SLR - August 2016 - Ted C. Lai

Introduction of a New Locking Nail for Treatment of Intraarticular Calcaneal Fractures

Reference: Zwipp H, Paša L, Žilka L, Amlang M, Rammelt S, Pompach M. Introduction of a New Locking Nail for Treatment of Intraarticular Calcaneal Fractures. J Orthop Trauma. 2016 Mar; 30 (3):88–92.

Scientific Literature Review
Reviewed By: Ted C. Lai, DPM
Residency Program: Aria Health System, Philadelphia, PA

Podiatric Relevance: Displaced intraarticular calcaneal fractures are devastating injuries that usually require extensive operative fixation to restore shape and articular anatomy. The traditional lateral extensile approach for open reduction internal fixation of intraarticular calcaneal fractures is an inherently fragile incisional approach due to the risk of sacrificing the lateral calcaneal artery. It carries a high risk of developing wound complications, which ultimately may lead to skin necrosis and infection. With advances in fixation options, stronger constructs are being developed with less invasive measures required. In this article, the authors present a new technique with the use of a locking nail and limited incision for treatment of intraarticular calcaneal fractures.

Methods: This is a prospective case-control study at level 1 trauma centers in which 103 patients with 106 calcaneal fractures were treated with the use of an interlocking nail from February 2011 to October 2013. Patients with neuropathy, vasculopathy or poorly controlled diabetes were excluded. Patients were followed up for a minimum of 12 months, and complication rates, radiographic results and functional results were assessed. Computed tomographic scans were taken postoperatively to evaluate reduction.  

This article introduced a new technique for fixating intraarticular calcaneal fractures with the use of an interlocking nail, “C-Nail” (C-Nail; Medin, Nové Mesto na Morave, Czech Republic). The C-Nail is an 8mm-diameter steel nail measuring 65mm in length, which is inserted from the posterior aspect of the calcaneal tuberosity through a small 10mm incision. A targeting guide is utilized to insert interlocking screws across the calcaneal fracture and C-Nail. Small percutaneous incisions or the sinus tarsi approach are utilized to aid in reduction of the fracture.

Results: One hundred and six calcaneal fractures, Sanders Classification 1-4 were repaired with the C-Nail. 26.2 percent of patients were smokers, and 5.8 percent were diabetic. All fractures were healed at 3 months with full weightbearing at that time. Complications that were observed were superficial wound necrosis, which was seen in 1.9 percent of patients, which healed with local care. Deep infection was noted in 1 case (0.9 percent) in which the patient had a Gustilo/Anderson type II open calcaneal fracture. Radiographic results displayed a Bohler angle, which improved from 7.3 degrees preoperatively to 28.7 degrees 6 months postoperatively. Posterior facet step off had improved from 5.3mm preoperatively to 0.7mm postoperatively. Average AOFAS ankle/hindfoot score was 92.6 at 12 months postoperatively.

Conclusions: Treatment of intraarticular calcaneal fractures are of significant difficulty to restore the anatomical alignment and articular congruity. Along with the arduousness with open reduction internal fixation, the soft-tissue healing component also is a significant factor due to the incision being prone to developing complications. These complications have been reported in literature to be as high as 25 percent. Complications, such as dehiscence, skin necrosis and infection, may lead to high morbidity and multiple returns to the OR for surgical treatment. With advancement in technology and procedures, innovative measures have been taken to create smaller incisions to prevent these complications. The authors have introduced the locking nail (C-Nail) as an alternative fixation for intraarticular calcaneal fractures that requires a less invasive incisional approach to decrease soft-tissue complications. From previous biomechanical studies, calcaneal locking nails have been shown to have significantly higher stiffness and load to failure when compared to AO calcaneal plates. The results from this study show that complications were minimal, correction was obtained and patients at 12 months postoperatively were functionally doing well. The locking calcaneal nail has shown promising results in this study, but further research is needed with longer follow-up to better assess the locking calcaneal nail before it becomes a conventional treatment option for intraarticular calcaneal fractures. 

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