Minimally invasive internal fixation of Sanders Ⅳ calcaneal fractures using tarsal sinus plate and cannulated screw

Minimally invasive internal fixation of Sanders Ⅳ calcaneal fractures using tarsal sinus plate and cannulated screw | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Minimally invasive internal fixation of Sanders Ⅳ calcaneal fractures using tarsal sinus plate and cannulated screw Jiandong Lin, Zhaofeng Jia, Xinjia Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4516307/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Jan, 2026 Read the published version in BMC Surgery → Version 1 posted 3 You are reading this latest preprint version Abstract Objectives This study aimed to assess the clinical efficacy of combining tarsal sinus plates with cannulated screw-based minimally invasive internal fixation for the management of Sanders type IV calcaneal fractures. Methods Between January 2019 and July 2023, we conducted a retrospective analysis of 32 cases involving Sanders type IV calcaneal fractures treated by our medical team. The treatment approach involved the utilization of tarsal sinus plates in conjunction with minimally invasive internal fixation using cannulated screws. Among the cases analyzed, there were 16 males and 16 females, with an average age of 34.5 years (ranging from 21 to 50 years). We observed and recorded key parameters, including operative duration, intraoperative blood loss, postoperative complications, preoperative and immediate postoperative calcaneal width, calcaneal Bohler angle, and Gissane angle. Additionally, we conducted a review and documented the healing progress six months postoperatively. Pain levels were assessed using the visual analogue scale (VAS) before the procedure and at the final follow-up, while foot function was evaluated using the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle Hindfoot Scale. Results The mean operative time for the 32 patients was 100.5 min (ranging from 62 to 144 min), with an average blood loss of 80 ml (ranging from 61 to 110 ml). Importantly, all fractures achieved union, with a 100% success rate, and no adverse complications were recorded. Postoperative X-ray imaging revealed statistically significant improvements in calcaneal width, Bohler angle, and Gissane angle compared to preoperative measurements (P < 0.05). All patients were subject to follow-up assessments, with the average follow-up duration being 18 months (ranging from 12 to 24 months). At the final follow-up, patients reported a notably lower VAS pain score of 1.3 ± 0.2 points, a statistically significant reduction (P < 0.05) when compared to preoperative values. Furthermore, the average AOFAS score at this stage was 84.4 ± 6.3 points, also demonstrating a statistically significant improvement compared to preoperative scores (P < 0.05). Conclusion Combining tarsal sinus plates with cannulated screw-based minimally invasive internal fixation is an effective treatment modality for Sanders type IV calcaneal fractures. This approach offers several advantages, including minimal trauma, a low risk of postoperative infection, reduced likelihood of soft tissue necrosis in the skin flap, superior fracture reduction and fixation, expedited functional recovery, and a reduced incidence of postoperative complications. Sanders type Ⅳ calcaneal fracture tarsal sinus plate cannulated screw minimally invasive clinical efficacy Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The calcaneus, serving as the primary structural component of the plantar aspect of the foot, constitutes the largest bone in the foot's skeletal framework and is predominantly composed of cancellous bone. Calcaneal fractures, while relatively infrequent, account for approximately 1–2% of all skeletal fractures. In recent years, there has been a noteworthy rise in the incidence of Sanders type IV calcaneal fractures, mainly attributed to an increase in high-energy traumatic incidents. Sanders type IV calcaneal fractures pertain to fractures of the posterior facet of the calcaneus, which are characterized by the presence of four or more fragmented articular components, often referred to as four-part intra-articular fractures. These fractures exhibit a pronounced degree of comminution and carry a substantial risk of residual deformity [ 1 ]. For the management of Sanders type IV calcaneal fractures, the conventional approach has involved open reduction and internal fixation utilizing an "L"-shaped incision technique [ 2 ]. However, this approach is often confronted with challenges in achieving precise anatomical realignment of the articular surface. Additionally, the use of steel plates and internal fixation in open reduction via the "L"-shaped incision can result in complications such as soft tissue flap necrosis, post-traumatic arthritis, postoperative wound infections, and, in severe cases, conditions like calcaneal osteomyelitis. This approach tends to yield less-than-optimal treatment outcomes [ 3 ]. Therefore, the surgical treatment of Sanders type IV calcaneal fractures remains a formidable clinical challenge. In 2000, Ebraheim introduced the sinus tarsi incision technique for the clinical treatment of calcaneal fractures. This technique, involving reduction and internal fixation through a sinus tarsi incision, has progressively emerged as a minimally invasive approach for addressing calcaneal fractures [ 4 , 5 ]. However, it should be noted that its applicability is predominantly limited to Sanders Type II and Sanders III calcaneal fractures. From January 2019 to July 2021, our medical team adopted a minimally invasive internal fixation approach employing tarsal sinus plates in conjunction with cannulated screws for the treatment of 32 cases of Sanders type IV calcaneal fractures. Subsequently, we conducted a comprehensive retrospective analysis of these cases, examining their clinical outcomes and experiences. Patients and methods General information Inclusion criteria: (1) Individuals aged less than 70 years were considered eligible for participation in the study. (2) Eligible participants were required to exhibit clinical presentations and signs indicative of calcaneal fracture, with confirmation of the fracture through both X-ray and CT imaging. Specifically, the calcaneal fracture type needed to be classified as Sanders type IV. (3) The surgical intervention adopted in this study involved the utilization of a tarsal sinus incision plate combined with cannulated screw fixation. Exclusion criteria: (1) Patients presenting with open fractures, fractures of the ipsilateral limb other than calcaneal fractures, vascular or nerve injuries, or severe skin and soft tissue injuries were excluded from the study. (2) Individuals with calcaneal fractures resulting from pathological causes were also excluded. The study protocol underwent a rigorous review and received approval from the Medical Ethics Committee of Shenzhen People's Hospital, Jinan University. Furthermore, informed consent was diligently obtained from all study participants. The minimum duration of the follow-up period was set at 18 months. (Typical cases can be seen in Fig. 1 ). Surgical methods Under either intralesional or general anesthesia, the patient is positioned in a supine manner with elevation of the affected side's kidney. A pneumatic tourniquet is applied to the affected thigh, and the surgical field of the affected limb is disinfected using 2% tincture of iodine and 75% alcohol. A sterile surgical towel is routinely placed. A transverse surgical incision, approximately 6 cm in length, is made from 1 cm below the tip of the outer ankle to the base of the fourth metatarsal. The skin and subcutaneous soft tissues are sequentially incised, exposing the lateral wall of the calcaneus. Subperiosteal dissection is performed along the lateral wall of the calcaneus, extending both upwards and downwards. This dissection maneuver raises the peroneal long and short tendons along with the skin flap, revealing the subtalar joint and the calcaneocuboid joint. If necessary, the affected ankle joint can be rotated inward, or a Steinmann pin can be inserted into the calcaneus tuberosity to enhance exposure of the subtalar joint. During the surgery, a thorough evaluation is conducted under direct visual guidance, assessing the collapse of both the subtalar joint surface and calcaneocuboid joint surface, as well as the angle of the calcaneal tubercle. Fracture fragments are gently manipulated and repositioned, especially in cases of comminuted or collapsed subtalar and calcaneocuboid joints. Following these steps, a tarsal sinus plate (Swiss Synthes) is positioned externally on the calcaneus after restoring the calcaneus tuberosity angle. Subsequently, eight screws (Swiss Synthes) are inserted in a sequential manner to ensure proper fixation. A cannulated screw is then introduced, originating from the calcaneal tubercle and extending towards the front of the calcaneus. Additionally, a cannulated screw (Synthes, Switzerland) is inserted along the vertical fracture line, proceeding from the exterior to the interior at the posterior and inferior border of the calcaneus. This serves to stabilize the calcaneal body fracture fragment. The reduction of the fracture and the angle of the calcaneal tubercle are assessed using C-arm X-ray fluoroscopy. To conclude the surgical procedure, the incision site is thoroughly irrigated with 0.5% iodophor disinfectant and saline. Hemostasis is ensured before proceeding to suture the wound layer by layer, with the placement of a single drainage tube in the surgical opening. (Figure 2 ) Postoperative Treatment Following the surgical procedure, the affected limb was elevated, and ice application, as well as medication administration, were employed to mitigate the risk of infection, reduce swelling, and manage pain. The drainage tube was subsequently removed 24 h post-surgery. During the initial three days post-surgery, the patient was encouraged to engage in active toe flexion and extension exercises while receiving intravenous analgesia. Additionally, exercises targeting subtalar joint function through circular movements were prescribed. Beyond the third day following surgery, the patient was assisted in transitioning out of bed with the aid of supports. However, it was still necessary for the patient to maintain bed rest with continued elevation of the affected limb. Indicators of evaluation The following parameters were recorded: age, gender, operation duration, blood loss, postoperative complications, as well as preoperative and postoperative X-ray measurements, including calcaneal width, Bohler Angle, Angle of Gissane. Additionally, X-ray assessments for fracture healing were conducted at the 1, 3, and 6-month postoperative intervals. During the final follow-up, patient pain levels were evaluated utilizing the VAS, which employs a scale ranging from 0 (indicating no pain) to 10 (signifying excruciating pain). The assessment of foot functional recovery was carried out using the AOFAS Ankle-Hindfoot Scoring System, which comprises ten criteria: pain, function, voluntary movement and support, maximum walking distance, ground walking, abnormal gait, anterior and posterior movement, hindfoot movement, ankle-hindfoot stability, and foot alignment. The total score attainable is 100 points, with scores categorized as follows: excellent (90–100 points), good (75–89 points), fair (50–74 points), and poor (below 50 points). Statistical Analysis Statistical analysis was performed using SPSS 26.0 software. Measurement data are presented as mean ± standard deviation (x̄ ± s ). Paired-Samples T Test was employed for the analysis of measurement data, with a two-sided significance level (α) set at 0.05, and significance indicated by P < 0.05. Results General Results A total of 32 patients participated in this study, with a follow-up duration ranging from 12 to 24 months and an average follow-up period of 18 months. The age of the patients ranged from 20 to 51 years, with a mean age of 34 years. The study cohort comprised 16 males (50%) and 16 females (50%). The surgical procedures had an operative duration ranging from 62 to 114 min, with an average operative time of 70.5 min. Intraoperative blood loss ranged from 61 to 110 ml, with an average blood loss of 80 ml. All patients exhibited delayed wound healing postoperatively, along with complications such as infections or necrosis. ( Table 1 ) Imaging findings All fractures had fully healed six months post-operation. Immediate postoperative X-ray examinations revealed a reduction in calcaneal width from 34.15 ± 2.58 mm prior to surgery to 30.49 ± 2.37 mm following the procedure (P < 0.05). The preoperative Bohler Angle measured (14.16 ± 3.27) °, and it significantly increased to (31.95 ± 3.07) ° postoperatively (P < 0.05). Additionally, the preoperative Gissane Angle recorded (128.45 ± 9.04) °, which subsequently decreased to (120.83 ± 8.15) ° after the operation (P < 0.05). ( Table 2 , see Fig. 3 for typical cases) Clinical treatment effect All patients were subject to follow-up assessments for an average duration of 18 months, within a range of 12 to 24 months. In the final follow-up evaluation, the VAS score exhibited a notable decrease from 7.6 ± 0. Moreover, the AOFAS score demonstrated a substantial increase, rising from an initial value of 15.68 ± 4.73 to 88.32 ± 2.65 (P < 0.05). Specifically, 25 cases achieved an excellent outcome, while 5 feet exhibited a good outcome, and 2 feet had a fair outcome. The overall success rate reached 95.9%.(Table 3 , Fig. 4 ) Discussion Calcaneal fractures often result from high-energy direct trauma, such as falls from heights and traffic accidents. In recent years, with the growth of the construction industry, incidents involving falls from significant heights have been on the rise, leading to a notable increase in severe, comminuted calcaneal fractures, including Sanders IV type fractures [ 6 ]. The calcaneus, a critical weight-bearing structure for upright ambulation, exhibits a higher morbidity rate when afflicted with Sanders IV type fractures [ 7 ]. However, there remains a lack of consensus in the clinical community regarding the optimal treatment approach for Sanders IV calcaneal fractures [ 8 , 9 ]. Traditional treatment methods involve employing an "L"-shaped incision to facilitate open reduction and internal plate fixation for Sanders IV calcaneal fractures. This approach offers the advantage of visualizing the fracture site directly, aiding in precise reduction, and promoting the restoration of normal heel height, Gissane Angle, and Bohler Angle. Nevertheless, due to the substantial subsidence and comminution often accompanying Sanders IV fractures, achieving precise anatomical reduction of the joint surface proves challenging with the "L"-shaped incision. Additionally, this approach may lead to suboptimal lateral flap coverage of the heel bone and necessitates extensive soft tissue dissection, jeopardizing the local blood supply around the calcaneus and adversely impacting flap vascularization, thereby impeding postoperative wound healing [ 10 , 11 ]. Christoph Eckstein has expressed concerns regarding the "L"-shaped incision approach, citing prolonged preoperative wait times, postoperative infections, skin necrosis, and the potential for traumatic arthritis [ 12 ]. Likewise, Huang Zhusong et al. have noted that although the "L"-shaped incision approach for open reduction and internal fixation with plates offers comprehensive exposure of the lateral calcaneus and articular surface, it is associated with a high incidence of postoperative skin necrosis and incisional infections [ 13 ]. Therefore, the tarsal sinus approach, as championed by Ebraheim, has emerged as a representative minimally invasive method for treating calcaneal fractures post-surgery. Attilio Basile et al. contend that both the tarsal sinus incision approach and the traditional lateral "L"-shaped incision approach yield similar postoperative results in terms of Bohler Angle recovery, anatomical reduction, AOFAs scores, and VAS scores. Nevertheless, the tarsal sinus approach offers notable advantages in terms of shorter operative times, reduced hospital stays, and quicker postoperative foot function recovery [ 14 ]. Furthermore, Andreas Brand et al. have found no significant differences in early biomechanical and functional results between calcaneal fractures treated with the tarsal sinus incision approach and those treated with the "L"-shaped incision approach. However, the tarsal sinus approach appears to better restore dynamic foot function, making it a preferable alternative to the "L"-shaped incision approach [ 15 ]. Shengli Xia, following a randomized controlled trial involving 108 patients with calcaneal fractures within the last three years, asserts that the tarsal sinus incision is situated in a region with a robust blood supply, resulting in a smaller surgical incision and less intraoperative dissection. This approach minimizes the impact on the surrounding soft tissue and vascular supply, culminating in shorter operative times compared to the traditional "L"-shaped incision and promoting superior foot functional recovery [ 16 ]. Currently, both domestic and international clinical research primarily focuses on the minimally invasive internal fixation of calcaneal fractures using tarsal sinus plates for Sanders type II fractures and some Sanders type III fractures [ 17 ]. It is noteworthy that minimally invasive internal fixation with tarsal sinus plates is suitable exclusively for Sanders type II calcaneal fractures and select Sanders type III calcaneal fractures. Li Zhichao [ 18 ] et al. ventured into innovative territory by exploring the use of the tarsal sinus approach for open reduction and internal fixation in treating Sanders type IV calcaneal fractures. However, their investigation was confined to Sanders type IV calcaneal fractures characterized by the primary fracture fragment of the articular surface exceeding 5mm. This approach necessitated lengthy surgical procedures and culminated in relatively diminished AOFAS ankle and hindfoot function scores during the final follow-up. To address these limitations, the author proposes a method involving a hollow fixed fracture block to simplify the treatment by transforming Sanders type IV calcaneal fractures into Sanders type III or even Sanders type II fractures, thereby reducing procedural complexity. Furthermore, the utilization of cannulated screws for calcaneal fracture fixation requires minimal demands on skin and soft tissue, resulting in shorter wait times, reduced preoperative and intraoperative damage to soft tissue around the fracture site, and a conducive environment for fracture healing. Additionally, the minimally invasive nature of cannulated screws, with their countersunk heads when inserted into the calcaneus, virtually eliminates tension on the skin surface, promoting postoperative wound healing and mitigating postoperative discomfort [19]. Nevertheless, cannulated screws alone may not provide effective recovery and support when the fracture extends distally from the articular surface [20, 21]. In such cases, plate fixation combined with the tarsal sinus approach is essential to ensure stability. Our research team has successfully employed the tarsal sinus plate in minimally invasive internal fixation treatment for hollow Sanders type IV calcaneal fractures, yielding satisfactory clinical outcomes. This approach, combining minimally invasive internal fixation with tarsal sinus plates and cannulated screws for Sanders type IV calcaneal fractures, essentially accomplishes anatomical reduction of the calcaneal articular surface, effectively restoring normal calcaneal dimensions, Bohler Angle, and Gissane Angle, ultimately leading to fracture healing. The procedure offers the advantages of shorter surgical duration, reduced bleeding, a lower incidence of adverse complications, and favorable functional recovery. The tarsal sinus plate combined with minimally invasive internal fixation for hollow Sanders type IV calcaneal fractures presents several advantages: (1) The tarsal sinus incision, extending from the external ankle to within 1 cm of the fourth metatarsal base, and positioned between the anterior tibial and peroneal arteries, is closer to the dorsalis pedis artery. This region offers excellent soft tissue coverage, abundant flap blood supply, and minimizes the extent of soft tissue dissection during surgery compared to the "L"-shaped lateral incision [22]. (2) The sinus tarsi incision aligns parallel to the inferior peroneal longus and brevis tendons, sural nerve, and small saphenous vein, maintaining a safe distance from the lateral calcaneal artery, calcaneofibular ligament, and subperoneal retinaculum. This technique obviates the need to sever the calcaneofibular ligament and subperoneal retinaculum, reduces the risk of injuring the sural nerve, and has minimal impact on calcaneus blood supply [23]. (3) This procedure is well-suited for patients with challenging medical conditions like diabetes and heavy smoking, or those with compromised local soft tissue conditions, such as significant swelling or tension blister formation. None of these conditions contraindicate the tarsal sinus plate combined with cannulated screw fixation, leading to shorter preoperative wait times [23]. (4) The porous cancellous bone in the lateral wall of the calcaneus may not offer sufficient fixation strength following fracture reduction. Hollow nail fixation primarily targets the anterior aspect of the heel bone, including the calcaneal tubercle and adjacent trabecular bone with enhanced density. This reinforcement bolsters internal fixation [24]. Consequently, tarsal sinus plate combined with hollow minimally invasive internal fixation effectively maintains the height and length of the calcaneal bone, particularly in cases of severe comminuted Sanders type IV calcaneal fractures. (5) For severe comminuted Sanders type IV calcaneal fractures, hollow nail fixation along different fracture lines enhances stability and can even downgrade the fracture complexity from Sanders type IV to Sanders type III or even Sanders type II fractures. This extends the indications for minimally invasive internal fixation with tarsal sinus plates [25]. (6) The dual fixation approach with tarsal sinus plates and cannulated screws not only preserves postoperative calcaneal dimensions, Bohler Angle, and Gissane Angle but also provides stable support for the articular surface, reducing the need for extensive bone grafts in cases of articular surface collapse. This study exhibits several limitations that warrant consideration. Firstly, the study's scope is restricted due to the performance of minimally invasive internal fixation solely for Sanders type IV calcaneal fractures utilizing tarsal sinus plates and cannulated screws. Consequently, the study features a limited sample size and a relatively brief surgical duration. Additionally, the investigation exclusively concentrated on Sanders type IV calcaneal fractures, with the absence of a control group for comparative analysis. Moreover, despite an 18-month follow-up period (ranging from 12 to 24 months), we acknowledge that this timeframe may not be sufficiently long to comprehensively assess the development of complications accurately. Summary The utilization of the tarsal sinus plate in minimally invasive internal fixation for hollow Sanders type IV calcaneal fractures offers significant advantages in both anatomical and physiological aspects, as well as demonstrating favorable biomechanical effects in the treatment of Sanders type IV calcaneal fractures, ultimately leading to positive clinical outcomes. However, it is important to note that this surgical procedure is notably challenging, with a relatively limited surgical field exposure, necessitating a substantial learning curve. Successful execution of the procedure demands a surgeon with a considerable degree of expertise in fracture fragment manipulation to prevent reduction failures or complications arising from improper techniques. Furthermore, it is essential to acknowledge that the limited case volume in this study underscores the necessity for future prospective investigations involving larger sample sizes to provide a more comprehensive understanding of the procedure's outcomes. Declarations Funding Natural Science Foundation of China (Grant Number: 81902196), Shenzhen Science and Technology Projects (Grant Number: JCYJ20220530152214032；JCYJ20220530152213030; JCYJ20190806160014794). Availability of data and materials All the data and materials can be found in the manuscript. Ethics approval and consent to participate The study was approved by the ethics committee at Shenzhen People’s Hospital and was conducted in accordance with the Protocol of Helsinki. Informed consent was signed by the relatives of the patients. Consent for publication All authors have approved the publication of the data. Competing interests The authors declare that they have no competing interests. Author details 1 Department of Orthopaedic trauma, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology) 2 Shenzhen Clinical Research Center for Geriatrics, Shenzhen People’s Hospital. References Mehta CR, An VVG, Phan K, Sivakumar B, Kanawati AJ, Suthersan M. Extensile lateral versus sinus tarsi approach for displaced, intra-articular calcaneal fractures: a meta-analysis. J Orthop Surg Res. 2018 Sep 24;13(1):243. doi: 10.1186/s13018-018-0943-6. PMID: 30249288; PMCID: PMC6154938. Weinraub GM, David MS. Sinus Tarsi Approach with Subcutaneously Delivered Plate Fixation for Displaced Intra-Articular Calcaneal Fractures. Clin Podiatr Med Surg. 2019 Apr;36(2):225-231. doi: 10.1016/j.cpm.2018.10.005. Epub 2019 Jan 24. PMID: 30784533. Zhou HC, Yu T, Ren HY, Li B, Chen K, Zhao YG, Yang YF. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Jan, 2026 Read the published version in BMC Surgery → Version 1 posted Editor assigned by journal 10 Jun, 2024 Submission checks completed at journal 10 Jun, 2024 First submitted to journal 02 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4516307","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":313507521,"identity":"37675e66-3ca2-45a8-b2a6-822e836c3b6c","order_by":0,"name":"Jiandong Lin","email":"","orcid":"","institution":"ShenZhen People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiandong","middleName":"","lastName":"Lin","suffix":""},{"id":313507522,"identity":"e6b68e6f-0259-4d7c-a285-47ae1fb74a25","order_by":1,"name":"Zhaofeng Jia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBACPgYehgM8DECSvbHhwIcKCTl5QlrY4Fp4Dh88OOOMhbFhAxFaQIiBQSIt+TBnW0UiwwFCWtjPHjzwpuawjDlDjsFhxnkSCYwNzA8f3cCnhScv4eCcY2k8lg1nDA4XbpPIY2dgMzbOweswoOE8bDY8Bgd7DA7P3CZRzNjAwyaNVwv/G6CWfxI8QNLgMO8cicSGA4S0SABt4W0D2nKMLeEwbwNRWt4lHJzbl8ZjcIb5wMEZxySMDZsJ+IWfP/fwhzffDtsb3H/Y/OFDTZ2cPHvzw8f4tGABzKQpHwWjYBSMglGABQAAaLlOdJT9i4IAAAAASUVORK5CYII=","orcid":"","institution":"ShenZhen People’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zhaofeng","middleName":"","lastName":"Jia","suffix":""},{"id":313507523,"identity":"e11b935d-aa4e-4d80-b7d3-30ec2c404b48","order_by":2,"name":"Xinjia Hu","email":"","orcid":"","institution":"ShenZhen People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xinjia","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2024-06-02 08:44:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4516307/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4516307/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-02916-7","type":"published","date":"2026-01-05T15:59:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59514376,"identity":"8519e2f0-9d68-47d1-a25e-cf3a300fc4c2","added_by":"auto","created_at":"2024-07-02 17:26:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":381567,"visible":true,"origin":"","legend":"\u003cp\u003eMale, 41 years old, with Sanders Ⅳ calcaneal fracture.\u003c/p\u003e\n\u003cp\u003e(A) Preoperative Ortho x-rays;（B）Preoperative lateral x-rays ; (C、D) ; Preoperative coronal and sagittal CT scans; (E、F) 3D reconstruction results.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4516307/v1/e8f504b2656bb5ffb88b3a4b.png"},{"id":59515862,"identity":"a140fba1-8e8c-41bd-9797-1212fa375648","added_by":"auto","created_at":"2024-07-02 17:34:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":608196,"visible":true,"origin":"","legend":"\u003cp\u003eMale, 41 years old, with Sanders Ⅳ calcaneal fracture.\u003c/p\u003e\n\u003cp\u003e(A、B、C) Intraoperative operation image ;（D、E、F）Intraoperative fluoroscopy image.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4516307/v1/76c85a1e9db4dcf03c5db7d5.png"},{"id":59514374,"identity":"4eaace63-a7cc-44e7-a31b-da76651d251e","added_by":"auto","created_at":"2024-07-02 17:26:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":395477,"visible":true,"origin":"","legend":"\u003cp\u003eMale, 41 years old, with Sanders Ⅳ calcaneal fracture.\u003c/p\u003e\n\u003cp\u003e(A) results of lateral calcaneal X-ray examination immediately after operation; (B) immediately after heel bone shaft position X-ray results; (C) results of lateral calcaneal X-ray at 6 months after operation; (D) results of axial calcaneal X-ray examination at 6 months after operation; (E) results of lateral calcaneal X-ray examination after removal of internal fixation; (F) results of axial X-ray examination of calcaneus after removal of internal fixation.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4516307/v1/a0cc1c3d4272c24672b2430d.png"},{"id":59514373,"identity":"33cb13c3-7cd0-4fc0-ab48-52d30311ab33","added_by":"auto","created_at":"2024-07-02 17:26:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":322921,"visible":true,"origin":"","legend":"\u003cp\u003eMale, 41 years old, with Sanders Ⅳ calcaneal fracture.\u003c/p\u003e\n\u003cp\u003e(A) Resting position ;（B）Functional position ;(C) Dorsiflexion; (D) Plantar flexion.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4516307/v1/bc780dd2535d59cd77562da1.png"},{"id":100069482,"identity":"70bbd5f8-e4d8-400d-90ea-66e0fe39b8be","added_by":"auto","created_at":"2026-01-12 16:14:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3164871,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4516307/v1/ca650fb6-3715-4577-9003-26ad91cb4586.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimally invasive internal fixation of Sanders Ⅳ calcaneal fractures using tarsal sinus plate and cannulated screw","fulltext":[{"header":"Background","content":"\u003cp\u003eThe calcaneus, serving as the primary structural component of the plantar aspect of the foot, constitutes the largest bone in the foot's skeletal framework and is predominantly composed of cancellous bone. Calcaneal fractures, while relatively infrequent, account for approximately 1\u0026ndash;2% of all skeletal fractures. In recent years, there has been a noteworthy rise in the incidence of Sanders type IV calcaneal fractures, mainly attributed to an increase in high-energy traumatic incidents. Sanders type IV calcaneal fractures pertain to fractures of the posterior facet of the calcaneus, which are characterized by the presence of four or more fragmented articular components, often referred to as four-part intra-articular fractures. These fractures exhibit a pronounced degree of comminution and carry a substantial risk of residual deformity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For the management of Sanders type IV calcaneal fractures, the conventional approach has involved open reduction and internal fixation utilizing an \"L\"-shaped incision technique [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, this approach is often confronted with challenges in achieving precise anatomical realignment of the articular surface. Additionally, the use of steel plates and internal fixation in open reduction via the \"L\"-shaped incision can result in complications such as soft tissue flap necrosis, post-traumatic arthritis, postoperative wound infections, and, in severe cases, conditions like calcaneal osteomyelitis. This approach tends to yield less-than-optimal treatment outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, the surgical treatment of Sanders type IV calcaneal fractures remains a formidable clinical challenge.\u003c/p\u003e \u003cp\u003eIn 2000, Ebraheim introduced the sinus tarsi incision technique for the clinical treatment of calcaneal fractures. This technique, involving reduction and internal fixation through a sinus tarsi incision, has progressively emerged as a minimally invasive approach for addressing calcaneal fractures [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, it should be noted that its applicability is predominantly limited to Sanders Type II and Sanders III calcaneal fractures. From January 2019 to July 2021, our medical team adopted a minimally invasive internal fixation approach employing tarsal sinus plates in conjunction with cannulated screws for the treatment of 32 cases of Sanders type IV calcaneal fractures. Subsequently, we conducted a comprehensive retrospective analysis of these cases, examining their clinical outcomes and experiences.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eGeneral information\u003c/h2\u003e\n \u003cp\u003eInclusion criteria: (1) Individuals aged less than 70 years were considered eligible for participation in the study. (2) Eligible participants were required to exhibit clinical presentations and signs indicative of calcaneal fracture, with confirmation of the fracture through both X-ray and CT imaging. Specifically, the calcaneal fracture type needed to be classified as Sanders type IV. (3) The surgical intervention adopted in this study involved the utilization of a tarsal sinus incision plate combined with cannulated screw fixation.\u003c/p\u003e\n \u003cp\u003eExclusion criteria: (1) Patients presenting with open fractures, fractures of the ipsilateral limb other than calcaneal fractures, vascular or nerve injuries, or severe skin and soft tissue injuries were excluded from the study. (2) Individuals with calcaneal fractures resulting from pathological causes were also excluded.\u003c/p\u003e\n \u003cp\u003eThe study protocol underwent a rigorous review and received approval from the Medical Ethics Committee of Shenzhen People\u0026apos;s Hospital, Jinan University. Furthermore, informed consent was diligently obtained from all study participants. The minimum duration of the follow-up period was set at 18 months. (Typical cases can be seen in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eSurgical methods\u003c/h2\u003e\n \u003cp\u003eUnder either intralesional or general anesthesia, the patient is positioned in a supine manner with elevation of the affected side\u0026apos;s kidney. A pneumatic tourniquet is applied to the affected thigh, and the surgical field of the affected limb is disinfected using 2% tincture of iodine and 75% alcohol. A sterile surgical towel is routinely placed. A transverse surgical incision, approximately 6 cm in length, is made from 1 cm below the tip of the outer ankle to the base of the fourth metatarsal. The skin and subcutaneous soft tissues are sequentially incised, exposing the lateral wall of the calcaneus. Subperiosteal dissection is performed along the lateral wall of the calcaneus, extending both upwards and downwards. This dissection maneuver raises the peroneal long and short tendons along with the skin flap, revealing the subtalar joint and the calcaneocuboid joint. If necessary, the affected ankle joint can be rotated inward, or a Steinmann pin can be inserted into the calcaneus tuberosity to enhance exposure of the subtalar joint. During the surgery, a thorough evaluation is conducted under direct visual guidance, assessing the collapse of both the subtalar joint surface and calcaneocuboid joint surface, as well as the angle of the calcaneal tubercle. Fracture fragments are gently manipulated and repositioned, especially in cases of comminuted or collapsed subtalar and calcaneocuboid joints. Following these steps, a tarsal sinus plate (Swiss Synthes) is positioned externally on the calcaneus after restoring the calcaneus tuberosity angle. Subsequently, eight screws (Swiss Synthes) are inserted in a sequential manner to ensure proper fixation. A cannulated screw is then introduced, originating from the calcaneal tubercle and extending towards the front of the calcaneus. Additionally, a cannulated screw (Synthes, Switzerland) is inserted along the vertical fracture line, proceeding from the exterior to the interior at the posterior and inferior border of the calcaneus. This serves to stabilize the calcaneal body fracture fragment. The reduction of the fracture and the angle of the calcaneal tubercle are assessed using C-arm X-ray fluoroscopy. To conclude the surgical procedure, the incision site is thoroughly irrigated with 0.5% iodophor disinfectant and saline. Hemostasis is ensured before proceeding to suture the wound layer by layer, with the placement of a single drainage tube in the surgical opening. (Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003ePostoperative Treatment\u003c/h2\u003e\n \u003cp\u003eFollowing the surgical procedure, the affected limb was elevated, and ice application, as well as medication administration, were employed to mitigate the risk of infection, reduce swelling, and manage pain. The drainage tube was subsequently removed 24 h post-surgery.\u003c/p\u003e\n \u003cp\u003eDuring the initial three days post-surgery, the patient was encouraged to engage in active toe flexion and extension exercises while receiving intravenous analgesia. Additionally, exercises targeting subtalar joint function through circular movements were prescribed. Beyond the third day following surgery, the patient was assisted in transitioning out of bed with the aid of supports. However, it was still necessary for the patient to maintain bed rest with continued elevation of the affected limb.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eIndicators of evaluation\u003c/h2\u003e\n \u003cp\u003eThe following parameters were recorded: age, gender, operation duration, blood loss, postoperative complications, as well as preoperative and postoperative X-ray measurements, including calcaneal width, Bohler Angle, Angle of Gissane. Additionally, X-ray assessments for fracture healing were conducted at the 1, 3, and 6-month postoperative intervals.\u003c/p\u003e\n \u003cp\u003eDuring the final follow-up, patient pain levels were evaluated utilizing the VAS, which employs a scale ranging from 0 (indicating no pain) to 10 (signifying excruciating pain).\u003c/p\u003e\n \u003cp\u003eThe assessment of foot functional recovery was carried out using the AOFAS Ankle-Hindfoot Scoring System, which comprises ten criteria: pain, function, voluntary movement and support, maximum walking distance, ground walking, abnormal gait, anterior and posterior movement, hindfoot movement, ankle-hindfoot stability, and foot alignment. The total score attainable is 100 points, with scores categorized as follows: excellent (90\u0026ndash;100 points), good (75\u0026ndash;89 points), fair (50\u0026ndash;74 points), and poor (below 50 points).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analysis was performed using SPSS 26.0 software. Measurement data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (x̄ \u0026plusmn; s ). Paired-Samples T Test was employed for the analysis of measurement data, with a two-sided significance level (\u0026alpha;) set at 0.05, and significance indicated by P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eGeneral Results\u003c/h2\u003e\n \u003cp\u003eA total of 32 patients participated in this study, with a follow-up duration ranging from 12 to 24 months and an average follow-up period of 18 months. The age of the patients ranged from 20 to 51 years, with a mean age of 34 years. The study cohort comprised 16 males (50%) and 16 females (50%). The surgical procedures had an operative duration ranging from 62 to 114 min, with an average operative time of 70.5 min. Intraoperative blood loss ranged from 61 to 110 ml, with an average blood loss of 80 ml. All patients exhibited delayed wound healing postoperatively, along with complications such as infections or necrosis. ( Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img171929856514.png\"\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eImaging findings\u003c/h2\u003e\n \u003cp\u003eAll fractures had fully healed six months post-operation. Immediate postoperative X-ray examinations revealed a reduction in calcaneal width from 34.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58 mm prior to surgery to 30.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.37 mm following the procedure (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The preoperative Bohler Angle measured (14.16\u0026thinsp;\u0026plusmn;\u0026thinsp;3.27) \u0026deg;, and it significantly increased to (31.95\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07) \u0026deg; postoperatively (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, the preoperative Gissane Angle recorded (128.45\u0026thinsp;\u0026plusmn;\u0026thinsp;9.04) \u0026deg;, which subsequently decreased to (120.83\u0026thinsp;\u0026plusmn;\u0026thinsp;8.15) \u0026deg; after the operation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). \u003cstrong\u003e(\u003c/strong\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cstrong\u003esee\u003c/strong\u003e Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cstrong\u003efor typical cases)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1719298565.png\"\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical treatment effect\u003c/h2\u003e\n \u003cp\u003eAll patients were subject to follow-up assessments for an average duration of 18 months, within a range of 12 to 24 months. In the final follow-up evaluation, the VAS score exhibited a notable decrease from 7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0. Moreover, the AOFAS score demonstrated a substantial increase, rising from an initial value of 15.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73 to 88.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Specifically, 25 cases achieved an excellent outcome, while 5 feet exhibited a good outcome, and 2 feet had a fair outcome. The overall success rate reached 95.9%.(Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1719298564.png\"\u003e\u003cbr\u003e\u003c/p\u003e\n\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCalcaneal fractures often result from high-energy direct trauma, such as falls from heights and traffic accidents. In recent years, with the growth of the construction industry, incidents involving falls from significant heights have been on the rise, leading to a notable increase in severe, comminuted calcaneal fractures, including Sanders IV type fractures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The calcaneus, a critical weight-bearing structure for upright ambulation, exhibits a higher morbidity rate when afflicted with Sanders IV type fractures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, there remains a lack of consensus in the clinical community regarding the optimal treatment approach for Sanders IV calcaneal fractures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Traditional treatment methods involve employing an \"L\"-shaped incision to facilitate open reduction and internal plate fixation for Sanders IV calcaneal fractures. This approach offers the advantage of visualizing the fracture site directly, aiding in precise reduction, and promoting the restoration of normal heel height, Gissane Angle, and Bohler Angle. Nevertheless, due to the substantial subsidence and comminution often accompanying Sanders IV fractures, achieving precise anatomical reduction of the joint surface proves challenging with the \"L\"-shaped incision. Additionally, this approach may lead to suboptimal lateral flap coverage of the heel bone and necessitates extensive soft tissue dissection, jeopardizing the local blood supply around the calcaneus and adversely impacting flap vascularization, thereby impeding postoperative wound healing [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Christoph Eckstein has expressed concerns regarding the \"L\"-shaped incision approach, citing prolonged preoperative wait times, postoperative infections, skin necrosis, and the potential for traumatic arthritis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Likewise, Huang Zhusong et al. have noted that although the \"L\"-shaped incision approach for open reduction and internal fixation with plates offers comprehensive exposure of the lateral calcaneus and articular surface, it is associated with a high incidence of postoperative skin necrosis and incisional infections [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the tarsal sinus approach, as championed by Ebraheim, has emerged as a representative minimally invasive method for treating calcaneal fractures post-surgery. Attilio Basile et al. contend that both the tarsal sinus incision approach and the traditional lateral \"L\"-shaped incision approach yield similar postoperative results in terms of Bohler Angle recovery, anatomical reduction, AOFAs scores, and VAS scores. Nevertheless, the tarsal sinus approach offers notable advantages in terms of shorter operative times, reduced hospital stays, and quicker postoperative foot function recovery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, Andreas Brand et al. have found no significant differences in early biomechanical and functional results between calcaneal fractures treated with the tarsal sinus incision approach and those treated with the \"L\"-shaped incision approach. However, the tarsal sinus approach appears to better restore dynamic foot function, making it a preferable alternative to the \"L\"-shaped incision approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Shengli Xia, following a randomized controlled trial involving 108 patients with calcaneal fractures within the last three years, asserts that the tarsal sinus incision is situated in a region with a robust blood supply, resulting in a smaller surgical incision and less intraoperative dissection. This approach minimizes the impact on the surrounding soft tissue and vascular supply, culminating in shorter operative times compared to the traditional \"L\"-shaped incision and promoting superior foot functional recovery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, both domestic and international clinical research primarily focuses on the minimally invasive internal fixation of calcaneal fractures using tarsal sinus plates for Sanders type II fractures and some Sanders type III fractures [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. It is noteworthy that minimally invasive internal fixation with tarsal sinus plates is suitable exclusively for Sanders type II calcaneal fractures and select Sanders type III calcaneal fractures. Li Zhichao [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] et al. ventured into innovative territory by exploring the use of the tarsal sinus approach for open reduction and internal fixation in treating Sanders type IV calcaneal fractures. However, their investigation was confined to Sanders type IV calcaneal fractures characterized by the primary fracture fragment of the articular surface exceeding 5mm. This approach necessitated lengthy surgical procedures and culminated in relatively diminished AOFAS ankle and hindfoot function scores during the final follow-up. To address these limitations, the author proposes a method involving a hollow fixed fracture block to simplify the treatment by transforming Sanders type IV calcaneal fractures into Sanders type III or even Sanders type II fractures, thereby reducing procedural complexity. Furthermore, the utilization of cannulated screws for calcaneal fracture fixation requires minimal demands on skin and soft tissue, resulting in shorter wait times, reduced preoperative and intraoperative damage to soft tissue around the fracture site, and a conducive environment for fracture healing. Additionally, the minimally invasive nature of cannulated screws, with their countersunk heads when inserted into the calcaneus, virtually eliminates tension on the skin surface, promoting postoperative wound healing and mitigating postoperative discomfort [19]. Nevertheless, cannulated screws alone may not provide effective recovery and support when the fracture extends distally from the articular surface [20, 21]. In such cases, plate fixation combined with the tarsal sinus approach is essential to ensure stability. Our research team has successfully employed the tarsal sinus plate in minimally invasive internal fixation treatment for hollow Sanders type IV calcaneal fractures, yielding satisfactory clinical outcomes. This approach, combining minimally invasive internal fixation with tarsal sinus plates and cannulated screws for Sanders type IV calcaneal fractures, essentially accomplishes anatomical reduction of the calcaneal articular surface, effectively restoring normal calcaneal dimensions, Bohler Angle, and Gissane Angle, ultimately leading to fracture healing. The procedure offers the advantages of shorter surgical duration, reduced bleeding, a lower incidence of adverse complications, and favorable functional recovery. The tarsal sinus plate combined with minimally invasive internal fixation for hollow Sanders type IV calcaneal fractures presents several advantages: (1) The tarsal sinus incision, extending from the external ankle to within 1 cm of the fourth metatarsal base, and positioned between the anterior tibial and peroneal arteries, is closer to the dorsalis pedis artery. This region offers excellent soft tissue coverage, abundant flap blood supply, and minimizes the extent of soft tissue dissection during surgery compared to the \"L\"-shaped lateral incision [22]. (2) The sinus tarsi incision aligns parallel to the inferior peroneal longus and brevis tendons, sural nerve, and small saphenous vein, maintaining a safe distance from the lateral calcaneal artery, calcaneofibular ligament, and subperoneal retinaculum. This technique obviates the need to sever the calcaneofibular ligament and subperoneal retinaculum, reduces the risk of injuring the sural nerve, and has minimal impact on calcaneus blood supply [23]. (3) This procedure is well-suited for patients with challenging medical conditions like diabetes and heavy smoking, or those with compromised local soft tissue conditions, such as significant swelling or tension blister formation. None of these conditions contraindicate the tarsal sinus plate combined with cannulated screw fixation, leading to shorter preoperative wait times [23]. (4) The porous cancellous bone in the lateral wall of the calcaneus may not offer sufficient fixation strength following fracture reduction. Hollow nail fixation primarily targets the anterior aspect of the heel bone, including the calcaneal tubercle and adjacent trabecular bone with enhanced density. This reinforcement bolsters internal fixation [24]. Consequently, tarsal sinus plate combined with hollow minimally invasive internal fixation effectively maintains the height and length of the calcaneal bone, particularly in cases of severe comminuted Sanders type IV calcaneal fractures. (5) For severe comminuted Sanders type IV calcaneal fractures, hollow nail fixation along different fracture lines enhances stability and can even downgrade the fracture complexity from Sanders type IV to Sanders type III or even Sanders type II fractures. This extends the indications for minimally invasive internal fixation with tarsal sinus plates [25]. (6) The dual fixation approach with tarsal sinus plates and cannulated screws not only preserves postoperative calcaneal dimensions, Bohler Angle, and Gissane Angle but also provides stable support for the articular surface, reducing the need for extensive bone grafts in cases of articular surface collapse.\u003c/p\u003e \u003cp\u003eThis study exhibits several limitations that warrant consideration. Firstly, the study's scope is restricted due to the performance of minimally invasive internal fixation solely for Sanders type IV calcaneal fractures utilizing tarsal sinus plates and cannulated screws. Consequently, the study features a limited sample size and a relatively brief surgical duration. Additionally, the investigation exclusively concentrated on Sanders type IV calcaneal fractures, with the absence of a control group for comparative analysis. Moreover, despite an 18-month follow-up period (ranging from 12 to 24 months), we acknowledge that this timeframe may not be sufficiently long to comprehensively assess the development of complications accurately.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSummary\u003c/h2\u003e \u003cp\u003eThe utilization of the tarsal sinus plate in minimally invasive internal fixation for hollow Sanders type IV calcaneal fractures offers significant advantages in both anatomical and physiological aspects, as well as demonstrating favorable biomechanical effects in the treatment of Sanders type IV calcaneal fractures, ultimately leading to positive clinical outcomes. However, it is important to note that this surgical procedure is notably challenging, with a relatively limited surgical field exposure, necessitating a substantial learning curve. Successful execution of the procedure demands a surgeon with a considerable degree of expertise in fracture fragment manipulation to prevent reduction failures or complications arising from improper techniques. Furthermore, it is essential to acknowledge that the limited case volume in this study underscores the necessity for future prospective investigations involving larger sample sizes to provide a more comprehensive understanding of the procedure's outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNatural Science Foundation of China (Grant Number: 81902196), Shenzhen Science and Technology Projects (Grant Number:\u003c/p\u003e\n\u003cp\u003eJCYJ20220530152214032；JCYJ20220530152213030; JCYJ20190806160014794).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data and materials can be found in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee at Shenzhen People\u0026rsquo;s Hospital and was conducted in accordance with the Protocol of Helsinki. Informed consent was signed by the relatives of the patients.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have approved the publication of the data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Orthopaedic trauma, Shenzhen People\u0026rsquo;s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eShenzhen Clinical Research Center for Geriatrics, Shenzhen People\u0026rsquo;s Hospital.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMehta CR, An VVG, Phan K, Sivakumar B, Kanawati AJ, Suthersan M. Extensile lateral versus sinus tarsi approach for displaced, intra-articular calcaneal fractures: a meta-analysis. J Orthop Surg Res. 2018 Sep 24;13(1):243. doi: 10.1186/s13018-018-0943-6. PMID: 30249288; PMCID: PMC6154938.\u003c/li\u003e\n\u003cli\u003eWeinraub GM, David MS. Sinus Tarsi Approach with Subcutaneously Delivered Plate Fixation for Displaced Intra-Articular Calcaneal Fractures. Clin Podiatr Med Surg. 2019 Apr;36(2):225-231. doi: 10.1016/j.cpm.2018.10.005. Epub 2019 Jan 24. PMID: 30784533.\u003c/li\u003e\n\u003cli\u003eZhou HC, Yu T, Ren HY, Li B, Chen K, Zhao YG, Yang YF. Clinical Comparison of Extensile Lateral Approach and Sinus Tarsi Approach Combined with Medial Distraction Technique for Intra-Articular Calcaneal Fractures. Orthop Surg. 2017 Feb;9(1):77-85. doi: 10.1111/os.12310. Epub 2017 Mar 9. PMID: 28276647; PMCID: PMC6584293.\u003c/li\u003e\n\u003cli\u003eEbraheim NA , Elgafy H , Sabry FF , et al . Sinus tarsi approach with transartieular fixation for displaced intra-artieular fractures of the ealcaneus IJ . Foot Ankle Int ,2000,88(11):1474-1479\u003c/li\u003e\n\u003cli\u003eSchepers T. Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures. Clin Podiatr Med Surg. 2019 Apr;36(2):211-224. doi: 10.1016/j.cpm.2018.10.004. Epub 2019 Jan 24. PMID: 30784532.\u003c/li\u003e\n\u003cli\u003eCottom JM, Douthett SM, McConnell KK. Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures. Clin Podiatr Med Surg. 2019 Apr;36(2):269-277. doi: 10.1016/j.cpm.2018.10.008. Epub 2019 Jan 24. PMID: 30784536.\u003c/li\u003e\n\u003cli\u003eRodemund C, Krenn R, Kihm C, Leister I, Ortmaier R, Litzlbauer W, Schwarz AM, Mattiassich G. Minimally invasive surgery for intra-articular calcaneus fractures: a 9-year, single-center, retrospective study of a standardized technique using a 2-point distractor. BMC Musculoskelet Disord. 2020 Nov 14;21(1):753. doi: 10.1186/s12891-020-03762-9. PMID: 33189140; PMCID: PMC7666766.\u003c/li\u003e\n\u003cli\u003eRammelt S, Swords MP. Calcaneal Fractures-Which Approach for Which Fracture? Orthop Clin North Am. 2021 Oct;52(4):433-450. doi: 10.1016/j.ocl.2021.05.012. Epub 2021 Jul 29. PMID: 34538353.\u003c/li\u003e\n\u003cli\u003eKhazen G, Rassi CK. Sinus Tarsi Approach for Calcaneal Fractures: The New Gold Standard? Foot Ankle Clin. 2020 Dec;25(4):667-681. doi: 10.1016/j.fcl.2020.08.003. Epub 2020 Sep 18. PMID: 33543722.\u003c/li\u003e\n\u003cli\u003eKwon JY, Guss D, Lin DE, et al. Effect of delay to definitive surgical fixation on wound complications in the treatment of closed, intra-articular calcaneus fractures. Foot Ankle Int 2015;36(5):508\u0026ndash;17.\u003c/li\u003e\n\u003cli\u003eSchepers T. Calcaneal fractures: looking beyond the metaanalyses. J Foot Ankle Surg 2016;55(4):897\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eECKSTEIN C，KOTTMANN T，FUCHTMEIER B，et al． Long-term results of surgically treated calcaneal fractures: an analysis with a minimum follow-up period of twenty years［J］． Int Orthop，2016，40 ( 2) : 365 － 370\u003c/li\u003e\n\u003cli\u003eHuang Zhisong, Chen Xiang, LAN Jinfu, Guan Yong: comparison of the effect of mini-plate combined with cannulated screw internal fixation and L-shaped incision plate internal fixation for calcaneal fractures through tarsal sinus incision [J]. Chinese Journal of Bone and Joint Injury,2020,35(2):205-207\u003c/li\u003e\n\u003cli\u003eBasile A , Albo F , Via AG . Comparison between sinus tarsi approach and extensile lateral approach for treatment of closed displaced in-tra-artieular caleaneal fractures : a multicenter prospective study [ J . JFoot Ankle Surg ,2016,55(3):513-521. DOl :10.1053/ jjfas .2015.11.008.\u003c/li\u003e\n\u003cli\u003eBrand A, Klopfer-Kramer I, Bottger M, et al. Gait characteristics and functional outcomes during early follow-up are comparable in patients with calcaneal fractures treated by either the Sinus Tarsi or the Extended Lateral Approach. Gait Posture 2019;70:190\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eXia S , Lu Y , Wang H , et al . Open reduction and interal fixation with conventional plate via L-shaped lateral approach versus interal fixation with pereutaneous plate via a sinus tarsi approach for cal . caneal fractures-A randomized controled trial [ J . Int Surg ,2014.12(5):475-480.D0:10.1016/ j . ijsu .20 \u003c/li\u003e\n\u003cli\u003ePark J, Che JH. The sinus tarsi approach in displaced intra-articular calcaneal fractures. Arch Orthop Trauma Surg. 2017 Aug;137(8):1055-1065. doi: 10.1007/s00402-017-2714-y. Epub 2017 May 10. PMID: 28493041.\u003c/li\u003e\n\u003cli\u003eLi Zhichao, Xue Yong. Minimally invasive open reduction and internal fixation for Sanders type Ⅳ calcaneal fractures through tarsal sinus approach [J]. Chinese journal of bone and joint injury, 2017, 32 (10) : 1104-1105.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sanders type Ⅳ calcaneal fracture, tarsal sinus plate, cannulated screw, minimally invasive, clinical efficacy","lastPublishedDoi":"10.21203/rs.3.rs-4516307/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4516307/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to assess the clinical efficacy of combining tarsal sinus plates with cannulated screw-based minimally invasive internal fixation for the management of Sanders type IV calcaneal fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween January 2019 and July 2023, we conducted a retrospective analysis of 32 cases involving Sanders type IV calcaneal fractures treated by our medical team. The treatment approach involved the utilization of tarsal sinus plates in conjunction with minimally invasive internal fixation using cannulated screws. Among the cases analyzed, there were 16 males and 16 females, with an average age of 34.5 years (ranging from 21 to 50 years). We observed and recorded key parameters, including operative duration, intraoperative blood loss, postoperative complications, preoperative and immediate postoperative calcaneal width, calcaneal Bohler angle, and Gissane angle. Additionally, we conducted a review and documented the healing progress six months postoperatively. Pain levels were assessed using the visual analogue scale (VAS) before the procedure and at the final follow-up, while foot function was evaluated using the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle Hindfoot Scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean operative time for the 32 patients was 100.5 min (ranging from 62 to 144 min), with an average blood loss of 80 ml (ranging from 61 to 110 ml). Importantly, all fractures achieved union, with a 100% success rate, and no adverse complications were recorded. Postoperative X-ray imaging revealed statistically significant improvements in calcaneal width, Bohler angle, and Gissane angle compared to preoperative measurements (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). All patients were subject to follow-up assessments, with the average follow-up duration being 18 months (ranging from 12 to 24 months). At the final follow-up, patients reported a notably lower VAS pain score of 1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 points, a statistically significant reduction (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) when compared to preoperative values. Furthermore, the average AOFAS score at this stage was 84.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 points, also demonstrating a statistically significant improvement compared to preoperative scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCombining tarsal sinus plates with cannulated screw-based minimally invasive internal fixation is an effective treatment modality for Sanders type IV calcaneal fractures. This approach offers several advantages, including minimal trauma, a low risk of postoperative infection, reduced likelihood of soft tissue necrosis in the skin flap, superior fracture reduction and fixation, expedited functional recovery, and a reduced incidence of postoperative complications.\u003c/p\u003e","manuscriptTitle":"Minimally invasive internal fixation of Sanders Ⅳ calcaneal fractures using tarsal sinus plate and cannulated screw","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-02 17:26:33","doi":"10.21203/rs.3.rs-4516307/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-06-10T07:45:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-10T07:45:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-06-02T08:41:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f56129b7-7dc5-401f-a318-344429bfb9a2","owner":[],"postedDate":"July 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:07:02+00:00","versionOfRecord":{"articleIdentity":"rs-4516307","link":"https://doi.org/10.1186/s12893-025-02916-7","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-01-05 15:59:25","publishedOnDateReadable":"January 5th, 2026"},"versionCreatedAt":"2024-07-02 17:26:33","video":"","vorDoi":"10.1186/s12893-025-02916-7","vorDoiUrl":"https://doi.org/10.1186/s12893-025-02916-7","workflowStages":[]},"version":"v1","identity":"rs-4516307","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4516307","identity":"rs-4516307","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}