SLR - September 2023 - Malagic
Title: Does the postoperative quality of reduction, regardless of the surgical method used in treating a calcaneal fracture, influence patients’ functional outcomes?Reference: Sayyed-Hosseinian SH, Shirazinia M, Arabi H, Aghaee MA, Vahedi E, Bagheri F. Does the postoperative quality of reduction, regardless of the surgical method used in treating a calcaneal fracture, influence patients' functional outcomes? BMC Musculoskelet Disord. 2023 Jul 10;24(1):562. doi: 10.1186/s12891-023-06697-z. PMID: 37430205; PMCID: PMC10331959.
Level of Evidence: 3
Reviewed by: Murisa Malagic, DPM
Residency Program: SSM Health Depaul Hospital, Bridgeton, MO
Podiatric Relevance: Calcaneal fractures are the most common tarsal fracture. Malreduction or improper care of these fractures can lead to long term consequences such as osteoarthritis, chronic pain, and severe foot deformities. The literature remains mixed as to treatment protocols for fixing calcaneal fractures, and more specifically which surgical approach leads to better patient outcomes. This article evaluates the extensile lateral approach (ELA) and sinus tarsi approach (STA) utilizing functional outcome measures and pain scores. While it aims to provide a clearer picture as to which approach is superior, this study also evaluates the quality of the reduction on functional outcome.
Methods: This is a retrospective cohort study of a database of operatively treated Sanders type-II and type-III calcaneal fractures performed from March 2018 to March 2021 by a single surgeon in a single hospital. Inclusion criteria consisted of adult patients over the age of 18, closed fractures, fractures managed surgically utilizing the STA or ELA, and Sanders type-II and type-III fractures. Functional capacity was evaluated via the validated Manchester Oxford Foot Questionnaire (MOXFQ) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Pain was assessed utilizing the Visual analogue score (VAS). Anatomic reduction was evaluated utilizing CT imaging and radiographs obtained pre and post operatively and the quality of reduction was classified into four categories: excellent (anatomic), good, fair, and poor. Imaging was interpreted by a single foot and ankle surgeon.
Results: The study included 68 patients with 50 undergoing ELA and 18 undergoing STA. Reduction was excellent in 33 patients (48.5%), good in 26 (38.2%), fair in 8 (11.8%), and poor in one. Excellent reduction when compared to good, fair, or poor reduction was significantly associated with a decrease in MOXFQ, increase in AOFAS, and reduction in VAS. There was no significant difference between ELA and STA groups when evaluating functional (MOXFQ and AOFAS) and pain (VAS) scores. Secondary findings include a significant decrease in Gissane’s angle for the ELA group, but not for the STA group. All 6 (8.8%) wound complications occurred in the ELA group.
Conclusions: Based off the findings of this article, there is no significant difference in functional or pain scores between the ELA and STA for calcaneal fractures, suggesting that either technique could be utilized in treating calcaneal fractures with similar outcomes. All wound complications observed in this study occurred in the ELA group suggesting that a surgeon may prefer the STA in patients to decrease risk of possible wound complications. More importantly, excellent anatomic reduction is the key factor when addressing calcaneal fractures, as the authors found that excellent (anatomic) reduction of the posterior facet significantly correlated with improved functional scores compared to less than excellent reduction. This highlights the magnitude of importance in achieving near anatomic reduction on the functional and pain outcomes of patients. In conclusion, the surgical approach to calcaneal fractures is less important than achieving anatomic reduction.