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Objective:To investigate the efficacy of treatment of Sanders Ⅱ & Ⅲ calcaneal fractures with an absorbable stick plus Kirschner wire through the tarsal sinus incision.Methods:From July 2017 to May 2020, 37 patients with 42 Sanders Ⅱ & Ⅲ calcaneal fractures were treated with an absorbable stick plus Kirschner wire through the tarsal sinus incision at The Third Ward of Department of Traumatic Orthopeadics, The Sixth Hospital of Ningbo. There were 25 males and 12 females, with an age of (48.2±5.6) years (from 20 to 69 years). The fractures were at the left side in 12 cases, at the right side in 20 and at bilateral sides in 5. By Sanders classification, 20 fractures were type Ⅱ and 22 ones type Ⅲ. Fracture union time and complications were recorded. Their B?hler and Gissane angles were compared between preoperation, postoperation and the last follow-up. The range of motion of the subtalar joint was evaluated by the Morrey method at 6 months postoperation. The functional recovery was evaluated by the American Society of Foot and Ankle Surgery (AOFAS) ankle-hindfoot score at 12 months postoperation.Results:The 37 patients were followed up for (15.2±2.7) months (from 13 to 18 months). There were no such complications as incision skin necrosis, Kirschner wire deformation, loss of fracture reduction or Kirschner wire infection. The anatomical morphology of the calcaneus was restored satisfactorily in the 37 patients. At preoperation, postoperation and the last follow-up, the B?hler angles were 13.3°±1.6°, 32.5°±5.5° and 32.7°±5.4° and the Gissane angles 78.3°±6.7°, 127.2°±6.7° and 128.0°±6.4°, respectively, showing significant differences between the preoperative and postoperative values ( P<0.05) but no significant differences between postoperation and the last follow-up ( P>0.05). The range of motion of the subtalar joint at 6 months postoperation was slightly limited in 25 cases and moderately limited in 12 cases, giving a rate of moderate and above limitation of 32.4% (12/37). By the AOFAS ankle-hindfoot score at 12 months postoperation, 12 cases were excellent, 21 ones good and 4 ones fair, giving a good to excellent rate of 89.2% (33/37). Conclusion:Treatment with an absorbable stick plus Kirschner wire through the tarsal sinus incision may lead to fine clinical efficacy for Sanders Ⅱ & Ⅲ calcaneal fractures.
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Objective To provide anatomical basis for the treatment of sinus tarsi syndrome by developing the anatomical structure of sinus tarsi. Methods Thirty formalin fixed lower limb specimens were dissected. The anatomic structures of the sinus tarsi, neurovascular tissue, ligament and adipose tissue were observed and measured. Morphologies of the sinus tarsi and canal of tarsus in intact dry calcaneus and talus of 136 Chinese adult specimens were investigated and measured. Results The artery of the sinus tarsi and its periphery issued from the dorsalis pedis artery, anterior medial malleolar artery, perforating peroneal artery and lateral tarsal artery. The laterosuperior point of cuboidal articular surface of calcaneus was the obvious osseous marks of the lateral surface of sinus tarsi. The length canal of tarsus, sinus tarsi and the calcaneal sulcus were (14. 85 ±2. 08) ( 8. 33-22. 00) mm, (26.38±3.05) ( 16. 54-35. 79) mm and (41. 25 ± 3. 52) (31. 06-53. 92) mm respectively. There was a angle between two axes of calcaneus and tarsal canal, which was (49. 37± 4.76) (39. 18~56.37)°. Conclusion During the treatment of sinus tarsi syndrome by the local steroid injection, the laterosuperior point of cuboidal articular surface of calcaneus should be palpated firstly, which is the point of inserting the needle. Then, the injection needle is towards posteromedial at 49°, and advance 2.5 mm to touch the sinus tarsi.
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Objective To study the effect of sinus tarsi approach in patients with calcaneus fracture combined with high risk factors of incision complications. Methods The clinical data of 18 patients with calcaneus fracture combined with high risk factors of incision complications in Jinzhou Center Hospital from July 2015 to July 2017 were retrospectively analyzed. In all patients, combined diabetes mellitus was in 8 cases, long-term smoking history was in 13 cases, combined diabetes mellitus and smoking was in 3 cases. Active and passive smoking were prohibited in hospital, and fasting and postprandial blood glucose were monitored and controlled. In order to reduce swelling , plaster fixation, limb elevation and cold compression were performed. After the blood glucose was stable and local swelling was reduced, surgery was performed via the sinus tarsi approach. After 1 to 2 weeks of postoperative gypsum fixation, the non-weight-bearing function exercise was allowed. After early activities and late loading, the weight-bearing function exercise began at least 12 weeks after surgery. Results All patients were followed up for 12 to 20 months (mean 14.3 months). No skin necrosis and infection occurred. All fractures healed, and fracture healing time was 11 to 16 weeks, with mean time of 13.5 weeks. The American Orthopaedic Foot and Ankle Society Ankle Hindfoot score was used to evaluate the curative effect. Six cases were excellent, 10 cases were good, and 2 cases were passable. Conclusions Treatment of calcaneal fracture via tarsal sinus approach has little interference with soft tissue. It is especially suitable for the patients with high risk factors of incision complications, which can effectively avoid the occurrence of incision complications. At the same time, the postoperative functional recovery is satisfactory. It is a good approach in patients with calcaneal fracture combined with high risk factors of incision complications.
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Objective@#To study the effect of sinus tarsi approach in patients with calcaneus fracture combined with high risk factors of incision complications.@*Methods@#The clinical data of 18 patients with calcaneus fracture combined with high risk factors of incision complications in Jinzhou Center Hospital from July 2015 to July 2017 were retrospectively analyzed. In all patients, combined diabetes mellitus was in 8 cases, long-term smoking history was in 13 cases, combined diabetes mellitus and smoking was in 3 cases. Active and passive smoking were prohibited in hospital, and fasting and postprandial blood glucose were monitored and controlled. In order to reduce swelling, plaster fixation, limb elevation and cold compression were performed. After the blood glucose was stable and local swelling was reduced, surgery was performed via the sinus tarsi approach. After 1 to 2 weeks of postoperative gypsum fixation, the non-weight-bearing function exercise was allowed. After early activities and late loading, the weight-bearing function exercise began at least 12 weeks after surgery.@*Results@#All patients were followed up for 12 to 20 months (mean 14.3 months). No skin necrosis and infection occurred. All fractures healed, and fracture healing time was 11 to 16 weeks, with mean time of 13.5 weeks. The American Orthopaedic Foot and Ankle Society Ankle Hindfoot score was used to evaluate the curative effect. Six cases were excellent, 10 cases were good, and 2 cases were passable.@*Conclusions@#Treatment of calcaneal fracture via tarsal sinus approach has little interference with soft tissue. It is especially suitable for the patients with high risk factors of incision complications, which can effectively avoid the occurrence of incision complications. At the same time, the postoperative functional recovery is satisfactory. It is a good approach in patients with calcaneal fracture combined with high risk factors of incision complications.
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OBJECTIVE@#To compare the clinical effects of closed reduction and internal fixation with limited transtarsal sinus incision in the treatment of Sanders type II calcaneal fractures.@*METHODS@#From June 2015 to February 2018, 60 patients with Sanders type II calcaneal fractures were treated by minimally invasive method. According to the different treatment methods, they were divided into two groups: closed prying reduction and internal fixation with hollow nails(group A) and limited transtarsal sinus incision internal fixation (group B). There were 34 cases in group A, including 22 males and 12 females, aged 21 to 60(38.90±3.25) years old, 14 cases of Sanders type IIA, 14 cases of Sanders type IIB and 6 cases of Sanders type IIC. There were 20 cases in group B, including 14 males and 6 females, aged 20 to 59(39.20±2.96) years old, 8 cases of Sanders type IIA, 9 cases of Sanders type IIB and 3 cases of Sanders type IIC. Calcaneal height, calcaneal width, Gissane angle and Bohler angle were measured before and after operation. The complications, hospitalization time and cost were compared. Functional evaluation was performed by AOFAS score system one year after operation.@*RESULTS@#Fifty-four cases were followed up for 6 to 16(11.40±2.55) months and 6 cases were lost. All the wounds healed in grade A without complications such as skin infection and necrosis. There were 1 case of nerve injury in group A, 2 cases of tendon entrapment, 2 cases of nerve injury in group B, there was no significant difference(>0.05). There was no significant difference in calcaneal width, height, Bohlers angle and Gissane angle between group A and group B (>0.05). There was no significant difference in AOFAS score between group A and group B(89.2±4.7 vs 88.7±4.8, >0.05). The hospitalization expenditure and length of stay in group A were(5 021.25±1 047.19) yuan, (6.31±4.75) d, and those in group B were(13 591.35±1 975.21) yuan, (9.65±3.42) d, respectively, with significant difference(<0.05).@*CONCLUSIONS@#Closed reduction and internal fixation is as effective as transtarsal sinus incision reduction and internal fixation for Sanders typeIIfracture. It has the advantages of less trauma and fewer complications. Closed reduction and hollow nail fixation group can significantly shorten hospitalization time, reduce hospitalization costs, and is more economical. It is worth recommending, but attention should be paid to avoid choosing to comminute serious calcaneal fracture.
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Adult , Female , Humans , Male , Middle Aged , Young Adult , Ankle Injuries , Calcaneus , Fracture Fixation, Internal , Fractures, Bone , Treatment OutcomeABSTRACT
PURPOSE: This study evaluated the radiologic and clinical results in patients who underwent minimal invasive surgery using sinus tarsi approach in Sanders type IV calcaneal fracture. MATERIALS AND METHODS: This retrospective study evaluated 13 cases of Sanders type IV calcaneus fractures that were treated by minimal invasive surgery using the sinus tarsi approach from July 2012 to April 2017. Further, these cases could be followed up for more than 12 months. Bone union, radiologic parameters such as Böhler's angle, Gissane's angle, calcaneal height, length, and width, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the postoperative complications were evaluated. RESULTS: Bony union was achieved in all the cases at the final follow up, and the mean union time was 5.5 months. One patient underwent reoperation for a surgical site infection, six patients had post traumatic arthritis, and two of them underwent subtalar joint fusion. The mean AOFAS ankle-hindfoot score was 81.2. At the final follow-up, the mean values of Böhler's angle and Gissane's angle were 20° and 119.8°, respectively, and the mean values of the calcaneus height, length, and width were 46.8 mm, 81.8 mm, and 45.6 mm, respectively. CONCLUSION: Minimal invasive surgery using the sinus tarsi approach for Sanders type IV calcaneal fracture resulted in satisfactory anatomic reduction and stable fixation, and satisfactory clinical and radiologic results were obtained in most of the patients. Minimal invasive surgery is thought to reduce the soft tissue-related complications as compared to surgery using the extensile lateral approach.
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Humans , Ankle , Arthritis , Calcaneus , Follow-Up Studies , Foot , Minimally Invasive Surgical Procedures , Postoperative Complications , Reoperation , Retrospective Studies , Subtalar Joint , Surgical Wound InfectionABSTRACT
PURPOSE: To evaluate the clinical and radiographic results of surgical treatment for patients with sinus tarsi pain due to accessory talar facet impingement. MATERIALS AND METHODS: Between July 2013 and July 2015, nine patients who underwent surgery for the accessory talar facet impingement were reviewed. The mean follow-up period was 18.6 months (12~36 months), and the mean age was 33.1 years (19~60 years). Previous trauma history, duration of symptom, and types of surgery were analyzed. The clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS). Radiographic results were assessed using Meary's angle, calcaneal pitch angle, heel alignment angle, and heel alignment ratio. RESULTS: All patients had evident trauma history prior to the initial symptom. The mean duration of symptoms was 25.6 months (6~120 months). Four patients received only accessory anterolateral talar facet (AALTF) excision, and four patients received medial sliding calcaneal osteotomy (MSCO). One patient underwent both AALTF excision and MSCO. The AOFAS ankle-hindfoot score was significantly improved from 73 (62~77) preoperatively to 93 (67~100) postoperatively. The VAS score was decreased from 6 (5~7) preoperatively to 1 (0~5) postoperatively. The Meary's angle and calcaneal pitch angle showed no significant difference after surgery. The heel alignment angle and ratio increased from −3.6° (−10°~5°) and 0.22 (−0.15~0.6) preoperatively to 2.8° (1°~5°) and 0.42 (0.3~0.6) postoperatively, respectively. CONCLUSION: If there is persistent sinus tarsi pain in patients with hindfoot valgus, accessory talar facet impingement caused by AALTF could be considered as a cause of chronic sinus tarsi pain.
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Humans , Ankle , Follow-Up Studies , Foot , Heel , OsteotomyABSTRACT
Objective To compare sinus tarsi approach(STA) and extensile L shape approach (ELA) in the surgical treatment of calcaneal fractures. Methods A total of 51 cases of calcaneal fractures treated from May 2014 to December 2016 were enrolled. Twenty of them were performed ORIF via the sinus tarsi approach, while the other 31 cases were performed ORIF via lateral extensile L shape approach. X-ray films were taken postoperatively to record the changes of B?hler angle and Gissane angle. The AOFAS, VAS and SF-36 scores were adopted to assess the therapeutic effect. Results The average follow-up period of STA group was 15.5 months. And patients in ELA group were followed up for an average period of 18.4 months. All the fractures in the series had a boney union at or before the final follow-up. The final correction of B?hler angle (34.60 ± 2.91)° , and Gissane angle (114.45 ± 2.91)° was significantly increased in the STA group; and the final correction of B?hler angle (33.55 ± 2.73)° , and Gissane angle (112.81 ± 4.15)° was also significantly increased in the ELA group; while there was no significant difference between the two groups. The final AOFAS scores , VAS scores and SF-36 scores of the STA were (83.56 ± 7.13), (1.78 ± 0.89), (88.95 ± 4.31) scores, while those in ELA group were (81.91 ± 9.89), (2.01 ± 1.33) and (86.65 ± 4.95) scores. There was no significant difference between the two groups (P>0.05). No wound problem happened in STA group, but there were 2 cases who had wound complications in ELA group. Conclusions No significant difference is found between the two groups in the short-term efficacy of the treatment for calaneal fracture. However, STA has the advantages of lower soft tissue complication rate.
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Objective To explore the efficacy of internal fixation in the treatment of intra-articular calcaneum fractures via the sinus tarsi approach . Methods A retrospective study was made on 55 feet with intra-articular calcaneum fractures in 51 patients treated with open reduction and intemal fixation via sinus tarsi approach from January 2010 to June 2015.According to the Sanders classification, there were 15 feet of type Ⅱfractures and 40 feet of type Ⅲfractures. Results All the patients were followed up for a mean period of 15.7 months (range, 6-33 months).The fractures were completely healed .According to the Maryland Foot Scores , the operative effect was excellent in 43 feet, good in 7 feet, fair in 4 feet, and poor in 1 foot.The excellent and good rate was 90.9%(50/55).The postoperative width of the calcaneum , B?hler angle, and Gissane angle were significantly improved than before operation (P=0.000). Conclusion Open reduction and internal fixation via sinus tarsi approach is a simple and effective method for minimally invasive treatment of Sanders type Ⅱand Ⅲintra-articular calcaneum fractures .
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PURPOSE: The purpose of this study was to evaluate the radiographic and clinical outcomes of subtalar arthroereisis as a method of treatment for pediatric flexible flatfoot. MATERIALS AND METHODS: We retrospectively investigated 14 feet among 10 patients with flexible flatfoot, who were treated with a subtalar arthroereisis using a sinus tarsi implant between March 2007 and June 2012. Radiographically, the talo-1st metatarsal angle, talar declination, and calcaneal pitch angle have all been measured on lateral radiographs. The talo-navicular coverage angle and talo-1st metatarsal angle was measured on anteroposterior (AP) radiographs and tibio-calcaneal angle was assessed by hindfoot alignment view. Visual analogue scale (VAS) pain scores and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were used for clinical evaluation. RESULTS: The mean follow-up was 48.7 months (16–98 months), and the mean age was 11.6 years (6–19 years). Radiographically, the mean pre-operative and postoperative values measured by the lateral foot radiograph were −25.1° and −7.5° for talo-1st metatarsal angle, 37.4° and 23.2° for talar declination, and 8.3° and 15.0° for calcaneal pitch angle, respectively. The mean preoperative and postoperative values measured by foot AP radiograph were 23.0° and 11.9° for talo-navicular coverage angle and 17.2° and 9.0° for talo-1st metatarsal angle, respectively. Moreover, tibio-calcaneal angle improved from valgus 17.4° on average to 4.5° on average. Clinically, the VAS score and AOFAS score was improved from 5.8 to 1.5 and from 61.8 to 90.4, respectively. Complication was sinus tarsi pain that occurred in 5 cases (35.7%). CONCLUSION: We achieved a satisfactory correction of pediatric flexible flatfoot deformities via subtalar arthroereisis, using a sinus tarsi implant with favorable radiographic and clinical measures. However, high potential complication rate of postoperative sinus tarsi pain on weight-bearing should carefully be considered.
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Humans , Ankle , Congenital Abnormalities , Flatfoot , Follow-Up Studies , Foot , Metatarsal Bones , Methods , Retrospective Studies , Weight-BearingABSTRACT
Objective To analyze the clinical effects of sinus tarsi approach with minimal-inva-sive percutaneous screw fixation of calcaneal fractures. Methods From February 2014 to July 2015,28 ca-ses of calcaneal fracture patients(Sanders Ⅰ ~ Ⅲ)were treated with minimal-invasive percutaneous screw fixation via sinus tarsi approach in our department. There were 18 males and 10 females with age ranging from 16 to 68 years(mean,32 years). According to the classification of Sanders,six cases were classified as Type I,twelve as Type Ⅱ,and ten as Type Ⅲ. The Bohler angle and Gissane angle were compared be-fore and after operation. Clinical results were evaluated with the Maryland foot scoring system. Results All the patients were followed up for 14 to 20 months(mean,15. 5 months). Anatomic or almost anatomic reduction was achieved in all patients according to the results of postoperative images. All fractures healed,and the healing time ranged from 4 to 7 months(average,5. 3 months). There was no wound infec-tion,necrosis or bone nonunion. According to the Maryland foot scoring system,16 cases were defined as excellent,10 cases as good,and 2 cases as poor. The good and excellent rate was 92. 8% . Conclusion For calcaneal fractures,sinus tarsi approach with minimal-invasive percutaneous screw fixation has the ad-vantages of small trauma,safe operation,limited complication,and stable fixation,which is a satisfactory clinical treatment.
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Objective To evaluate the therapeutic effect of minimally invasive retractor reduction and fixation through sinus tarsi approach together with external application of Chinese medicine for displaced intra-articular calcaneal fractures. Methods From October of 2009 to June of 2013, 52 patients with displaced intra-articular calcaneal fractures (Sanders type Ⅱ, Ⅲ) were enrolled into the study. The patients received minimally invasive retractor reduction through sinus tarsi approach and fixation with small plate and cannulated screws, and after the operation were given external washing with Chinese herbal formula Shenxing Fang ( mainly composed of Herba Lycopodii, Herba Speranskiae Tuberculatae, Rhizoma Sparganii, Rhizoma Curcumae, Herba Asari, Radix Aconiti Preparata, Radix Aconiti Kusnezoffii Preparat). Follow-up was carried out for the evaluation of the therapeutic effect of displaced intra-articular calcaneal fractures ( Sanders type Ⅱ, Ⅲ). Results Forty cases (involving 44 feet) received the postoperative follow-up for 12-18 months (average being 14.2 months). The Maryland foot scores were 95 points for type Ⅱ displaced intra-articular calcaneal fractures, and 86 points for type Ⅲ fractures. Satisfactory results were achieved in the height, width and length of the calcaneus as well as the B?hler's and Gissane angle ( P<0.01). Conclusion Minimally invasive retracter reduction and fixation through sinus tarsi approach together with external application of Chinese medicine exert satisfying effect for the treatment of displaced intra-articular calcaneal fractures.
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Open reduction and internal fixation is currently considered as a gold standard of treatment in most of the intra-articular calcaneal fractures. Among various different approaches, extensile lateral approach is the most popular since it provides good exposure to the subtalar joint. However, wide skin incision followed by extensive soft tissue dissection leading to increased risk of wound breakdown is the most serious drawback. Sinus tarsi approach, a minimal invasive technique to approach the subtalar joint and reduce the intra-articular calcaneal fractures, provides good clinical outcome and less wound complications compared to the extensile lateral approach. This article introduces the surgical technique and review of the literature regarding the sinus tarsi approach.
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Calcaneus , Skin , Subtalar Joint , Wounds and InjuriesABSTRACT
PURPOSE: This study was performed to evaluate the clinical outcomes of operative treatment using mini-open sinus tarsi approach for displaced intraarticular calcaneal fractures. MATERIALS AND METHODS: We studied 18 cases (16 patients) of intraarticular calcaneal fractures who were treated with sinus tarsi approach by same surgeon. The mean age of patients was 44.8 years, and mean follow-up period was 17.2 months. The measurement of Bohler angle, Gissane angle, the degree of articular surface depression, and the period to union were performed through preoperative and postoperative radiographs. The clinical evaluation was performed according to hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) and scale of the Creighton-Nebraska health foundation (CNHF). RESULTS: Bohler angle and Gissane angle had improved significantly from preoperative average 9.8degrees, 117.6degrees to average 22.4degrees, 113.4degrees immediate postoperatively, and had maintained to average 21.8degrees and 114.2degrees at the last follow-up. The degree of articular surface depression had improved significantly from preoperative average 5.2 mm to 1.2 mm at the last follow-up. All cases achieved bone union, and the period to union was average 10.5 weeks. AOFAS score was average 86.2 points at the last follow-up. There were 7 excellent, 9 good, and 2 fair results according to the CNHF scale. Therefore, 16 cases (88.8%) achieved satisfactory results. CONCLUSION: The minimally invasive sinus tarsi approach using headless compression screw seems to be an effective surgical method for displaced intraarticular calcaneal fractures, because of the possibility of accurate restoration of articular surface and the low risk of postoperative soft tissue complications.
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Animals , Humans , Ankle , Calcaneus , Depression , Follow-Up Studies , Foot , Intra-Articular FracturesABSTRACT
PURPOSE: To compare the clinical results between the extensile lateral approach and sinus tarsi approach in the open reduction of the Sanders type II calcaneal fracture. MATERIALS AND METHODS: From July 2002 to Februry 2007, thirty two patients having thirty three calcaneal fractures of Sanders type II were managed with open reduction and internal fixation using the extensile lateral approach or sinus tarsi approach. The mean age of 19 patients using extensile lateral approach was 43.3 years. The mean age of 13 patients using sinus tarsi approach was 46.3 years. Clinical outcome, radiographic parameters, and postoperative complications were compared between both groups. RESULTS: There was no difference between two groups associated with patients demographs. The mean AOFAS score and VAS between both groups were not different (p=0.716, p=0.774). The mean Bohler's angle and Gissane's angle between both groups were not different (p=0.343, p=0.357). Two cases of sural nerve injury, one malunion, and one deep infection were occurred in the group of extensile lateral approach. However, patients using sinus tarsi approach had no postoperative complications. CONCLUSION: The clinical results of sinus tarsi approach may be comparable with those of extensile lateral approach, with the advantages of reduced risk of postoperative complications.
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Humans , Calcaneus , Organic Chemicals , Postoperative Complications , Sural NerveABSTRACT
PURPOSE: Wound problems occur in 5~30% of intra-articular calcaneal fractures following operation. Diabetes mellitus, large incisions and abundant dissection can increase the risk of wound problems that may require skin graft or other additional care. The authors used minimally invasive technique to treat intra-articular calcaneal fractures in diabetic patients and evaluated the results and complications of this method. MATERIALS AND METHODS: Between January 2002 and July 2005, 12 patients with intra-articular calcaneal fractures who had underlying diabetes mellitus were treated using minimally invasive technique with a modified sinus tarsi approach. The patients had an average age of 47 years (39~67) and were followed an average of 19 months (13~32). The mean period between injury and operation was 8 days (5~14). Crutch assisted partial weight bearing was advised for an average of 7.3 weeks (6~9) and full weight bearing was allowed after average of 9.3 weeks (7~11). RESULTS: According to AOFAS scale for ankle and hindfoot, patients had the following results: excellent - 1 patient (8%), good - 9 patients (75%), fair - 1 patient (8%), unsatisfied - 1 patient (8%). Bone union was achieved in all cases and there were no events of deep infection or skin necrosis. CONCLUSION: Treating intra-articular calcaneal fractures by minimally invasive technique is an excellent operative method for patients with diabetes mellitus, as this method can minimize soft tissue incision and resulting deep infection and skin necrosis.