Combined Extensile Medial and Sinus Tarsi Approaches for Intra-Articular Calcaneus Fractures

Combined Extensile Medial and Sinus Tarsi Approaches for Intra-Articular Calcaneus Fractures | 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 Combined Extensile Medial and Sinus Tarsi Approaches for Intra-Articular Calcaneus Fractures Yuefei Liu, Qianheng Jin, Chenglong Wu, Jihui Ju This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7308021/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract Background This study aimed to evaluate the clinical efficacy of combining the extensile medial approach with the sinus tarsi approach for treating intra-articular calcaneus fractures. Methods The outcomes of 11 patients treated with the combined extensile medial and sinus tarsi approaches were evaluated. Specifically, the length, width, height, Böhler´s angle, Gissane angle, varus angle of the calcaneus body, intraoperative bleeding, incision complications and the American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed. Results The anatomical structure and articular surface of the calcaneus were recovered at the final follow-up. The mean values (final follow-up vs. preoperatively) were 83.4 ± 4.3 mm vs. 79.9 ± 4.6 mm for length (p < 0.05), 43.5 ± 2.5 mm vs. 48.3 ± 2.3 mm for height (p < 0.001), 50.2 ± 4.1 mm vs.42.0 ± 2.6 mm for width (p < 0.001), 11.5 ± 7.6° vs. 29.1 ± 8.7° for Böhler´s angle (p 0.05) and 8.5 ± 4.0° vs. 2.8 ± 2.0° for varus angle (p < 0.001). The mean AOFAS score at the final follow-up was 91.3 ± 7.6. Conclusion Utilising the extensile medial approach with the sinus tarsi approach allows for better visualisation and reduction of the medial wall and joint surfaces under direct and indirect visions. Postoperative joint and bone alignment were restored. Thus, this combined approach represents a novel and effective method deserving clinical promotion. Trial registration Not applicable (retrospective study). calcaneal fracture medial and external union varus deformity medial wall Figures Figure 1 Figure 2 Figure 3 1. Introduction Calcaneal fractures account for approximately 60% of tarsal fractures, with 60–75% involving the subtalar joint [ 1 , 2 ]. Several approaches exist to treat intra-articular calcaneal fractures, with open reduction and internal fixation being the most effective method [ 3 , 4 ]. The extensile lateral approach, a classic technique, provides excellent exposure and a clear field of view but is highly invasive and offers limited access to the medial side [ 5 , 6 ]. The tarsal sinus approach minimises soft tissue damage and allows direct reduction and fixation of posterior articular fractures. However, this approach inadequately exposes the posterior lateral surface, complicating restoration of height and width and elevating the risk of sural nerve injury [ 7 , 8 ]. Calcaneal fracture treatment aims to restore its length, width, height and joint surface [ 9 ]. In a severe calcaneal fracture, the anatomical structure cannot be fully restored due to the damaged lateral wall. The cortical bone on the medial wall is relatively thick, and most fractures are split-type fractures with distinct anatomical landmarks. By reducing the medial wall through the extensile medial approach, the length, height and varus angle could automatically recover. Additionally, the aim of resetting calcaneal fractures can be achieved by restoring the posterior articular surface and readjusting the lateral wall to restore width through the tarsal sinus approach. Hence, we employed the extensile medial and sinus tarsi approaches for treating intra-articular calcaneus fractures, in which the medial wall exhibits significant displacement, involving the sustentaculum tali to achieve favourable clinical outcomes. 2. Methods 2.1 Subjects Inclusion criteria comprised (1) Sanders type II and III closed fresh calcaneal fractures, (2) fractures with significantly displaced, crushed medial wall and severe varus and (3) patients aged 18–60 years. Exclusion criteria consisted of (1) Sanders type I and IV fractures; (2) open, old or pathological fractures; (3) severe osteoporosis and (4) serious internal diseases. Eleven patients (12 feet) were treated with the combined extensile medial and sinus tarsi approach from January 2022 to July 2023. All the patients were males, with a mean age of 44.1 ± 7.6 years (range 34–58). The right side was involved in eight (72.7%) cases, the left side was involved in two (18.2%) cases and both sides were involved in one case (9.1%). All the cases occurred due to a high falling injury. According to the classification system of Essex-Lopresti, nine (75%) feet were classified as type IIA, while three (25%) feet were classified as type IIB. According to the classification system of Sanders, five (41.7%) feet were classified as type IIA, three (25%) feet were classified as type IIB, one (8.3%) foot was classified as type IIIAC, one (8.3%) foot was classified as type IIIBC and two (16.6%) feet were classified as type IIIAB. Five (41.7%) fractures involved the sustentaculum tail (Fig. 1 ). All patients underwent external fixation with plaster or braces. Additionally, they were treated with limb elevation, intermittent ice compresses and swelling reduction therapy. Surgery was conducted once the swelling subsided or the crease sign was observed. The mean operative time was 171.5 ± 29.0 min (range 132–216). The mean time from fracture to surgery was 8.5 ± 3.0 days (range 5–14) (Table 1 ). Table 1 The statistical description of case series (N = 12 feet of 11 patients). Parameter Frequency count (%) or mean ± SD Sex Male 11 (100%) Female 0 (0%) Mean age(y) 44.1 ± 7.6 Fracture side Right 8 (72.7%) Left Bilateral Essex-Lopresti IIA IIB Sanders IIA IIB IIIAB IIIBC IIIAB Mean operative time (min) Mean time to surgery (d) Complications Infection Nerve injury 2 (18.2%) 1 (9.1%) 9 (75%) 3 (25%) 5 (41.7%) 3 (25%) 1 (8.3%) 1 (8.3%) 2 (16.6%) 171.5 ± 29.0 8.5 ± 3.0 1 2 2.2 Standard operative technique The operation was performed under continuous epidural anaesthesia in a prone position. An incision was made starting from 1 cm above the calcaneal tubercle, moving down along the medial edge of the Achilles tendon to the plantar skin and turning to a transverse incision to 1 cm in front of the calcaneal tubercle. Afterwards, a full-thickness incision was made through the skin and subcutaneous tissue to expose the abductor pollicis muscle. The abductor pollicis muscle was retracted downwards, followed by skin flap elevation. Then, a careful exposure of the medial wall of the calcaneus was performed to protect the plantar branch of the tibial nerve. The lateral incision, representing a conventional tarsal sinus approach, of about 4–5 cm from 1 cm below the lateral malleolus to the base of the fourth metatarsal was made. After the skin was incised, the fibular long and short tendon sheaths and the lateral wall of the calcaneus were sharply separated. The fibular long and short tendons were retracted downwards, and the extensor digitorum brevis muscle was stripped. The joint capsule was incised to expose the collapsed articular surface. The peroneal long and short tendon sheaths were precisely disentangled from the lateral wall of the calcaneus. Then, the peroneal long and short tendons were retracted inferiorly, followed by detaching the extensor digitorum brevis muscle. Afterwards, the joint capsule was incised to reveal the collapsed articular surface. The reduction procedure started with the medial aspect and progressed to the lateral, initially restoring the height and length of the calcaneus bone and subsequently addressing the alignment and flatness of the articular surface. A Steinmann pin 4.0 mm in diameter was inserted into the medial inferior aspect of the calcaneal tubercle. It was pulled downwards and backwards to preliminarily restore the height and length of the calcaneus bone. The calcaneal varus was corrected by applying the eversion Steinmann pin. After the reduction of the medial wall and talocalcaneal, the length and height of the calcaneus, as well as the varus and valgus, were further restored. Then, the fracture fragments were temporarily fixed with Kirschner wires. For tongue-shaped fractures, a Steinmann pin was inserted transversely at the back of the fracture fragment, and the joint surface was reduced by prying downwards. The fracture was fixed by a double-headed compression screw or locking plate through the medial incision. After rinsing, the extensor digitorum brevis muscle was repaired. Afterwards, the skin was closed with intermittent sutures, and a drainage tube was left in place for negative pressure drainage (Fig. 2 ). 2.3 Postoperative care All patients were treated with limb elevation. Drainage tubes were removed 24–48 hrs after surgery. Afterwards, patients began to perform non-weight-bearing active ankle joint flexion and extension exercises. The calcaneus was examined with lateral and axial X-ray films at 1 week and 1, 2, 3, 6 and 12 months. At 6–8 weeks after surgery, patients were advised to bear partial weight with the aid of crutches and transitioned to full weight-bearing walking 3 months after surgery. 2.4 Postoperative follow-up and assessment Clinical and imaging evaluations were conducted before and after surgery. The length, width, height, varus angle, Böhler’s angle and Gissane angle of the calcaneus were obtained from the lateral axial radiograph. Clinical evaluation was employed according to the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scoring system [ 10 ]. The AOFAS score included pain, ankle joint mobility, foot alignment and other aspects, with a maximum score of 100 points. Among them, 90–100 points represented the excellent score, 75–89 points represented the good score, 50–74 points represented the acceptable score, and < 50 points represented the poor score. 2.5 Statistical analysis Statistical analysis was performed using SPSS 26.0 software. Measurement data were expressed as mean ± standard deviation, and t-tests were used to compare imaging observation indicators before and after surgery. A p < 0.05 indicated statistical significance. 3. Results All operations were successful, with a mean surgery time of 171.5 ± 29.0 min (range 132– 216) (Table 1 ). The average amount of bleeding was 97.7 ± 47.1 mL (range 40–200 mL). Postoperative follow-up lasted from 11 to 23 months (average, 18.8 ± 3.5 months), with a 100% follow-up rate. In all patients, 11 feet showed primary wound healing. A case of feet medial wound infection was treated with local pedicle skin flap transfer. There was no obvious sensory abnormality on the inner and outer sides of the foot in 10 feet. Two cases of numbness in the lateral plantar area and 4th and 5th toes occurred, improving during the last follow-up and not affecting the patients’ life (Table 1 ). Imaging evaluation before surgery and at the last follow-up showed significant increases in calcaneal length, height and Böhler angle (p < 0.05, Table 2 ). The postoperative width and varus angle of the calcaneus were significantly reduced (p 0.05, Table 2 ). Additionally, no significant changes were observed in length, width, height, Böhler angle or varus angle between the postoperative period and and at the last follow-up (p > 0.05, Table 2 , Fig. 3 ). At the last follow-up, the average AOFAS score was 91.3 ± 7.6 points, with seven cases (8 feet) rated as excellent, three cases (3 feet) rated as good and one case (1 foot) rated as fair (Table 3 , Support Fig. 1 ). Table 2 The results of the radiographic measurements on plain radiographs (N = 12 feet of 11 patients). Time Length (mm) Height (mm) Width (mm) Böhler’s angle (°) Gissane angle (°) Varus angle (°) Preoperative 79.9 ± 4.6 43.5 ± 2.5 50.2 ± 4.1 11.5 ± 7.6 117.7 ± 11.7 8.5 ± 4.0 Postoperative 84.1 ± 4.7 49.8 ± 2.8 42.0 ± 3.5 28.9 ± 7.3 123.8 ± 5.6 2.6 ± 2.2 One year post-surgery 83.4 ± 4.3 48.3 ± 2.3 42.0 ± 2.6 29.1 ± 8.7 124.1 ± 6.3 2.8 ± 2.0 P a P b 0.036 0.725 0.000 0.169 0.000 0.985 0.000 0.948 0.125 0.890 0.000 0.854 Table 3 Clinical results according to the AOFAS score at the last follow-up (N = 12 feet of 11 patients). Clinical Results According to AOFAS Score Excellent Good Fair Poor (90–100) (75–89) (50–74) < 50 Numbers 8 3 1 0 Ratio 66.7% 25% 8.3% 0 4. Discussion The calcaneus is an arc-shaped structure with a medial curve. The inner column bears stress, whereas the outer column is the tension side [ 11 , 12 ]. The medial cortex is thick and robust, while the lateral cortex is thin. The posterior articular surface is elevated medially and depressed laterally [ 13 ]. Axial force is applied to the posterior articular surface causes lateral bone collapse and extensive damage, while the medial wall remains relatively intact [ 14 ]. The medial talus was believed to be rarely displaced in calcaneal fractures. However, a recent study has shown that up to 40% of fractures involving the talus are difficult to maintain in its original position [ 15 ]. In our group, 43% of cases involved talus with significant displacement. Common surgical approaches for intra-articular calcaneal fractures include the extensile lateral approach, tarsal sinus approach and arthroscopy-assisted closed prying reduction [ 16 ]. All these methods involve indirect reduction of the medial wall, complicating the restoration of the calcaneal normal height. Restoration of the varus angle relies on intraoperative fluoroscopy and necessitates extensive experience and skills. Consequently, the reduction and fixation of fractures involving the talocrural joint are characterised by a high failure rate [ 17 ]. The goal of the operation for calcaneal fractures is to restore the normal anatomy of the posterior articular surface, the Böhler's and Gissane angles, the normal width and the normal height and correct varus and valgus deformities. The varus and valgus deformity caused by the misalignment of the hindfoot force line can directly lead to early reduction failure and require osteotomy or subtalar arthrodesis [ 18 ]. The medial incision can directly expose the fracture of the medial wall and the sustentaculum talus fracture. Previously reported medial approaches have mainly included transverse or oblique incisions between the medial malleolus and the plantar surface. These incisions can precisely restore the medial wall, while a unilateral medial incision fails to expose the entire posterior articular surface and may inadvertently harm critical intravascular nerves [ 19 , 20 ]. Thus, the combination of medial and external incisions can effectively restore the force line and anatomical shape of the calcaneus, especially in fractures involving the sustentaculum talus. In this study, the extensile medial approach was performed along the periosteal layer to ensure minimal damage to the main blood vessels and nerves and clearly expose the sustentaculum talus fracture. The medial wall typically presents as a simple fracture. After reduction, the height, length and alignment (varus and valgus) of the calcaneus can all be corrected. However, the medial approach has limited exposure to the posterior articular surface. Hence, combining it with a small lateral incision can effectively reduce the protrusion of the articular surface and lateral wall, thereby restoring the width of the calcaneus. After reducing the medial wall, a reference template can be used for the lateral side. The approach is medial-to-lateral, initially restoring the length and height of the calcaneus and then restoring the smoothness of the articular surface and calcaneal width. Advantages First, direct vision reduction and fixation can be performed for intra-articular fractures of the calcaneus involving the sustentaculum talus, avoiding the previous deficiency of the inaccurate restoration of the calcaneal height through lateral incisions. The calcaneal varus is mainly caused by the displacement of the medial wall. After restoring the medial wall, the length and height of the calcaneus naturally recover. Furthermore, the varus and valgus are corrected simultaneously, reducing the time required for intraoperative C-arm X-ray fluoroscopy, especially for the axial view. Second, the medial side of the posterior articular surface can be observed through the medial incision for Essex-Lopresti IIA tongue-shaped fractures. A Steinmann pin is inserted posterior to the calcaneal tuberosity, followed by the downwards application of pressure to reposition the posterior articular surface of the medial wall. At this stage, the lateral incision serves solely as an observational site to assess the smoothness of the posterior articular surface, allowing for necessary adjustments. Third, the medial wall of the calcaneus is thick and hard, which can provide good support and holding force for the steel plate screw after reduction and fixation. The length, height and varus deformity of the calcaneus are not easily compromised after surgery, ensuring early functional exercise. Fourth, the space on the medial side of the calcaneus is more expansive, ensuring that the insertion of a steel plate will not lead to wound closure complications. Fifth, the medial incision reveals the sustentaculum talus to enhance the precision of the sustentaculum talus screw placement. Technical key points First, the longitudinal incision extensile medial approach should be maximised in length given no vital blood vessels or nerves on the posterior side. The transverse incision should be kept as short as possible and may be extended as needed through additional surgery. Caution is needed to avoid harming the plantar branch of the tibial nerve if extending the transverse incision. If necessary, the nerve branch is isolated first to ensure its protection. When securing the distal end of the steel plate using screws, the external steel plate can serve as a template. Then, a small incision is made to cut through the skin and implant the screws. Second, one longitudinal and one transverse Steinmann pins are inserted into the calcaneal tuberosity for leveraging purposes. Pulling down the longitudinal Steinmann pin can help restore the length and height of the calcaneus bone. However, the transverse Steinmann pin is applied to restore the smoothness of the posterior articular surface. In cases of comminuted, bone-loss and compression fractures, the restoration achieved by the medial wall fails to satisfy the requirements for the lateral articular surface. At this stage, synchronously repositioning the internal and external sides is essential. Priority should be given to resetting the collapsed articular surface fractures on the external side, ensuring that the articular surface is smooth, and then fine-tuning the internal side reposition. Third, after the restoration of the medial wall, the Kirschner wire used for temporary fixation should be positioned as close as possible to the medial side of the calcaneus to prevent interference with the reduction of the lateral articular surface. Disadvantages The lateral wall is inadequately exposed, and its realignment depends on hand pressure and C-arm X-ray fluoroscopy. Second, two patients experienced numbness in the lateral plantar area and 4th and 5th toe tips after surgery. When making a transverse plantar incision, prioritise identifying and protecting the plantar branch of the tibial nerve. Third, further research is warranted due to the limited surgical cases and the absence of anatomical plates. 5. Conclusion Combining the extensile medial approach and sinus tarsi approaches effectively restores intra-articular calcaneus fractures, especially those involving the medial wall, the talocalcaneal process and the sustentaculum tali. This method is a favourable option for treating calcaneal fractures clinically. Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Suzhou Ruihua Orthopedic Hospital(Approval No. 2021055). Informed consent was obtained from all participants prior to their inclusion in the study. Participants were informed about the purpose of the study, the procedures involved, and their right to withdraw at any time without penalty. All data collected were kept confidential and used solely for research purposes. Consent for publication Not applicable. Competing interests All the authors declare that they have no competing interests. Consent to Publish Not applicable. Funding This work was mainly supported by Natural Science Foundation of Jiangsu province (BK20221245) Author Contribution YL and QJ designed the study. YL wrote the manuscript. YL and CW collected, analyzed, and interpreted the data. JJ critically reviewed, edited, and approved the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable Availability of data and materials The datasets generated and/or analyzed during the current study are available in the MIMIC III database ( https://mimic.mit.edu/docs/iii/ ) and MIMIC IV database ( https://mimic.mit.edu/docs/iv/ ). References Najefi A, Najefy A, Vemulapalli K. Paediatric calcaneal fractures: a guide to management based on a review of the literature. Injury. 2020;51:1432–8. doi.org/10.1016/j.injury.2020.03.050 . Rammelt S, Marx C. Managing severely malunited calcaneal fractures and fracture-dislocations. Foot Ankle Clin. 2020;25:239–56. doi.org/10.1016/j.fcl.2020.02.005 . Wagstrom E, Downes J. Limited approaches to calcaneal fractures. Curr Rev Musculoskelet Med. 2018;11:485–94. https://doi.org/10.1007/s12178-018-9511-2 . Welck M, Hayes T, Pastides P, Khan W, Rudge B. Stress fractures of the foot and ankle. Injury. 2017;48:1722–6. doi.org/10.1016/j.injury.2015.06.015 . Park C, Yan H, Park J. Randomized comparative study between extensile lateral and sinus tarsi approaches for the treatment of Sanders type 2 calcaneal fracture. Bone Joint J. 2021;103–B:286–93. doi.org/10.1302/0301-620X.103B.BJJ-2020-1313.R1 . Kiewiet N, Sangeorzan B. Calcaneal fracture management: extensile lateral approach versus small incision technique. Foot Ankle Clin. 2021;22:77–91. doi.org/10.1016/j.fcl.2016.09.013 . Khazen G, Rassi C. Sinus tarsi approach for calcaneal fractures: the new god standard? Foot Ankle Clin. 2020;25:667–81. doi.org/10.1016/j.fcl.2020.08.003 . Xu H, Ju J, Hou R, Liu Y, Zhou R, Chen LC, Hu C, Yang L. Sinus tarsi approach with percutaneous screw fixation for intra-articular calcaneal fractures. J Foot Ankle Surg. 2022;61:792–7. doi.org/10.1053/j.jfas.2021.11.018 . Hsu A, Anderson R, Cohen B. 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J Bone Joint Surg Am. 2015;97:341. doi.org/10.2106/JBJS.9704.ebo101 . Additional Declarations No competing interests reported. Supplementary Files SFigure1.jpg Support Figure 1: The functional status of both feet one year after surgery. (A) The dorsiflexion position. (B) The plantar flexion position. (C) The valgus position. (D) The inversion position. Cite Share Download PDF Status: Published Journal Publication published 10 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 20 Oct, 2025 Reviews received at journal 09 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviews received at journal 08 Oct, 2025 Reviews received at journal 06 Oct, 2025 Reviewers agreed at journal 30 Sep, 2025 Reviewers agreed at journal 28 Sep, 2025 Reviewers agreed at journal 26 Sep, 2025 Reviewers invited by journal 25 Sep, 2025 Editor invited by journal 01 Sep, 2025 Editor assigned by journal 29 Aug, 2025 Submission checks completed at journal 29 Aug, 2025 First submitted to journal 06 Aug, 2025 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. 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08:02:40","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":308784,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/2933a1dcf71b9983e5fcb2c3.png"},{"id":93017697,"identity":"c858e543-a4cb-45f6-8b40-46262d3f6881","added_by":"auto","created_at":"2025-10-08 08:18:40","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":650928,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/2d286dbe57c26224abec9c00.png"},{"id":93016145,"identity":"24922595-2182-422f-908c-4ab8425fa2dd","added_by":"auto","created_at":"2025-10-08 08:02:40","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":959741,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/76ee24e9cd9fbeda342f69fc.png"},{"id":93016151,"identity":"a61316b5-34e4-46b5-b1e3-4a79d1c65a7c","added_by":"auto","created_at":"2025-10-08 08:02:40","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65833,"visible":true,"origin":"","legend":"","description":"","filename":"68272c6975a34c889510ec984f330f9d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/f549488be7ce6ff2f1d27d97.xml"},{"id":93016149,"identity":"473e49cd-cd31-4c46-852f-2ebc1ece94f3","added_by":"auto","created_at":"2025-10-08 08:02:40","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74322,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/ce619ff501c51ef037d022f4.html"},{"id":93016137,"identity":"f063b89d-cef1-4bb1-bb5d-49d511844d4a","added_by":"auto","created_at":"2025-10-08 08:02:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2515535,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative imaging examination. (A, B) The preoperative X-ray lateral axial film of the right foot. (C) The preoperative computed tomography (CT) of the right foot. (D, E) The preoperative X-ray lateral axial film of the left foot. (F) The preoperative computed tomography (CT) of the left foot.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/2da468846f36869ab9cc7270.png"},{"id":93016144,"identity":"c216c15f-8b7a-4672-813d-6e2d33720b99","added_by":"auto","created_at":"2025-10-08 08:02:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3926133,"visible":true,"origin":"","legend":"\u003cp\u003eIncision and approach. (A, B) The surgical incision design of combined extensile medial and sinus tarsi approaches. (C, D) The intraoperative display of the medial wall of the calcaneus and internal fixation of the right foot. (E, F) The intraoperative display of the medial wall of the calcaneus and internal fixation of the left foot.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/aaeafe1f888919705c2d9518.png"},{"id":93017337,"identity":"a2ae871f-443d-4f48-941f-37894df3f515","added_by":"auto","created_at":"2025-10-08 08:10:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":961627,"visible":true,"origin":"","legend":"\u003cp\u003eImaging examination one year after surgery. (A, B) The right foot lateral axial X-ray at one year after the operation. (C, D) The left foot lateral axial X-ray at one year after the operation.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/0a94d5a6249bb6e0acdc1ff4.png"},{"id":104739534,"identity":"d50ffd50-cc87-499c-a3ef-a1cbada0de19","added_by":"auto","created_at":"2026-03-16 16:08:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11049808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/11479802-57d1-4c7d-ad73-33a2ad029a54.pdf"},{"id":93016134,"identity":"0d76260e-4948-4795-a339-72e72984fd2c","added_by":"auto","created_at":"2025-10-08 08:02:39","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":78083,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupport Figure 1: \u003c/strong\u003eThe functional status of both feet one year after surgery. (A) The dorsiflexion position. (B) The plantar flexion position. (C) The valgus position. (D) The inversion position.\u003c/p\u003e","description":"","filename":"SFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7308021/v1/c018f672183ef7c19baa9faf.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Combined Extensile Medial and Sinus Tarsi Approaches for Intra-Articular Calcaneus Fractures","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCalcaneal fractures account for approximately 60% of tarsal fractures, with 60\u0026ndash;75% involving the subtalar joint [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Several approaches exist to treat intra-articular calcaneal fractures, with open reduction and internal fixation being the most effective method [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The extensile lateral approach, a classic technique, provides excellent exposure and a clear field of view but is highly invasive and offers limited access to the medial side [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The tarsal sinus approach minimises soft tissue damage and allows direct reduction and fixation of posterior articular fractures. However, this approach inadequately exposes the posterior lateral surface, complicating restoration of height and width and elevating the risk of sural nerve injury [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCalcaneal fracture treatment aims to restore its length, width, height and joint surface [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In a severe calcaneal fracture, the anatomical structure cannot be fully restored due to the damaged lateral wall. The cortical bone on the medial wall is relatively thick, and most fractures are split-type fractures with distinct anatomical landmarks. By reducing the medial wall through the extensile medial approach, the length, height and varus angle could automatically recover. Additionally, the aim of resetting calcaneal fractures can be achieved by restoring the posterior articular surface and readjusting the lateral wall to restore width through the tarsal sinus approach. Hence, we employed the extensile medial and sinus tarsi approaches for treating intra-articular calcaneus fractures, in which the medial wall exhibits significant displacement, involving the sustentaculum tali to achieve favourable clinical outcomes.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Subjects\u003c/h2\u003e\n \u003cp\u003eInclusion criteria comprised (1) Sanders type II and III closed fresh calcaneal fractures, (2) fractures with significantly displaced, crushed medial wall and severe varus and (3) patients aged 18\u0026ndash;60 years. Exclusion criteria consisted of (1) Sanders type I and IV fractures; (2) open, old or pathological fractures; (3) severe osteoporosis and (4) serious internal diseases.\u003c/p\u003e\n \u003cp\u003eEleven patients (12 feet) were treated with the combined extensile medial and sinus tarsi approach from January 2022 to July 2023. All the patients were males, with a mean age of 44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 years (range 34\u0026ndash;58). The right side was involved in eight (72.7%) cases, the left side was involved in two (18.2%) cases and both sides were involved in one case (9.1%). All the cases occurred due to a high falling injury. According to the classification system of Essex-Lopresti, nine (75%) feet were classified as type IIA, while three (25%) feet were classified as type IIB. According to the classification system of Sanders, five (41.7%) feet were classified as type IIA, three (25%) feet were classified as type IIB, one (8.3%) foot was classified as type IIIAC, one (8.3%) foot was classified as type IIIBC and two (16.6%) feet were classified as type IIIAB. Five (41.7%) fractures involved the sustentaculum tail (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). All patients underwent external fixation with plaster or braces. Additionally, they were treated with limb elevation, intermittent ice compresses and swelling reduction therapy. Surgery was conducted once the swelling subsided or the crease sign was observed. The mean operative time was 171.5\u0026thinsp;\u0026plusmn;\u0026thinsp;29.0 min (range 132\u0026ndash;216). The mean time from fracture to surgery was 8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 days (range 5\u0026ndash;14) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe statistical description of case series (N\u0026thinsp;=\u0026thinsp;12 feet of 11 patients).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency count (%) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean age(y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFracture side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (72.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003cp\u003eEssex-Lopresti\u003c/p\u003e\n \u003cp\u003eIIA\u003c/p\u003e\n \u003cp\u003eIIB\u003c/p\u003e\n \u003cp\u003eSanders\u003c/p\u003e\n \u003cp\u003eIIA\u003c/p\u003e\n \u003cp\u003eIIB\u003c/p\u003e\n \u003cp\u003eIIIAB\u003c/p\u003e\n \u003cp\u003eIIIBC\u003c/p\u003e\n \u003cp\u003eIIIAB\u003c/p\u003e\n \u003cp\u003eMean operative time (min)\u003c/p\u003e\n \u003cp\u003eMean time to surgery (d)\u003c/p\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003cp\u003eNerve injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (75%)\u003c/p\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (41.7%)\u003c/p\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003cp\u003e2 (16.6%)\u003c/p\u003e\n \u003cp\u003e171.5\u0026thinsp;\u0026plusmn;\u0026thinsp;29.0\u003c/p\u003e\n \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Standard operative technique\u003c/h2\u003e\n \u003cp\u003eThe operation was performed under continuous epidural anaesthesia in a prone position. An incision was made starting from 1 cm above the calcaneal tubercle, moving down along the medial edge of the Achilles tendon to the plantar skin and turning to a transverse incision to 1 cm in front of the calcaneal tubercle. Afterwards, a full-thickness incision was made through the skin and subcutaneous tissue to expose the abductor pollicis muscle. The abductor pollicis muscle was retracted downwards, followed by skin flap elevation. Then, a careful exposure of the medial wall of the calcaneus was performed to protect the plantar branch of the tibial nerve. The lateral incision, representing a conventional tarsal sinus approach, of about 4\u0026ndash;5 cm from 1 cm below the lateral malleolus to the base of the fourth metatarsal was made. After the skin was incised, the fibular long and short tendon sheaths and the lateral wall of the calcaneus were sharply separated. The fibular long and short tendons were retracted downwards, and the extensor digitorum brevis muscle was stripped. The joint capsule was incised to expose the collapsed articular surface. The peroneal long and short tendon sheaths were precisely disentangled from the lateral wall of the calcaneus. Then, the peroneal long and short tendons were retracted inferiorly, followed by detaching the extensor digitorum brevis muscle. Afterwards, the joint capsule was incised to reveal the collapsed articular surface. The reduction procedure started with the medial aspect and progressed to the lateral, initially restoring the height and length of the calcaneus bone and subsequently addressing the alignment and flatness of the articular surface. A Steinmann pin 4.0 mm in diameter was inserted into the medial inferior aspect of the calcaneal tubercle. It was pulled downwards and backwards to preliminarily restore the height and length of the calcaneus bone. The calcaneal varus was corrected by applying the eversion Steinmann pin. After the reduction of the medial wall and talocalcaneal, the length and height of the calcaneus, as well as the varus and valgus, were further restored. Then, the fracture fragments were temporarily fixed with Kirschner wires. For tongue-shaped fractures, a Steinmann pin was inserted transversely at the back of the fracture fragment, and the joint surface was reduced by prying downwards. The fracture was fixed by a double-headed compression screw or locking plate through the medial incision. After rinsing, the extensor digitorum brevis muscle was repaired. Afterwards, the skin was closed with intermittent sutures, and a drainage tube was left in place for negative pressure drainage (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Postoperative care\u003c/h2\u003e\n \u003cp\u003eAll patients were treated with limb elevation. Drainage tubes were removed 24\u0026ndash;48 hrs after surgery. Afterwards, patients began to perform non-weight-bearing active ankle joint flexion and extension exercises. The calcaneus was examined with lateral and axial X-ray films at 1 week and 1, 2, 3, 6 and 12 months. At 6\u0026ndash;8 weeks after surgery, patients were advised to bear partial weight with the aid of crutches and transitioned to full weight-bearing walking 3 months after surgery.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Postoperative follow-up and assessment\u003c/h2\u003e\n \u003cp\u003eClinical and imaging evaluations were conducted before and after surgery. The length, width, height, varus angle, B\u0026ouml;hler\u0026rsquo;s angle and Gissane angle of the calcaneus were obtained from the lateral axial radiograph. Clinical evaluation was employed according to the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scoring system [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. The AOFAS score included pain, ankle joint mobility, foot alignment and other aspects, with a maximum score of 100 points. Among them, 90\u0026ndash;100 points represented the excellent score, 75\u0026ndash;89 points represented the good score, 50\u0026ndash;74 points represented the acceptable score, and \u0026lt;\u0026thinsp;50 points represented the poor score.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analysis was performed using SPSS 26.0 software. Measurement data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and t-tests were used to compare imaging observation indicators before and after surgery. A p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated statistical significance.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eAll operations were successful, with a mean surgery time of 171.5\u0026thinsp;\u0026plusmn;\u0026thinsp;29.0 min (range 132\u0026ndash; 216) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The average amount of bleeding was 97.7\u0026thinsp;\u0026plusmn;\u0026thinsp;47.1 mL (range 40\u0026ndash;200 mL). Postoperative follow-up lasted from 11 to 23 months (average, 18.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5 months), with a 100% follow-up rate. In all patients, 11 feet showed primary wound healing. A case of feet medial wound infection was treated with local pedicle skin flap transfer. There was no obvious sensory abnormality on the inner and outer sides of the foot in 10 feet. Two cases of numbness in the lateral plantar area and 4th and 5th toes occurred, improving during the last follow-up and not affecting the patients\u0026rsquo; life (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Imaging evaluation before surgery and at the last follow-up showed significant increases in calcaneal length, height and B\u0026ouml;hler angle (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The postoperative width and varus angle of the calcaneus were significantly reduced (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). While the Gissane angle increased postoperatively, the change was not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Additionally, no significant changes were observed in length, width, height, B\u0026ouml;hler angle or varus angle between the postoperative period and and at the last follow-up (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). At the last follow-up, the average AOFAS score was 91.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 points, with seven cases (8 feet) rated as excellent, three cases (3 feet) rated as good and one case (1 foot) rated as fair (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Support Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe results of the radiographic measurements on plain radiographs (N\u0026thinsp;=\u0026thinsp;12 feet of 11 patients).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLength (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHeight (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWidth (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eB\u0026ouml;hler\u0026rsquo;s angle (\u0026deg;)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGissane angle (\u0026deg;)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eVarus angle (\u0026deg;)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e117.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e123.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne year post-surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e124.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003cp\u003e0.725\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003cp\u003e0.169\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003cp\u003e0.985\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003cp\u003e0.948\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.125\u003c/p\u003e\u003cp\u003e0.890\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003cp\u003e0.854\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical results according to the AOFAS score at the last follow-up (N\u0026thinsp;=\u0026thinsp;12 feet of 11 patients).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eClinical Results According to AOFAS Score\u003c/p\u003e\u003cp\u003eExcellent Good Fair Poor\u003c/p\u003e\u003cp\u003e(90\u0026ndash;100) (75\u0026ndash;89) (50\u0026ndash;74)\u0026thinsp;\u0026lt;\u0026thinsp;50\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumbers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRatio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe calcaneus is an arc-shaped structure with a medial curve. The inner column bears stress, whereas the outer column is the tension side [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The medial cortex is thick and robust, while the lateral cortex is thin. The posterior articular surface is elevated medially and depressed laterally [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Axial force is applied to the posterior articular surface causes lateral bone collapse and extensive damage, while the medial wall remains relatively intact [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The medial talus was believed to be rarely displaced in calcaneal fractures. However, a recent study has shown that up to 40% of fractures involving the talus are difficult to maintain in its original position [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our group, 43% of cases involved talus with significant displacement. Common surgical approaches for intra-articular calcaneal fractures include the extensile lateral approach, tarsal sinus approach and arthroscopy-assisted closed prying reduction [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. All these methods involve indirect reduction of the medial wall, complicating the restoration of the calcaneal normal height. Restoration of the varus angle relies on intraoperative fluoroscopy and necessitates extensive experience and skills. Consequently, the reduction and fixation of fractures involving the talocrural joint are characterised by a high failure rate [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The goal of the operation for calcaneal fractures is to restore the normal anatomy of the posterior articular surface, the B\u0026ouml;hler's and Gissane angles, the normal width and the normal height and correct varus and valgus deformities. The varus and valgus deformity caused by the misalignment of the hindfoot force line can directly lead to early reduction failure and require osteotomy or subtalar arthrodesis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The medial incision can directly expose the fracture of the medial wall and the sustentaculum talus fracture. Previously reported medial approaches have mainly included transverse or oblique incisions between the medial malleolus and the plantar surface. These incisions can precisely restore the medial wall, while a unilateral medial incision fails to expose the entire posterior articular surface and may inadvertently harm critical intravascular nerves [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Thus, the combination of medial and external incisions can effectively restore the force line and anatomical shape of the calcaneus, especially in fractures involving the sustentaculum talus.\u003c/p\u003e\u003cp\u003eIn this study, the extensile medial approach was performed along the periosteal layer to ensure minimal damage to the main blood vessels and nerves and clearly expose the sustentaculum talus fracture. The medial wall typically presents as a simple fracture. After reduction, the height, length and alignment (varus and valgus) of the calcaneus can all be corrected. However, the medial approach has limited exposure to the posterior articular surface. Hence, combining it with a small lateral incision can effectively reduce the protrusion of the articular surface and lateral wall, thereby restoring the width of the calcaneus. After reducing the medial wall, a reference template can be used for the lateral side. The approach is medial-to-lateral, initially restoring the length and height of the calcaneus and then restoring the smoothness of the articular surface and calcaneal width.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAdvantages\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFirst, direct vision reduction and fixation can be performed for intra-articular fractures of the calcaneus involving the sustentaculum talus, avoiding the previous deficiency of the inaccurate restoration of the calcaneal height through lateral incisions. The calcaneal varus is mainly caused by the displacement of the medial wall. After restoring the medial wall, the length and height of the calcaneus naturally recover. Furthermore, the varus and valgus are corrected simultaneously, reducing the time required for intraoperative C-arm X-ray fluoroscopy, especially for the axial view. Second, the medial side of the posterior articular surface can be observed through the medial incision for Essex-Lopresti IIA tongue-shaped fractures. A Steinmann pin is inserted posterior to the calcaneal tuberosity, followed by the downwards application of pressure to reposition the posterior articular surface of the medial wall. At this stage, the lateral incision serves solely as an observational site to assess the smoothness of the posterior articular surface, allowing for necessary adjustments. Third, the medial wall of the calcaneus is thick and hard, which can provide good support and holding force for the steel plate screw after reduction and fixation. The length, height and varus deformity of the calcaneus are not easily compromised after surgery, ensuring early functional exercise. Fourth, the space on the medial side of the calcaneus is more expansive, ensuring that the insertion of a steel plate will not lead to wound closure complications. Fifth, the medial incision reveals the sustentaculum talus to enhance the precision of the sustentaculum talus screw placement.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTechnical key points\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFirst, the longitudinal incision extensile medial approach should be maximised in length given no vital blood vessels or nerves on the posterior side. The transverse incision should be kept as short as possible and may be extended as needed through additional surgery. Caution is needed to avoid harming the plantar branch of the tibial nerve if extending the transverse incision. If necessary, the nerve branch is isolated first to ensure its protection. When securing the distal end of the steel plate using screws, the external steel plate can serve as a template. Then, a small incision is made to cut through the skin and implant the screws. Second, one longitudinal and one transverse Steinmann pins are inserted into the calcaneal tuberosity for leveraging purposes. Pulling down the longitudinal Steinmann pin can help restore the length and height of the calcaneus bone. However, the transverse Steinmann pin is applied to restore the smoothness of the posterior articular surface. In cases of comminuted, bone-loss and compression fractures, the restoration achieved by the medial wall fails to satisfy the requirements for the lateral articular surface. At this stage, synchronously repositioning the internal and external sides is essential. Priority should be given to resetting the collapsed articular surface fractures on the external side, ensuring that the articular surface is smooth, and then fine-tuning the internal side reposition. Third, after the restoration of the medial wall, the Kirschner wire used for temporary fixation should be positioned as close as possible to the medial side of the calcaneus to prevent interference with the reduction of the lateral articular surface.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDisadvantages\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe lateral wall is inadequately exposed, and its realignment depends on hand pressure and C-arm X-ray fluoroscopy. Second, two patients experienced numbness in the lateral plantar area and 4th and 5th toe tips after surgery. When making a transverse plantar incision, prioritise identifying and protecting the plantar branch of the tibial nerve. Third, further research is warranted due to the limited surgical cases and the absence of anatomical plates.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eCombining the extensile medial approach and sinus tarsi approaches effectively restores intra-articular calcaneus fractures, especially those involving the medial wall, the talocalcaneal process and the sustentaculum tali. This method is a favourable option for treating calcaneal fractures clinically.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Suzhou Ruihua Orthopedic Hospital(Approval No. 2021055). Informed consent was obtained from all participants prior to their inclusion in the study. Participants were informed about the purpose of the study, the procedures involved, and their right to withdraw at any time without penalty. All data collected were kept confidential and used solely for research purposes.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eAll the authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent to Publish\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was mainly supported by Natural Science Foundation of Jiangsu province (BK20221245)\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYL and QJ designed the study. YL wrote the manuscript. YL and CW collected, analyzed, and interpreted the data. JJ critically reviewed, edited, and approved the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available\u003c/p\u003e\u003cp\u003ein the MIMIC III database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mimic.mit.edu/docs/iii/\u003c/span\u003e\u003cspan address=\"https://mimic.mit.edu/docs/iii/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) and MIMIC IV\u003c/p\u003e\u003cp\u003edatabase (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mimic.mit.edu/docs/iv/\u003c/span\u003e\u003cspan address=\"https://mimic.mit.edu/docs/iv/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNajefi A, Najefy A, Vemulapalli K. 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J Bone Joint Surg Am. 2015;97:341. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.2106/JBJS.9704.ebo101\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.9704.ebo101\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\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":"calcaneal fracture, medial and external union, varus deformity, medial wall","lastPublishedDoi":"10.21203/rs.3.rs-7308021/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7308021/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThis study aimed to evaluate the clinical efficacy of combining the extensile medial approach with the sinus tarsi approach for treating intra-articular calcaneus fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe outcomes of 11 patients treated with the combined extensile medial and sinus tarsi approaches were evaluated. Specifically, the length, width, height, B\u0026ouml;hler\u0026acute;s angle, Gissane angle, varus angle of the calcaneus body, intraoperative bleeding, incision complications and the American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe anatomical structure and articular surface of the calcaneus were recovered at the final follow-up. The mean values (final follow-up vs. preoperatively) were 83.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 mm vs. 79.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 mm for length (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), 43.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 mm vs. 48.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 mm for height (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1 mm vs.42.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 mm for width (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u0026deg; vs. 29.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u0026deg; for B\u0026ouml;hler\u0026acute;s angle (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 117.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u0026deg; vs. 124.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u0026deg; for Gissane angle (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and 8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u0026deg; vs. 2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u0026deg; for varus angle (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean AOFAS score at the final follow-up was 91.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eUtilising the extensile medial approach with the sinus tarsi approach allows for better visualisation and reduction of the medial wall and joint surfaces under direct and indirect visions. Postoperative joint and bone alignment were restored. Thus, this combined approach represents a novel and effective method deserving clinical promotion.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eNot applicable (retrospective study).\u003c/p\u003e","manuscriptTitle":"Combined Extensile Medial and Sinus Tarsi Approaches for Intra-Articular Calcaneus Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 08:02:35","doi":"10.21203/rs.3.rs-7308021/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-20T08:57:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-09T04:28:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233857630157134495263928350445222154920","date":"2025-10-09T03:21:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-08T20:02:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T20:12:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231832411477273933558058036222548796141","date":"2025-09-30T05:11:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35467241424029657024382265386660966906","date":"2025-09-28T07:04:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100503232035727034244610392343326750273","date":"2025-09-26T06:41:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T05:02:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-01T18:51:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-30T03:55:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-30T03:54:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-08-06T09:11:01+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":"2238cb37-727a-485a-bc8c-cb67782eb5f2","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:04:27+00:00","versionOfRecord":{"articleIdentity":"rs-7308021","link":"https://doi.org/10.1186/s12893-026-03521-y","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-03-10 15:58:34","publishedOnDateReadable":"March 10th, 2026"},"versionCreatedAt":"2025-10-08 08:02:35","video":"","vorDoi":"10.1186/s12893-026-03521-y","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03521-y","workflowStages":[]},"version":"v1","identity":"rs-7308021","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7308021","identity":"rs-7308021","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}