217415

The sinus tarsi approach for calcaneus fractures has been shown to decrease operative time and infection rate.

The traditional approach to the calcaneus is the extensile lateral approach. It produces a skin flap which is supplied by the lateral calcaneal branch of the peroneal artery. However, this blood supply is notoriously tenuous, leading to increased wound and infection-related complications. The sinus tarsi approach is a 2-4 cm incision from the tip of the fibula in line with the 4th metatarsal. The EDB is retracted cephalad and the peroneal tendons are retracted posteriorly. It allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall. While more technically challenging, particularly in subacute or extensively comminuted fractures, when done successfully it is more forgiving on the soft tissues.

Xia et al. performed a randomized controlled trial of 117 displaced intra-articular calcaneus fractures. Patients were randomized to standard extensile approach or sinus tarsi approach. They found higher wound complication rates, longer OR times, and worse Maryland foot scores with the extensile lateral approach. There were no differences in the reduction parameters.

Hsu et al. reviewed emerging techniques in the treatment of calcaneus fractures. They note that the extensile approach is associated with numerous complications including hematoma, skin necrosis, wound problems, and infection. They reviewed newer techniques that have fewer complications including sinus tarsi approach, percutaneous fixation, and arthroscopic assisted fixation.

Figure A shows a displaced Sanders II calcaneus fracture. Figure B shows the sinus tarsi approach. Figure C shows the extensile lateral approach.

Incorrect Answers:
Answer 1: No difference has been found in the ability to restore Bohler’s angle between the two approaches.
Answer 3: The minimally invasive approach is more likely to increase radiation exposure than the open extensile lateral approach, which affords more direct visualization.
Answer 4: The sinus tarsi approach has been shown to lower infection rates.
Answer 5: The sinus tarsi approach has been shown to improve Maryland foot scores.