Sinus Tarsi Approach and Osteosynthesis with Cannulated Screws in Calcaneal Fractures with Articular Depression
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Published:
Apr 30, 2025
Keywords:
Calcaneus, minimally invasive approach, sinus tarsi
Main Article Content
Abstract
Introduction: Open reduction and internal fixation via an extended lateral approach is the most commonly accepted surgical strategy for managing intra-articular calcaneal fractures with articular depression. However, the high rate of soft tissue complications associated with this technique has led to the development of less invasive alternatives that aim to reduce complications and improve functional outcomes.
Objective: To evaluate the complications and functional outcomes of calcaneal fracture fixation usingthe sinus tarsi approach and cannulated screws.
Materials and Methods: Between June 2016 and June 2022, 14 intra-articular calcaneal fractures with articular depression were treated using the sinus tarsi approach and cannulated screw fixation. Postoperative complications, radiographic outcomes (Gissane angle, Böhler angle, calcaneal length and width), and CT findings (Sanders classification) were assessed, along with functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) score and a self-administered satisfaction questionnaire.
Results: With a mean follow-up of 19.28 months, the average AOFAS score was 84.14. One superficial infection was reported and successfully treated with oral antibiotics. In two patients, hardware removal was required. Immediate and late postoperative imaging showed no significant differences compared to the contralateral healthy calcaneus. No postoperative articular step-offs greater than 2 mm were observed on CT scans. Eight patients reported being satisfied with the outcome, and six were very satisfied.
Conclusion: The sinus tarsi approach combined with cannulated screw fixation provides functional and radiographic outcomes comparable to or better than those achieved with the extended lateral approach and lateral plating, with fewer soft tissue complications.
Objective: To evaluate the complications and functional outcomes of calcaneal fracture fixation usingthe sinus tarsi approach and cannulated screws.
Materials and Methods: Between June 2016 and June 2022, 14 intra-articular calcaneal fractures with articular depression were treated using the sinus tarsi approach and cannulated screw fixation. Postoperative complications, radiographic outcomes (Gissane angle, Böhler angle, calcaneal length and width), and CT findings (Sanders classification) were assessed, along with functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) score and a self-administered satisfaction questionnaire.
Results: With a mean follow-up of 19.28 months, the average AOFAS score was 84.14. One superficial infection was reported and successfully treated with oral antibiotics. In two patients, hardware removal was required. Immediate and late postoperative imaging showed no significant differences compared to the contralateral healthy calcaneus. No postoperative articular step-offs greater than 2 mm were observed on CT scans. Eight patients reported being satisfied with the outcome, and six were very satisfied.
Conclusion: The sinus tarsi approach combined with cannulated screw fixation provides functional and radiographic outcomes comparable to or better than those achieved with the extended lateral approach and lateral plating, with fewer soft tissue complications.
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How to Cite
Yapur, P. M., Herrera, H. S., Rofrano Botta, M. A., Pereira, F. J., & Paitampoma Álvarez, P. (2025). Sinus Tarsi Approach and Osteosynthesis with Cannulated Screws in Calcaneal Fractures with Articular Depression. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 90(2), 166-176. https://doi.org/10.15417/issn.1852-7434.2025.90.2.2025
Section
Clinical Research
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References
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reduction and internal fixation of calcaneal fractures with an extended lateral approach. Int Orthop 2014;38(4):767-73. https://doi.org/10.1007/s00264-013-2181-1
2. Potter MQ, Nunley JA. Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2009;91(8):1854-60. https://doi.org/10.2106/JBJS.H.01475
3. Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular
calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2013;95(15):1351-7. https://doi.org/10.2106/JBJS.L.00759
4. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82(2):225-50.
https://doi.org/10.2106/00004623-200002000-00009
5. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;(290):87-95. PMID: 8472475
6. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma
2014;28(10):551-63. https://doi.org/10.1097/BOT.0000000000000169
7. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18(1):1-6. https://doi.org/10.1097/00005131-200401000-00001
8. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: analysis of
190 fractures. J Orthop Trauma 1999;13(5):369-72. https://doi.org/10.1097/00005131-199906000-00008
9. Harvey EJ, Grujic L, Early JS, Benirschke SK, Sangeorzan BJ. Morbidity associated with ORIF of intra-articular
calcaneus fractures using a lateral approach. Foot Ankle Int 2001;22(11):868-73. https://doi.org/10.1177/107110070102201102
10. Peng C, Yuan B, Guo W, Li N, Tian H. Extensile lateral versus sinus tarsi approach for calcaneal fractures: A metaanalysis. Medicine (Baltimore) 2021;100(31):e26717. https://doi.org/10.1097/MD.0000000000026717
11. Khazen G, Rassi CK. Sinus tarsi approach for calcaneal fractures: The new gold standard? Foot Ankle Clin
2020;25(4):667-681. https://doi.org/10.1016/j.fcl.2020.08.003
12. Ni M, Mei J, Li K, Niu W, Zhang M. The primary stability of different implants for intra-articular calcaneal
fractures: an in vitro study. Biomed Eng Online 2018;17(1):50. https://doi.org/10.1186/s12938-018-0484-6
13. Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, et al. Mini-open sinus tarsi approach with
percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography-based study. Foot Ankle Int 2012;33(11):925-33. https://doi.org/10.3113/FAI.2012.0925
14. Gallino RM, Gray AC, Buckley RE. The outcome of displaced intra-articular calcaneal fractures that involve the
calcaneocuboid joint. Injury 2009;40(2):146-9. https://doi.org/10.1016/j.injury.2008.10.021
15. Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma 2003;17(2):106-12. https://doi.org/10.1097/00005131-200302000-00005
16. Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int 1996;17(1):2-9. https://doi.org/10.1177/107110079601700102
17. Nosewicz TL, Dingemans SA, Backes M, Luitse JSK, Goslings JC, Schepers T. A systematic review and metaanalysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures. Foot Ankle Surg 2019;25(5):580-8. https://doi.org/10.1016/j.fas.2018.08.006
18. Weber M, Lehmann O, Sägesser D, Krause F. Limited open reduction and internal fixation of displaced intraarticular fractures of the calcaneum. J Bone Joint Surg Br 2008;90(12):1608-16. https://doi.org/10.1302/0301-620X.90B12.20638
19. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Minimally invasive technique versus an extensile lateral
approach for intra-articular calcaneal fractures. Foot Ankle Int 2013;34(6):773-80. https://doi.org/10.1177/1071100713477607
20. Nelson JD, McIff TE, Moodie PG, Iverson JL, Horton GA. Biomechanical stability of intramedullary technique for
fixation of joint depressed calcaneus fracture. Foot Ankle Int 2010;31(3):229-35. https://doi.org/10.3113/FAI.2010.0229
21. Wang Q, Zhang N, Guo W, Wang W, Zhang Q. Cannulated screw fixation versus plate fixation in treating displaced intra-articular calcaneus fractures: a systematic review and meta-analysis. Int Orthop 2021;45(9):2411-21. https://doi.org/10.1007/s00264-021-05141-y
22. Guo C, Xu Y, Li C, Li X, Wang Z, Cai M, et al. Comparing less invasive plate fixation versus screw fixation of
displaced intra-articular calcaneus fracture via sinus tarsi approach. Int Orthop 2021;45(9):2231-7.
https://doi.org/10.1007/s00264-020-04867-5
23. Pitts CC, Almaguer A, Wilson JT, Quade JH, Johnson MD. Radiographic and postoperative outcomes of plate versus screw constructs in open reduction and internal fixation of calcaneus fractures via the sinus tarsi. Foot Ankle Int 2019;40(8):929-35. https://doi.org/10.1177/1071100719848063
24. Weng QH, Dai GL, Tu QM, Liu Y, Lutchooman V, Hong JJ, et al. Comparison between percutaneous screw fixation and plate fixation via sinus tarsi approach for calcaneal fractures: An 8-10-year follow-up study. Orthop Surg 2020;12(1):124-32. https://doi.org/10.1111/os.12597
25. Driessen M, Edwards M, Biert J, Hermans E. Long-term results of displaced intra-articular calcaneal fractures
treated with minimal invasive surgery using percutaneous screw fixation. Injury 2021;52(4):1054-59.
https://doi.org/10.1016/j.injury.2020.12.003
26. Rodemund C, Krenn R, Kihm C, Leister I, Ortmaier R, Litzlbauer W, et al. Minimally invasive surgery for intraarticular calcaneus fractures: a 9-year, single-center, retrospective study of a standardized technique using a 2-point distractor. BMC Musculoskelet Disord 2020;21(1):753. https://doi.org/10.1186/s12891-020-03762-9
27. Shams A, Gamal O, Mesregah MK. Outcome of minimally invasive osteosynthesis for displaced intra-articular
calcaneal fractures using cannulated screws: A prospective case series. J Foot Ankle Surg 2021;60(1):55-60.
https://doi.org/10.1053/j.jfas.2020.06.017
reduction and internal fixation of calcaneal fractures with an extended lateral approach. Int Orthop 2014;38(4):767-73. https://doi.org/10.1007/s00264-013-2181-1
2. Potter MQ, Nunley JA. Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2009;91(8):1854-60. https://doi.org/10.2106/JBJS.H.01475
3. Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular
calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2013;95(15):1351-7. https://doi.org/10.2106/JBJS.L.00759
4. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82(2):225-50.
https://doi.org/10.2106/00004623-200002000-00009
5. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;(290):87-95. PMID: 8472475
6. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma
2014;28(10):551-63. https://doi.org/10.1097/BOT.0000000000000169
7. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18(1):1-6. https://doi.org/10.1097/00005131-200401000-00001
8. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: analysis of
190 fractures. J Orthop Trauma 1999;13(5):369-72. https://doi.org/10.1097/00005131-199906000-00008
9. Harvey EJ, Grujic L, Early JS, Benirschke SK, Sangeorzan BJ. Morbidity associated with ORIF of intra-articular
calcaneus fractures using a lateral approach. Foot Ankle Int 2001;22(11):868-73. https://doi.org/10.1177/107110070102201102
10. Peng C, Yuan B, Guo W, Li N, Tian H. Extensile lateral versus sinus tarsi approach for calcaneal fractures: A metaanalysis. Medicine (Baltimore) 2021;100(31):e26717. https://doi.org/10.1097/MD.0000000000026717
11. Khazen G, Rassi CK. Sinus tarsi approach for calcaneal fractures: The new gold standard? Foot Ankle Clin
2020;25(4):667-681. https://doi.org/10.1016/j.fcl.2020.08.003
12. Ni M, Mei J, Li K, Niu W, Zhang M. The primary stability of different implants for intra-articular calcaneal
fractures: an in vitro study. Biomed Eng Online 2018;17(1):50. https://doi.org/10.1186/s12938-018-0484-6
13. Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, et al. Mini-open sinus tarsi approach with
percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography-based study. Foot Ankle Int 2012;33(11):925-33. https://doi.org/10.3113/FAI.2012.0925
14. Gallino RM, Gray AC, Buckley RE. The outcome of displaced intra-articular calcaneal fractures that involve the
calcaneocuboid joint. Injury 2009;40(2):146-9. https://doi.org/10.1016/j.injury.2008.10.021
15. Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma 2003;17(2):106-12. https://doi.org/10.1097/00005131-200302000-00005
16. Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int 1996;17(1):2-9. https://doi.org/10.1177/107110079601700102
17. Nosewicz TL, Dingemans SA, Backes M, Luitse JSK, Goslings JC, Schepers T. A systematic review and metaanalysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures. Foot Ankle Surg 2019;25(5):580-8. https://doi.org/10.1016/j.fas.2018.08.006
18. Weber M, Lehmann O, Sägesser D, Krause F. Limited open reduction and internal fixation of displaced intraarticular fractures of the calcaneum. J Bone Joint Surg Br 2008;90(12):1608-16. https://doi.org/10.1302/0301-620X.90B12.20638
19. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Minimally invasive technique versus an extensile lateral
approach for intra-articular calcaneal fractures. Foot Ankle Int 2013;34(6):773-80. https://doi.org/10.1177/1071100713477607
20. Nelson JD, McIff TE, Moodie PG, Iverson JL, Horton GA. Biomechanical stability of intramedullary technique for
fixation of joint depressed calcaneus fracture. Foot Ankle Int 2010;31(3):229-35. https://doi.org/10.3113/FAI.2010.0229
21. Wang Q, Zhang N, Guo W, Wang W, Zhang Q. Cannulated screw fixation versus plate fixation in treating displaced intra-articular calcaneus fractures: a systematic review and meta-analysis. Int Orthop 2021;45(9):2411-21. https://doi.org/10.1007/s00264-021-05141-y
22. Guo C, Xu Y, Li C, Li X, Wang Z, Cai M, et al. Comparing less invasive plate fixation versus screw fixation of
displaced intra-articular calcaneus fracture via sinus tarsi approach. Int Orthop 2021;45(9):2231-7.
https://doi.org/10.1007/s00264-020-04867-5
23. Pitts CC, Almaguer A, Wilson JT, Quade JH, Johnson MD. Radiographic and postoperative outcomes of plate versus screw constructs in open reduction and internal fixation of calcaneus fractures via the sinus tarsi. Foot Ankle Int 2019;40(8):929-35. https://doi.org/10.1177/1071100719848063
24. Weng QH, Dai GL, Tu QM, Liu Y, Lutchooman V, Hong JJ, et al. Comparison between percutaneous screw fixation and plate fixation via sinus tarsi approach for calcaneal fractures: An 8-10-year follow-up study. Orthop Surg 2020;12(1):124-32. https://doi.org/10.1111/os.12597
25. Driessen M, Edwards M, Biert J, Hermans E. Long-term results of displaced intra-articular calcaneal fractures
treated with minimal invasive surgery using percutaneous screw fixation. Injury 2021;52(4):1054-59.
https://doi.org/10.1016/j.injury.2020.12.003
26. Rodemund C, Krenn R, Kihm C, Leister I, Ortmaier R, Litzlbauer W, et al. Minimally invasive surgery for intraarticular calcaneus fractures: a 9-year, single-center, retrospective study of a standardized technique using a 2-point distractor. BMC Musculoskelet Disord 2020;21(1):753. https://doi.org/10.1186/s12891-020-03762-9
27. Shams A, Gamal O, Mesregah MK. Outcome of minimally invasive osteosynthesis for displaced intra-articular
calcaneal fractures using cannulated screws: A prospective case series. J Foot Ankle Surg 2021;60(1):55-60.
https://doi.org/10.1053/j.jfas.2020.06.017