SLR - July 2023 - Michaela K. Heys
Title: Soft Tissue Complications Following Extensile Lateral Compared with Minimally Invasive Surgical Approaches in the Operative Treatment of Calcaneus FracturesReference: Larose G, Tufescu T, Vidal R, Laxdal I. Soft tissue complications following extensile lateral compared with minimally invasive surgical approaches in the operative treatment of calcaneus fractures. Can J Surg. 2022 Nov 23;65(6)
Level of Evidence: 3- Retrospective Review
Scientific Literature Review
Reviewed By: Michaela K. Heys
Residency Program: Regions Hospital, Saint Paul Minnesota
Podiatric Relevance: Management of calcaneus fractures for foot and ankle surgeons has long been achieved through use of an extensile lateral approach (ELA). This incisional approach, however, has been associated with post-operative wound complications. A more minimally invasive surgical approach (MIS) has been gaining popularity as a way to reudce these soft tissue complications. There are multiple small case series documented in scientific literature comparing the wound healing complication rates between these two surgical approaches, however this particular study is the largest comparative study known to statistically analyze this topic.
Methods: A retrospective review of the medical records of all calcaneus fracture patients treated with ELA or MIS between July 2011- July 2018 was done at the authors institution. The ELA group was treated with standard L-shape approach with internal fixation of plates and screws. The MIS group surgical technique was either closed reduction with percutaneous screw fixation, sinus tarsi incision approach with a small fragment plate, or arthroscopic-assisted reduction and internal fixation with cannulated screws. Both groups received the same post-operative care in a non-weightbearing plaster splint. Soft tissue complications were characterized as a wound needing nonsurgical management while deep infections were those requiring surgical debridement.
Results: 52 patients were treated with ELA and 149 were treated with MIS. The mean surgical duration for the ELA group was 152.3 minutes compared to 99.6 minutes for the MIS group. At final follow up, 29% of patients in the ELA group had soft tissue complications compared to 8% of the MIS patients. 19% of the ELA group required an additional surgery while only 5% of the MIS patients did. The most common procedure for both groups was an irrigation and debridement only. Presence of an open fracture or use of the ELA was shown to be significant independent predictors for any soft tissue complication.
Conclusions: The use of the ELA is predictive of an increased incidence of soft tissue complications compared with MIS. Furthermore, the ELA and open fractures were found to be independent risk factors associated with soft tissue complications and requiring reoperation. This study suggests that selecting the ELA compared with the MIS approach for calcaneus fracture fixation puts patients at a higher risk of wound complications, thus higher risk for reoperation and should be avoided when possible. The treating surgeon should take this into consideration, as well as their ability to restore the anatomy of the calcaneus successfully through a minimally invasive approach.