Joseph Noah M, Sinkler Margaret A, Magister Steven, Bacharach Abigail, Pang Aaron, Boes Kirsten, Vallier Heather A, Hirschfeld Adam G, Ochenjele George
Department of Orthopaedics, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
Department of Orthopaedics, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
Injury. 2023 Feb 23. doi: 10.1016/j.injury.2023.02.036.
Management of displaced intra-articular calcaneus fractures continues to challenge surgeons. Use of the extensile lateral surgical approach (ELA) had been standard practice however wound necrosis and infection have become deterrents. The sinus tarsi approach (STA) has gained popularity as a less invasive technique to optimize articular reduction while minimizing soft tissue injury. Our aim was to compare wound complications and infections following calcaneus fractures treated using ELA versus STA.
Retrospective review of 139 displaced intra-articular calcaneus fractures (AO/OTA 82C; Sanders II-IV injuries) treated operatively at 2 level-I trauma centers using STA (n = 84) or ELA (n = 55) over a 3-year period with minimum 1-year follow up was performed. Demographic, injury, and treatment-related characteristics were collected. Primary outcomes of interest included wound complications, infection, reoperation, and American Orthopaedic Foot and Ankle Society ankle and hindfoot scores. Univariate comparisons between groups were conducted using Chi-Square, Mann-Whitney, and independent sample t-tests at the p < 0.05 significance level, where appropriate. Multivariable regression analysis was performed to identify risk factors for poor outcomes.
Demographic characteristics were homogenous between cohorts. Most sustained falls from height (77%). Sanders III fractures were most common (42%). Patients treated with STA went to surgery earlier (6.0 days STA vs 13.2 ELA, p < 0.001). No differences were seen in restoration of Bohler's angle, varus/valgus angle, or calcaneal height, yet the ELA significantly improved calcaneal width (-2 mm STA vs -13.3 mm ELA, p < 0.001). There were no significant differences in wound necrosis or deep infection based on surgical approach (12% STA vs 22% ELA, p = 0.15). Seven patients underwent subtalar arthrodesis for arthrosis (4% STA vs 7% ELA). No differences in AOFAS scores were seen. Risk factors for reoperation included Sanders type IV patterns (OR = 6.6, p = 0.001), increasing BMI (OR = 1.2, p = 0.021), and advanced age (OR = 1.1, p = 0.005), not surgical approach.
Despite prior concerns, use of ELA versus STA for fixation of displaced intra-articular calcaneus fractures was not associated with more complication risk, illustrating both are safe when indicated and executed appropriately.
移位的关节内跟骨骨折的治疗一直是外科医生面临的挑战。采用外侧扩大入路（ELA）曾是标准术式，但伤口坏死和感染已成为阻碍因素。距下窦入路（STA）作为一种侵入性较小的技术，在优化关节复位同时减少软组织损伤方面越来越受欢迎。我们的目的是比较采用ELA与STA治疗跟骨骨折后的伤口并发症和感染情况。
回顾性分析在两家一级创伤中心接受手术治疗的139例移位的关节内跟骨骨折（AO/OTA 82C；Sanders II - IV型损伤），在3年期间采用STA（n = 84）或ELA（n = 55）治疗，随访至少1年。收集人口统计学、损伤及治疗相关特征。主要关注的结局包括伤口并发症、感染、再次手术以及美国矫形足踝协会踝关节和后足评分。在适当情况下，使用卡方检验、曼 - 惠特尼检验和独立样本t检验在p < 0.05显著性水平进行组间单因素比较。进行多变量回归分析以确定预后不良的危险因素。
队列间人口统计学特征相似。大多数为高处坠落伤（77%）。Sanders III型骨折最常见（42%）。接受STA治疗的患者更早接受手术（STA为6.0天，ELA为13.2天，p < 0.001）。在Bohler角、内翻/外翻角或跟骨高度的恢复方面未发现差异，但ELA显著改善了跟骨宽度（STA为 - 2mm，ELA为 - 13.3mm，p < 0.001）。基于手术入路的伤口坏死或深部感染无显著差异（STA为12%，ELA为22%，p = 0.15）。7例患者因关节病接受距下关节融合术（STA为4%，ELA为7%）。AOFAS评分未见差异。再次手术的危险因素包括Sanders IV型骨折（OR = 6.6，p = 0.001）、BMI增加（OR = 1.2，p = 0.021）和高龄（OR = 1.1，p = 0.005），而非手术入路。
尽管先前存在担忧，但采用ELA与STA固定移位的关节内跟骨骨折并不伴有更高的并发症风险，说明两者在适应证明确且操作适当时都是安全的。
