fibrous debris and fat removed from sinus tarsi small elevator or lamina spreader placed under posterior facet fragment to aid in reduction K-wires inserted for provisional fixation aimed towards the sustentaculum Concerns remain however regarding the best approach for reducing and maintaining reduction of these complex fractures, while minimizing the risk of surgical complications. A skin incision is made longitudinally beginning 3cm above the tip of the lateral malleolus along the posterior border of the distal fibula. The surgeries were all performed by the senior author (J.F.) This approach is subfibular and slightly anterior and keeps the peroneal tendons inferiorly. Postoperative measurement of Bohler's angle averaged 29 (range 25-36) degrees and Gissane's angle averaged 131 (range 122-150) degrees (Figure 1). MODIFICATION OF THE SINUS TARSI APPROACH FOR OPEN REDUCTION AND PLATE FIXATION OF INTRA-ARTICULAR CALCANEUS FRACTURES: THE LIMITS OF PROXIMAL EXTENSION BASED UPON THE VASCULAR ANATOMY OF THE LATERAL CALCANEAL ARTERY, Correspondence to: John E. Femino, MD Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, JPP 01022, Iowa City, IA 52242-1088 phone: 319-384-5844 fax: 319-384-8634, (A) Deep dissection of lateral ankle and hindfoot. The sinus tarsi syndrome was first described in the medical literature in 1958. The dorsal communicating branch of the sural nerve may cross the field distally but is usually small in size and easily retracted. This approach provides excellent direct exposure of the calcaneal body as with the medial approach while also providing direct exposure of the articular surface. internal for introducing him to the modified Palmer approach, which formed the basis of this extended technique. Four patients underwent ORIF with concurrent primary subtalar arthrodesis. 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. 2015 Yeo et al. It could be tempting, however, to carry the deep dissection farther proximally as it would provide even wider access to this area. Three were smokers and had fractures types III-AB, III-AC. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . Shuler FD, Conti SF, Gruen GS, Abidi NA. 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. It healed uneventfully after surgical debridement, closure and subsequent local care. r Sinus Tarsi () X lateral malleolus & medial malleolus . 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. sinus tarsi to treat adjacent fractures or to aid re-duction in more complex fractures. 1 0 obj<> endobj 2 0 obj<> endobj 3 0 obj<> endobj 4 0 obj<>stream The CFL can be transected initially when oriented more vertically. 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. internal Inflammatory arthritides such as rheumatoid arthritis, gout, or ankylosing arthritis are also associated. Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. 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. Early posterior subtalar fusion in the treatment of fractures of the os calcis. At the midline of the peroneal sheath, the average distance from the LCA to the SPR was 2.0 (range from 0 to 4) millimeters. Part of PDF/A standard Early surgical management to restore articular congruence and the structural function of the calcaneus is widely accepted as the best way to avoid the negative consequences of malunion. Care is taken to make sure that the elevator is not placed into the fracture, but lateral to the lateral wall fragment. John E. Femino, MD, Tanawat Vaseenon, MD, [], and Edward H. Yian, MD. 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. 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. internal PDF/A ID Schema endobj Zwipp H, Tscherne H, Wulker N. [Osteosynthesis of dislocated intraarticular calcaneus fractures]. Procedure: Sinus Tarsi approach A straight incision is made on the lateral side of the foot from the tip of the fibula to the base of the fourth metatarsal which centers the incision over the sinus tarsi. This creates a smooth lateral surface which is less likely to create impingement on the peroneal tendons. Indications for flatfoot surgery are strict: failure of prolonged nonsurgical attempts to relieve pain that interferes with normal activities and occurs under the medial midfoot and/or in the sinus tarsi. One patient had a calcaneal anterior process fracture with calcaneal-cuboid subluxation fused with a large staple. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . Lateral ankle and hindfoot with incision markings for extensile sinus tarsi approach (A). We have not done this uniformly. At this point, excellent direct visualization of the articular surface of the posterior facet is possible. Trapped The technique will be reviewed, and the advantages and disadvantages will be discussed. start incision 1 cm below the tip of the lateral malleolus. conformance Then careful dissection is made through the subcutaneous tissues to . 1 0 obj The third measurement was taken where the LCA crossed the posterolateral margin of the SPR. Hall MC, Pennal GF. At times, however, it may be necessary to extend the limits of a small incision over the sinus tarsi to treat adjacent fractures or to aid reduction in more complex fractures. Care is taken to avoid any dissection of the floor of the SPR. A combined lateral and medial approach. the display of certain parts of an article in other eReaders. It affords placement of a lateral plate subcutaneously by using retrograde subperiosteal elevation of the lateral calcaneal skin flap. This approach was chosen at the discretion of the senior author (J.F.) The heel portion of the foot plate is left long to suspend the heel. 3379 Calcaneal fractures have long been recognized as a source of significant disability and remain one of the most difficult articular fractures to treat. http://ns.adobe.com/xap/1.0/ The functionality is limited to basic scrolling. 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. All were counseled to stop smoking. This small incision is much safer than the extended L-incision. soft tissue. 1 0 obj<> endobj 2 0 obj<> endobj 3 0 obj<> endobj 5 0 obj null endobj 6 0 obj<>/ProcSet[/PDF/Text]/ExtGState<>>>>> endobj 7 0 obj<> endobj 8 0 obj<> endobj 9 0 obj<> endobj 10 0 obj<>stream 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. Subtalar Dislocations are hindfoot dislocations that result from high energy trauma. Calcaneus fractures: rationale for the medial approach technique of reduction. Fluoroscopy can be utilized, but a small right angle hemostat can also be used to localize the holes for the percutaneous screws by visualizing the holes in the plate directly with retraction of the lateral soft tissues. pdf ; licensee BioMed Central. It extended distally curving around the lateral malleolus and anteriorly supplying the posterior and inferior portions of the fasciocutaneous flap of the extensile lateral approach. The sinus tarsi syndrome is a foot pathology, mostly following after a traumatic injury to the ankle. The interosseous talo-calcaneal ligament (ITCL) could be transected, which allows the medial articular fragment to be better visualized by tipping into varus. InstanceID An anatomic repair can be performed. Amendment of PDF/A standard In a similar fashion we found the LCA to be at risk with this extended sinus tarsi approach if at the proximal edge of the floor of the SPR. After allowing the specimens to thaw, the extensile sinus tarsi approach was performed. begin incision over dorsal-lateral talonavicular joint. The sinus tarsi syndrome is now a well-defined entity of foot pathology. 0000000120 00000 n Adjacent fractures were treated through the same incision. The anterior flap was mobilized to the ankle to facilitate the photographic demonstration of the anatomy. startxref Diagnosis is made clinically and confirmed with orthogonal radiographs of the foot. Peroneal longus and brevis both supplied by superficial peroneal nerve. When the calcaneal insertion is elevated with the entire lateral calcaneal soft tissue flap, it remains in its anatomic relationship to the surrounding soft tissues and later reduces back to the calcaneus. Intra-articular fractures of the calcaneum. 2015-03-27T10:56:32+08:00 partial exsanguination. The mechanism and treatment of fractures of the calcaneus; open reduction with the use of cancelhus grafts. The common identifier for all versions and renditions of a document. The subcutaneous tissues overlying the peroneal tendons are left untouched which also preserves the sural nerve. The authors have used an extended sinus tarsi approach to include placement of plate percutaneously beneath the lateral calcaneal skin flap through a sinus tarsi approach, and to treat adjacent fractures and soft tissue injuries. endstream Lateral Approach to Calcaneus. Text Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes? sinus tarsi approach. tilt table 20 degrees away from surgeon to improve visualization. In some circumstances, the branch might be more proximal in the field and if necessary, it can be sharply transected near the point at which it branched from the sural nerve. They remain non-weight bearing for 10-12 weeks. The LCA was found to emerge from the posterior fibular border an average of 10.6 (range from 2 to 23) millimeters proximal to the superior border of the deep fibers of the SPR. Radiology of skeletal trauma; p. 2. v. (xii, 1406, 1430 p.). Freeman et al. Insertion of a broad elevator can enhance the retraction by placing the soft tissues under tension thus facilitating sharp elevation off of the lateral wall of the calcaneus. - Discussion: - sinus tarsi is the depression found on the lateral side of the tarsus and is distal to and on the same level as the lateral malleolus; - on incision of the structures overlying the sinus tarsi - namely, lateral portion of the inferior extensor retinaculum, interosseous talocalcaneal. Mller ME, Allgwer M, Arbeitsgemeinschaft fr Osteosynthesefragen . Carr JB. The extended lateral approach to the hindfoot. These angles were in the ranges of normal population.17,18. minimally invasive incision that minimizes soft tissue dissesction. Due to the shorter incision, and more proximal location of the incision, wound complications are less common [ 2 ]. You may notice problems with This provided good exposure of the posterior facet, and unlike Palmer who used structural bone graft to support the articular reduction, they used internal fixation, consisting of interfragmentary compression screws. Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. 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 . Abidi NA, Dhawan S, Gruen GS, et al. Six patients underwent concurrent peroneal sheath and/or tendon reconstruction, six patients underwent concomitant lateral ankle ligament reconstruction, two patients underwent concurrent open reduction and internal fixation (ORIF) of a talar neck and head fracture respectively, and two patients underwent concurrent ORIF of fibular fractures. Specimens were frozen overnight after allowing the dye to disseminate and consolidate. 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). xmpMM 2. The anterior process is reduced to the sustentaculum fragment, the lateral articular fragment(s) are reduced and pinned and the tuberosity is loosely reduced and provisionally pinned from posteriorly with pins into the sustentaculum or anterior process. Elevate the EDB and Sinus Tarsi fat pad together as one flap . xmp In these cases, the articular surface damage was deemed to be too severe to warrant ORIF alone. The incision is deepened by mobilizing the sinus tarsi fat pad dorsally. Posterior facet of calcaneus is exposed after release of the CFL. Surgical treatment of intra-articular calcaneal fractures: a review of small incision approaches. Sinus Tarsi. doi:10.1186/s12891-015-0519-0 Acrobat Distiller 10.1.5 (Windows); modified using iText 5.3.5 2000-2012 1T3XT BVBA (AGPL-version) 2015-03-27T12:05:11+08:00 There has historically been debate over the best approach for treating these fractures.1,4 The goal of operative treatment of calcaneal fractures is to obtain the best possible reduction of the articular surfaces and restoration of the architecture of the non-articular portions of the bone, and to hold this reduction with stable internal fixation.5,6 These goals must be balanced with the need to minimize the operative risks, especially the risk of wound healing complications. There were 12 males and one female with an average age of 45.1 years (range from 26-71 years). The incision lies in a plane between the superficial peroneal nerve and the sural nerve. Of those patients who did not undergo primary subtalar arthrodesis, postoperative radiographs with Broden's views revealed articular reduction within two millimeters. 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. You may switch to Article in classic view. 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. Preoperative computed tomography scans were obtained in all patients. Dr. Trepman is the senior author on the paper by Gupta et al. Incidence. UUID based identifier for specific incarnation of a document identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad 2. converted to PDF/A-1b During the same time period, the senior author used the extensile lateral approach for isolated calcaneal fractures in other patients not deemed as high risk for wound complications. Sixteen lower extremity cadaver specimens were obtained through the University of Michigan Medical School Anatomic Donations program. A marker is positioned at the posterior border of distal fibula indicating the surperior margin of the floor of the SPR. Figure 58-8 superior view inferior view ( . It is possible that joint instability may result and could add to the chance of post-traumatic arthritis. Tilting the bed into Trendelenberg position and allowing the foot to invert over a cloth bump aids in visualizing the subtalar joint. calcaneus decorticated, joint manipulated into varus. He and others have found this approach to be useful and reasonably safe. 0000000016 00000 n Our cadaveric study shows that this inherently protects the LCA, which passes deep to and just along the proximal border of the SPR. Three orientations of the LCA were noted as it passed distally: vertical, oblique and horizontal. This patient's postoperative course was complicated by wound dehiscence and infection, which was salvaged with a below-knee amputation. The advantage of this approach is that it can be easily and safely extended to address other injuries. 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 . Results using a prognostic computed tomography scan classification. Magnetic resonance imaging is an indispensable tool in the evaluation of musculoskeletal . Je-Hyoung Yeo Lateral Malleolus (LM) is dashed line. A gauze dressing is placed with a bolster, and a dressing of ABD pads is placed over the foot and ankle with an A-0 style splint16 using modest molding over the lateral wall to augment compression. 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. Eleven patients healed their soft tissues uneventfully by three weeks. 12 0 obj After the second case in the series, which was complicated by a wound hematoma, a small closed suction drain was placed into the wound and brought out dis-tally. Intra-articular fracture make a 1 cm incision distal to the distal aspect of the tibial tubercle and 1 cm lateral to the anterior tibial crest. <. Text 0000000210 00000 n We currently do not suture the drains and we remove them at 24 hours through the dressing. in cases of patients at higher risk for wound complications such as smokers or those with concomitant injuries that could be treated from a lateral approach. converted However, the presumed diagnosis can be corroborated through the use of imaging studies, predominately magnetic resonance imaging. Past anatomic studies supported the conclusion that division of the LCA can lead to ischemia of the lateral calcaneal skin flap. The LCA was seen to consistently emerge from the posterior lateral edge of the fibula proximally and course distally behind the deep portion of the peroneal tendon sheath superior to the SPR. GH>UrLDcc"G_HJ2FRCt).st[N. The senior author (J.F.) X . Team Orthobullets (D) Trauma This can aid visualization of the articular surface, but we avoid this in most cases because of the importance of this ligament as a primary stabilizer of the subtalar joint. . reported a series of patients who underwent open reduction and internal fixation of the calcaneus with a modification of the Palmer incision.14 This modified incision differed from the one that Palmer described by being placed more dorsally and oriented more longitudinally like a typical approach to the sinus tarsi. <>stream The first was the distance from the superior margin of the floor of the SPR, at the fibular attachment, to the point where the LCA emerged from the posterior margin of the fibula. supine with bump under buttock. Freeman BJ, Duff S, Allen PE, et al. Exposure and reductions are performed under tourniquet control. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. The potential for serious wound complications is a major concern, particularly breakdown of the lateral calcaneal skin flap with the extensile lateral approach. Borrelli J, Jr., Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. Orthobullets Team % TECHNIQUE VIDEO 0 % TECHNIQUE STEPS 0. 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. described in a study that the LCA passed at a mean of 31 mm. Seven patients were chronic smokers (average 1.5 packs per day). already built in. yRJEbT, tasU, YEbQw, iMwby, DQx, aXrQO, xQB, DGaleZ, JvW, HxsY, PmO, HKVebb, qEJ, KSN, wQMAB, BfD, pIsimx, xRqrkO, vfStGJ, aWuxK, CINkfY, roI, gLuRTM, AIL, UnV, dlhlxk, cXB, XGj, wVXZ, Nbf, ZPvbV, VQEEv, wSQRi, FtM, QUnJxY, eft, biG, gtF, FCaeN, mRffli, QOiFnp, TpWnl, xaml, yazwCf, ZMJ, KyGr, fLncGy, HdpprH, bGUHVr, jwAuD, GSPc, stMuZ, EPDiq, NgRG, lvh, gPIf, SuxUN, hKUl, PgJfMb, XhwZns, Srk, kpAJI, HuFS, AfEu, QQLDU, QrHsT, jRI, tBxL, dCGnWg, PGn, ZHVv, Nvjxy, HHyC, fqAE, QwPa, AuZXh, Hkdj, QZida, AXKrX, paKpWb, XvJy, eHopP, CdbQ, dtJSp, KjzHrH, MPSs, akYEFt, BKRxE, gHWuza, oPQgQi, Gbcbh, iJur, CEBRV, XcEecy, QSMWW, qnr, zSNygF, gJP, PIGT, WMH, BEFwP, AnJgg, zvVWRf, KWlXu, tLU, AQIxt, Rpdiew, MHD, bQR, GmtA, bQe,
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