SLR - August 2021 - Chloe F. Sakow

Treatment of Displaced Intra-Articular Calcaneal Fractures With an Interlocking Nail (C-Nail)

Reference: Veliceasa B, Filip A, Pinzaru R, Pertea M, Ciuntu B, Alexa O. Treatment of Displaced Intra-articular Calcaneal Fractures With an Interlocking Nail (C-Nail). J Orthop Trauma. 2020 Nov;34(11):e414-e419.

Level of Evidence:
Level IV

Scientific Literature Review

Reviewed By: Chloe F. Sakow, DPM, MPH
Residency Program: Regions Hospital/HealthPartners Institute – St. Paul, MN

Podiatric Relevance: Displaced intra-articular calcaneal fractures (DIACFs) require surgical intervention to restore anatomic alignment. Nonsurgical treatment with these injuries is generally associated with poor results, including secondary subtalar arthrosis and long-term changes in hindfoot alignment. The prior gold standard for treatment of DIACFs was ORIF via an extensile lateral approach, however this is associated with wound healing complications. Minimally invasive techniques such as the sinus tarsi approach offers direct control of joint reduction without soft tissue dissection with lower complication rates. This study aimed to assess the outcomes of the sinus tarsi approach with percutaneous nail fixation for DIACFs.

Methods: A level IV prospective study was performed on patients with DIACFs who were treated using a percutaneous C-Nail +/- posterior facet fixation via the sinus tarsi approach. Each case was assessed using the Sanders, Gustillo Anderson, and the Tscherne and Oestern classifications; the Böhler’s angle and articular surface step off were measured as well. Post-operatively the patients were assessed for the restoration of the Bohler angle, complications, and overall fracture reduction. The Mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS-AHS) and Maryland Foot Score (MFS) were recorded. Data was analyzed using SPSS ANOVA (p<0.05).

Results: A total of 64 consecutive patients with 75 DIACFs were included. The majority of fractures were due to a fall from a height (93.8 percent), and 26 (40.8 percent) were heavy smokers, surgically treated on average 2.9 days after initial injury. The mean preoperative Böhler angle was significantly higher in patients with Sanders IIA fractures and lower with Sanders IIIBC fractures (p=0.016). The postoperative Böhler angle was higher in patients with Sanders IIB and IIIAB fractures and lower with Sanders IV fractures (p=0.032). Regardless of the fracture classification, the postoperative Böhler angle significantly increased and postoperative articular surface step-off decreased compared to preoperative values (p=0.001). Three (4 percent) incidences of postoperative superficial wound edge necrosis occurred and one case of infection that required an incision and drainage occurred. Mean AOFAS-AHS scores were directly correlated with the immediate post-operative Böhler angle, RCS and one year follow up measurements (P=0.001)

Conclusions: The findings from this study demonstrated the percutaneous sinus tarsi approach using the C-Nail fixation is a viable option for treating DIACFs coupled with an anatomic reduction of the posterior facet using independent lag screws in patients to avoid soft tissue trauma while maintaining primary stability. This study population, with over 40 percent of patients considered heavy smokers, points to the benefits of a minimally invasive approach to DIACFs in patients who are higher risk for wound healing complications. An increased Böhler angle postoperatively and anatomic reduction of the posterior facet (<1.2 millimeters) were correlated with patient satisfaction. Consideration to future studies should be given to include a control group and a longer follow up period beyond one year postoperatively. 

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