Journal of

Orthopaedic
Article Surger y
Journal of Orthopaedic Surgery
27(2) 1–7
ª The Author(s) 2019
A modified tarsal sinus approach Article reuse guidelines:
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for intra-articular calcaneal fractures DOI: 10.1177/2309499019836165
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Junfeng Zhan1,2, Chuanzhen Hu3 , Nan Zhu2, Wang Fang2,

Juehua Jing2 and Gang Wang1

Abstract
Background: Plate fixation using traditional lateral L-shape approach for intra-articular calcaneal fractures is complicated
by 30% of wound complications, and the lateral small incision techniques with a tarsal sinus approach cannot sufficiently
address all the fragments. A modified tarsal sinus approach with combined advantages of traditional lateral L-shape and
tarsal sinus approaches for the treatment of intra-articular calcaneal fractures was developed. Method: This prospective
study included 29 patients (13 Sanders type II and 16 type III) with calcaneal fractures were managed with this technique.
Calcaneal height, width, length, Bohler’s angle, and Gissane angle were measured preoperatively, postoperatively, and at
1-year follow-up. Functional outcomes were assessed based on American Orthopedic Foot and Ankle Society (AOFAS)
ankle/hindfoot score. Results: Twenty-nine patients with average follow-up time of 18 (range 13–29) months were
included. The radiographs demonstrated significant corrections of the Bohler’s angle and Gissane angle, calcaneal width,
length, and height from preoperation to postoperation and 1-year follow-up. Among all follow-up patients, one case had
skin necrosis but healed after dressing. Another case had symptoms of numbness in the sural innervation area, which
disappeared after 5 months of physical therapy and drug therapy. One case showed degenerative changes of subtalar joint
at 1-year follow-up. No other wound complications like incision infection (superficial or deep) and wound dehiscence
occurred. At 1-year follow-up, the mean AOFAS score was 90.2 + 17.7 (range 70–98) and the good and excellent rate
was 89.7%. Conclusion: The modified tarsal sinus approach in the treatment of Sander’s type II and III calcaneal fractures
allowed adequate reduction and rigid fixation with low incidence of wound complications. Compared to sinus tarsi
approach, this technique required shorter learning curve and was more easily mastered by young orthopedic surgeons.
Thus, it was worthy of application clinically.

Keywords
calcaneal fractures, minimally invasive technique, soft tissue complications, tarsal sinus approach

Date received: 28 July 2018; Received revised 11 December 2018; accepted: 1 February 2019

Background
The extended lateral L-shaped approach is commonly used
for the treatment of calcaneal fractures. This approach
accurately reduces the subtalar joint, fully exposes, and
addresses the intra-articular calcaneal fragments and con-
veniently places the plate to achieve a stable fixation.1
However, the wound complications’ rates were reported
to be as high as 30%, including delayed wound healing,
infection, dehiscence, and flap necrosis.2 Thus, many mini-
mally invasive techniques have been developed, and sinus
tarsi approach being the most commonly used.3–5 This
1
Department of Orthopaedics and Traumatology, Nanfang Hospital,
Southern Medical University, Guangzhou, Guangdong Province, China
2
Department of Orthopaedics, The Second Affiliated Hospital of Anhui
Medical University, Hefei, Anhui Province, China
3
Department of Orthopaedics Surgery, Shanghai Tenth People’s Hospital
Affiliated to Tongji University, Shanghai, China
Corresponding authors:
Gang Wang, Department of Orthopaedics and Traumatology, Nanfang
Hosptital, Southern Medical University, Guangzhou 510515, Guangdong
Province, China.
Email: m18221853750@163.com
Chuanzhen Hu, Department of Orthopaedics Surgery, Shanghai Tenth
People’s Hospital Affiliated to Tongji University, Shanghai 200072, China.
Email: seak2007@sjtu.edu.cn

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2 Journal of Orthopaedic Surgery 27(2)
approach starts from the tip of the lateral malleolus in a
straight line toward the base of the fourth metatarsal,
mainly exposing the posterior facet and the calcaneocuboid
joint. Due to much smaller incisional design and no damage
to the blood supply of the calcaneal lateral flap, this tech-
nique effectively reduces the complications associated with
soft tissue and achieves good clinical efficacy.6 However,
this technique has problems, such as poor visualization,
inadequate reduction, and unreliable fixation, limiting its
use in the management of simple calcaneal fractures.7
Besides, a rich surgical experience is required for this tech-
nique, especially when addressing the complex intra-
articular calcaneal fractures, and thus this technique is hard
for young orthopedic surgeons. Therefore, designing a
modified approach combined with the advantages of tradi-
tional L-shape and sinus tarsi approaches to effectively
avoid soft tissue complications and to provide wide visua-
lization and rigid fixation has practical significance.
Therefore, we designed a modified sinus tarsi approach
that is located more distally to the tip of the lateral mal-
leolus along the calcaneal axis and extended from the base
of fourth metatarsal to 1 cm anterior of Achilles tendon.
This approach not only protected the blood supply of lateral
calcaneal flap but also provided wide exposure of the ante-
rior processes, calcaneocuboid joint, posterior facet, lateral
wall of calcaneus and three-fourth region of calcaneal
tuberosity. Besides, any plate (including traditional plates
used during the traditional L-shape approach) could be
placed using our modified sinus tarsi approach to acquire
rigid fixation. Because of its more wide exposure similar to
that of lateral L-shape approach, this approach could be
easily acquired by young orthopedic surgeons. Hence, in
the present study, we evaluated the outcomes of calcaneal
fractures after open reduction and internal fixation through
modified sinus tarsi approach.
Methods
This was a level IV prospective analytical study performed
from May 2014 to April 2016. A total of 29 patients (24
males and 5 females) of intra-articular calcaneal fractures
(Sander’s type II and III calcaneal fractures) were treated
with open reduction and internal fixation through a modi-
fied sinus tarsi approach. Inclusion criteria included
patients of Sander’s type II and III calcaneal fractures ages
18–75 years. Exclusion criteria include Sander’s type I and
IV fractures, open calcaneal fractures, and those with age
<18 and >75 years. All the surgeries were performed by
Dr Zhan Junfeng (an orthopedic resident). All patients had
anteroposterior, lateral, and axial X-ray views of both
injured and normal calcaneus; also, a CT scan of the frac-
tured site to classify the fracture patterns.
Of the 29 patients, one had a fracture in a traffic accident
and rest of them were due to fall from height. All fractures
were unilateral, with left side involvement in 16 cases and
right side in 13 cases. According to Sanders CT scan
classification system, there were 13 cases with type II (5
type IIA, 6 type IIB, and 2 type IIC) and 16 with type III (6
type IIIAB, 6 type IIIAC, and 4 type IIIBC). In addition, the
lumbar vertebral or thoracic vertebral fracture was compli-
cated in four cases, tibial plateau fracture in two cases,
femoral neck fracture in two cases, and ankle fracture in
one case. Fourteen patients had >5 years smoking history,
and five patients had a history of excessive consumption of
alcohol, and they were advised to stop smoking and abstain
from alcohol until wound healing. Two other patients had
diabetes, and their blood glucose levels were controlled to
prevent further complications. This study was conducted in
accordance with the declaration of Helsinki. This study was
conducted with approval from the Ethics Committee of
Nanfang hospital, Southern Medical University. Written
informed consent was obtained from all participants.
Surgery
All patients were administered with continuous epidural
anesthesia or general anesthesia. All of them were operated
in supine position. The brief steps of the operation were as
follows: (1) Incision: Firstly, the lateral malleolus, the fifth
metatarsal base, and sural nerves were marked. Then, a
transverse incision was made 1.5 cm distally to the tip of
the lateral malleolus along the calcaneal axis; starting from
the base of fourth metatarsal to 1 cm anterior of the Achilles
tendon (Figure 1(a)). The incision crossed over the peroneus
longus, and brevis tendon sheath and sural nerve require
separation and protection in this approach (Figure 1(b)).
We defined the operation visual field by peroneus tendon
sheath boundary as the anterior window (the one anterior of
the peroneus tendon sheath) and posterior window (the one
posterior to tendon sheath; Figure 1(c)). (2) Field exposure:
With the posterior traction of the peroneus tendon sheath can
expose the anterior window that includes the anterior pro-
cess, the calcaneocuboid articular and posterior facet (Figure
1(d)). By partly cutting the calcaneofibular ligament, poster-
ior facet and collapsed fracture blocks were completely
exposed (Figure 1(e)). To explore posterior window, we
anteriorly retract the peroneus tendon sheath and use a Hoff-
mann retractor to retract soft tissue posteriorly; this window
exposes body of the calcaneus and three-fourth region of the
anterior tubercle of the calcaneus (Figure 1(f)). (3) Fracture
reduction: A large Steinmann pin placed into tuberosity frag-
ment directed posteriorly to correct the Varus loss of height
and length. Once the tuberosity was reduced, place a Kirsch-
ner wire posterolateral from tuberosity into the medial sus-
tentaculum tali to provide provisional fixation and checked
under a fluoroscope to confirm fixation. Then, through the
posterior window, the lateral wall was dissected from the
calcaneal body and removed. A periosteum elevator was
used to displace the posterior facet fragment through the
medial fracture line. Later the articular surface is also
checked; if not, reduce it through the anterior window and
provide a provisional fixation by Kirschner wire
Zhan et al. 3

underneath the posterior facet and into the sustentacu-
lum tali from the lateral to the medial side. (4) Plate
fixation: Once a satisfied reduction was obtained and
take an intraoperative axial view to confirm neutral
alignment before application of the plate, then apply a
lateral plate that extends from the anterior process of
calcaneus into the most posterior aspect of tuberosity
through the anterior window (Figure 1(g)). The wound
was closed (Figure 1(h) and (i)).
day, the patients began to perform ankle dorsal flexion
function exercise. At week 4 after operation, partial weight
bearing was encouraged. Full weight bearing was allowed
until the signs of bone union were observed on the radio-
graph at weeks 10–12 postoperatively.
Anteroposterior, lateral, and axial radiographs were also
obtained postoperatively at 1, 3, 6, 12 months, and at the
latest follow-up period. American Orthopaedic Foot and
Ankle Society (AOFAS) ankle/hindfoot score was calcu-
lated at 1-year follow-up for all the cases.

Postoperative treatment
Postoperatively, the prophylactic antibiotics were given to Statistical analysis
prevent operative site infections. On the postoperative 3rd Statistical analysis was carried out using SPSS19.0 soft-
ware (SPSS, Chicago, Illinois, USA). Data are presented
Table 1. Demographic data of 29 patients with calcaneal as means + standard deviation (SD). Preoperative, post-
fractures. operative, and the last follow-up variables were compared
Frequency count (%)
using Student’s paired t test. p < 0.05 was considered to be
Characteristics or mean + SD statistically significant difference.

Sex
Female 5 (17.2%) Results
Male 24 (82.8%)
Age (year) 40 + 15 The average follow-up period of 29 patients was 18 (range,
Side 13–29) months, and the average age of the patients was 40
Left 16 (55.2%) + 15 (range 18–60) years. The average time between injury
Right 13 (44.8%) and surgery was 5.6 + 3.4 (range 1–9) days. The operation
Injury mechanism time was 79 + 20 (range 58–100) min. The average fracture
Fall from a height 28 (96.6) healing time was 11 + 4 (range 9–15) weeks (Table 1).
Traffic accidents 1 (3.4%)
Sanders classification
The lateral and axial radiographs of the calcaneus
Type IIA 5 (17.2%) showed good reduction and fixation, and significant correc-
Type IIB 6 (20.7%) tions of the Bohler’s angle, and Gissane angle, calcaneal
Type IIC 2 (6.9%) width, length, and height from preoperation to postopera-
Type IIIAB 6 (20.7%) tion and 1-year follow-up (p < 0.01). However, there were
Type IIIAC 6 (20.7%) no significant differences in the variables between
Type IIIBC 4 (13.8%)
History
Smoking 14 (48.2%) Table 3. Complications after surgery.
Diabetes 2 (6.9%) Complications Patients (number)
Excessive consumption of alcohol 5 (17.2%)
Complicated other fractures Superficial infection 0
Tibial plateau 2 (6.9%) Deep infection 0
Lumbar vertebra or thoracic vertebra 4 (13.8%) Skin necrosis 1
Femoral neck 2 (6.9%) Wound dehiscence 0
Ankle 1 (3.4%) Paresthesia over lateral aspect of foot 1
Time between injury and surgery (day) 8.6 + 3.1 Degenerative changes of subtalar joint 1
Operation time (min) 79.0 + 19.8 Loss of reduction of fracture 0
Fracture healing time (week) 10.8 + 3.8 Stimulation of screws 0

Table 2. Radiological results before and after operation.a

Group Bohler’s angle ( ) Gissane angle ( ) Calcaneal length (mm) Calcaneal width (mm) Calcaneal height (mm)

Preoperative 12.8 + 4.8 90.3 + 12.8 58.2 + 4.9 36.7 + 5.7 30.7 + 6.1
Postoperative 29.4 + 3.6b 121.3b + 10.4 63.7 + 3.7b 32.7 + 5.9b 34.3 + 4.9b
Last follow-up 29.4 + 3.3b 121.6 + 10.3b 65.7 + 5.7b 32.2 + 2.3b 34.4 + 1.6b
a
There was no statistical difference between the postoperative group and the last follow-up group.
b
p < 0.01: compared with the preoperative group.
4 Journal of Orthopaedic Surgery 27(2)

Figure 1. (a) The skin incision. (a0 ) lateral malleolus, (b0 ) the fifth metatarsal, (c0 ) sural nerve, and (d0 ) incision marker. (b) Sural nerve
was separated and protected. (c) The operation visual field was separated into double operative fields by peroneus tendon sheath. (a0 )
the anterior window and (b0 ) the posterior window. (d) With posterior traction of the peroneus tendon sheath, the anterior process
(a0 ) the calcaneocuboid articular (b0 ) and posterior facet (c0 ) were exposed in the anterior window. (e) By partly cutting off the
calcaneofibular ligament, posterior facet and collapsed fracture blocks were completely exposed. (f) With anterior traction of the
peroneus tendon sheath, the lateral wall of the calcaneus and three-fourth region of the calcaneal tuberosity were exposed in
the posterior window. (g) A neutralization plate was easily placed on the lateral wall through the anterior window. (h) The skin was
sutured. (i) Incision scar at 4-week follow-up visit.

postoperation and 1-year follow-up (Table 2). Among all
the follow-up patients, one case (3.4%) had skin necrosis
and healed after dressing. Another case (3.4%) showed
symptoms of numbness in the area of sural innervation,
which disappeared after 5 months of physical therapy and
drug therapy. One case (3.4%) showed degenerative
changes of subtalar joint at 1-year follow-up. No other
wound complications such as incision infection (superficial
or deep) and wound dehiscence occurred (Table 3).
At 1-year follow-up, the mean AOFAS score was 90.2
+ 17.7 (range 70–98), which was excellent in 20 cases,
good in 6 cases, and fair in 3 cases, and the good and
excellent rate was 89.7% (Figure 2 and Figure 3).
Discussion
The surgical treatment effects of calcaneal fracture vary
with the surgical approach and operative methods and the
incision complications directly affected the clinical results.
Previously, the extended lateral L-shaped approach has
been widely used for plate fixation of calcaneal fractures
and 60–85% of cases showed satisfactory clinical out-
comes; however, it is accompanied by high risk of soft
tissue complications.1 This approach devascularized the
central and anterior part of the calcaneal lateral wall, as
45% of the total blood supply of the calcaneus enters from
this site.8 Soft tissue complications reached 11–24.6%,
leading to a serious impact on the treatment of calcaneal
fractures.9 To solve the soft tissue complications related to
extended lateral L-shaped approach, several lateral mini-
mally invasive techniques with sinus tarsi approach for
treating calcaneal fractures were developed.3,4,10 Although
the soft tissue problem has been minimized with the use of
these techniques, issues of poor visualization, inadequate
reduction, and unreliable fixation should be addressed.11
Thus, we developed a modified approach by combining
the advantage of wide surgical field of extended lateral
L-shaped approach and the advantage of soft tissue protec-
tion of sinus tarsi approach.
According to the previous reports,12,13 the subcutaneous
tissues of the lateral hindfoot had two sets of blood supply
systems: the above flap was supplied by the lateral
Zhan et al. 5

Figure 2. (a) Schematic representation of the surgical incision for calcaneal fractures. Tarsal sinus approach: an incision of 4–5 cm
length is made from the tip of the lateral malleolus to the level of the calcaneocuboid joint in a straight line toward the base of the fourth
metatarsal. Modified tarsal sinus approach: a transverse incision is made 1.5 cm distally to the tip of the lateral malleolus along the
calcaneal axis, starting from the base of fourth metatarsal to 1 cm anterior of Achilles tendon. Extended L-shaped approach: the
posterior arm of the line is placed in between the Achilles tendon and the posterior margin of the fibula, parallel to the longitudinal axis
of the limb. The horizontal arm of the line is extended to the base of the fifth metatarsal, parallel to the plantar surface. (b) Schematic
view of anterior window of modified tarsal sinus approach. (1) Collapsed posterior facet, (2) anterior process, (3) talus, (4) calca-
neocuboid joint are visualized through the anterior window. (c) Schematic view of the posterior window of modified tarsal sinus
approach. Lateral wall of calcaneal and three-fourth region of calcaneal tuberosity are visualized through the posterior window.

calcaneal artery and the lateral malleolar artery, while the
tarsal side tissue was supplied by the lateral tarsal artery.
The lateral calcaneal artery was proximal to the vertical
portion of the traditional L-shaped incision, and it appeared
to be the most likely injured site due to inaccurate placement
of the incision. Besides, the horizontal incision of traditional
L-shaped incision damaged the vascular network from the
plantar flap. Thus, if the lateral calcaneal artery was
occluded during the injury or suffered iatrogenic injury, it
causes lateral flap vascular network destruction, blood sup-
ply damage, and soft tissue healing complications. Bibbo
et al. used preoperative ultrasound to determine if the lateral
calcaneal artery was the main blood supply artery for lateral
flap, and lateral calcaneal artery injury was closely related to
wound healing complications.14 In the present study, our
modified sinus tarsi approach by taking into consideration
that the lateral hindfoot anatomy and blood supply effec-
tively avoided the damage to plantar blood vessels net and
protected the lateral calcaneal artery in operation and prom-
ised the blood supply of the lateral flap.
In addition, compared to sinus tarsi approach, this mod-
ified approach had advantages in surgical field exposure,
fracture reduction, and fixation. Due to limited exposure of
the posterior facet and calcaneocuboid joint in sinus tarsi
approach, the collapsed posterior facet was indirectly
reduced through medial distraction technique and for the
comminuted fracture of the calcaneal body, the exposure
remained insufficient and difficult for the reduction and
fixation. Thus, this technique was challenging and required
a thorough understanding of the fracture patterns and cal-
caneal anatomy and should be performed by experienced
surgeons. In addition, fixation was achieved by screws,
K-wires, or minitype plate via sinus tarsi approach, and this
may not provide reliable fixation for comminuted calcaneal
fractures, calcaneal fractures with severely compressed
articular surface, and osteoporotic fractures in the elderly
patients. The visualization of fracture according to our
modified sinus tarsi approach was similar to that of the
traditional extended lateral L-shaped approach. A wide
exposure of anterior process, calcaneocuboid joint, poster-
ior facet, lateral wall of calcaneus, and three-fourth region
of calcaneal tuberosity could be obtained via double win-
dow in our approach. The reduction and fixation technique
was also similar to that of the extended lateral L-shaped
approach. Posterior facet and calcaneocuboid joint could be
directly visualized through anterior window of our
approach, while the posterior facet fragment was visualized
through posterior window and was directly reduced after
opening the calcaneal lateral wall. Therefore, this tech-
nique was easy for beginners to understand and master and
6 Journal of Orthopaedic Surgery 27(2)

Figure 3. Preoperative lateral (a) and axial (b) radiographs showing an intra-articular calcaneal fracture in a 37-year-old man who had
fallen from a height. Preoperative computed tomography images (c and d) showing a Sanders IIAB fractures with a bulked lateral wall.
Postoperative lateral (e) and axial (f) radiographs showing anatomical restoration of the subtalar joint.

did not require longer learning curve. Besides, through the
anterior window of our approach, traditional calcaneal
plate was easily placed on the lateral wall for rigid fixation
of comminuted calcaneal fractures, calcaneal fractures with
severely compressed articular surface, and osteoporotic
fractures in the elderly patients.
In our study, Bohler’s angle, Gissane angle, calcaneal
length, width, and height were significantly improved from
preoperation to postoperation after surgery with a p value
of <0.01. This indicated that anatomical reconstruction of
calcaneal fractures including length, width, height, Boh-
ler’s angle, and Gissane angle could be achieved with open
reduction and plate fixation through our modified sinus
tarsi approach. Better reduction of the calcaneus may result
in the better recovery of foot function. In our study, the
mean AOFAS ankle/hindfoot score was 90.2 + 17.7 (range
70–98), and the good and excellent rate was 89.7%. The
time for fracture healing was 10.8 + 3.8 (range 9–15)
weeks. Only one case showed degenerative changes of sub-
talar joint at 1-year follow-up period. Our results were
comparable with the results achieved using other minimally
invasive techniques.11,15
Among all the follow-up patients, only one case
(3.4%) had skin flap necrosis but was healed after dres-
sing. Another case (3.4%) had symptoms of numbness in
the area of sural innervations, which were disappeared
after 5 months of physical therapy and drug therapy. Our
results seemed to be superior to the results achieved
using sinus tarsi approach. In a systematic review of
calcaneal fractures treated with sinus tarsi approach, the
average rate of wound complication was 4.8%.16 Kiku-
chi et al. reported three cases (13.6%) with superficial
wound infections.4 Kline et al. had wound complications
in 29% of the extensile group and 6% of the sinus tarsi
group.17 Che et al. demonstrated that 3 out of 47 cases
(6.4%) had minor wound complications, and 7 cases
(14.9%) had painful hardware at the posterior calcaneal
tuberosity.18
The incision of our modified sinus tarsi approach was
small and the skin flap was not required during the sur-
gery, and thus operation through swollen tissue was less
concerned. We performed the operation as early as possi-
ble, even in the presence of swelling, without any exces-
sive soft tissue complications. For patients with Sanders
type II calcaneal fractures without serious swelling, the
operation was performed within 24 h after the fracture.
For patients with Sanders type III calcaneal fractures with
serious swelling, the operation was performed as earlier as
possible from 5 to 9 days after the fracture. The average
time interval between the injury and operation was 5.6 +
Zhan et al.
3.4 (range 1–9) days in our study, which was a relatively
short time interval for surgery.
Our study has several limitations including the small
number of cases, the short follow-up time, lack of long-
term curative effects, and prospective case–control study
design. Therefore, further investigation is necessary to
obtain a more precise efficacy evaluation by studying in
a larger sample size, longer follow-up time, and a rando-
mized control trial.
Conclusions
In conclusion, compared to the sinus tarsi approach, the
modified sinus tarsi approach could obtain wider exposure
and provide rigid fixation for Sander’s type II and III cal-
caneal fractures, limiting the soft tissue complications.
Furthermore, compared to the sinus tarsi approach, this
technique required short learning curve and can be easily
mastered by beginners. Hence, it was worthy of application
in clinics.
Authors’ note
The data sets supporting the conclusions of the article are included
within the article.
Author contributions
ZJF and HCZ contributed to this work equally as first author. WG,
HCZ, and JJH conceived and designed the study and drafted the
manuscript. All the operations were performed by ZJF. ZN and
FW collected the data and performed the statistical analysis. All
of the authors read and approved the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: This study was supported in part by Grants from
Shanghai Tenth hospital’s improvement plan for NSFC
(SYGZRPY2017021).
ORCID iD
Chuanzhen Hu https://orcid.org/0000-0002-1802-8875
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