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Surgical Pearls

Emerging Concepts In Treating Calcaneal Fractures

Surgical management of displaced intra-articular calcaneal fractures is cumbersome, complex and constantly evolving. Although calcaneal fractures account for approximately 60 percent of tarsal bone fractures, there is no consensus among foot and ankle surgeons as to the optimal surgical approach.1 Approximately 75 percent of calcaneal fractures are intra-articular and it is well accepted that if one does not restore the morphology of the bone and the subtalar joint is not aligned, sequelae will occur.2,3 These sequelae can include chronic pain, edema, malunion, varus deformity, soft tissue complications and post-traumatic arthritis. 

The traditional approach through a lateral extensile incision for open reduction and internal fixation (ORIF) of joint depression calcaneal fractures is well documented to have a high rate of wound healing complications and postoperative infections. The rate of wound edge necrosis is reportedly as high as 18 percent and infection rates are as high as 20 percent.4,5 Many of these patients also require additional surgical procedures.6 For these reasons, surgeons prefer a less invasive approach when it comes to the treatment of intra-articular joint depression calcaneal fractures. 

Reports show that open reduction and internal fixation through a minimal incision approach restores Bohler’s angle and the crucial angle of Gissane either as well as, or better than the lateral extensile approach.7,8 Researchers have also demonstrated that the minimal incision approach prevents wound dehiscence and soft tissue complications associated with the lateral extensile incision, and eliminates the need for additional surgery.5 Patient satisfaction rates and outcome scores are also superior for minimal incision patients versus those treated with the traditional approach.5 

Further evolution of surgical treatment for intra-articular joint depression calcaneal fractures has led to intraosseous reduction with interlocking nail fixation through a posterior approach. The surgeon aids the reduction with external fixation or a jig to distract the subtalar joint and stabilize the fracture fragment reduction. Benefits of this technique include the use of a small incision with minimal hardware, minimizing the risk of sural nerve injury and a reduced risk for loss of reduction with weightbearing. 

Essential Aspects Of The Surgical Technique 

One makes an approximately two cm incision at the junction between the posterior and plantar aspect of the heel. The surgeon then introduces a K-wire into the posterior calcaneal tuberosity in the direction of the posterior talar surface above the angle of Gissane and in the middle of the calcaneal tuberosity following the direction of the fourth digit or fourth intermetatarsal space. Confirmation of proper placement of the K-wire with fluoroscopy in lateral and calcaneal axial views is essential. One then places additional/K-wires laterally, one in the calcaneus superior to the posterior K-wire and the other in the lateral process of the talus. After connecting a Caspar-type distractor to the K-wires, one can proceed to distract the subtalar joint (see first photo above). 

Subsequent placement of a hollow reamer over the first K-wire creates a tunnel or work chamber for reduction of the fracture fragments. Direct the reamer toward the middle of the articular surface in order to remove a two to three cm bone plug and then remove the original K-wire (see second photo above). Then the surgeon reduces the fractures by making a series of curved and straight tamps in the bone tunnel (see third photo above). The senior author will usually make a small lateral incision over the sinus tarsi to clinically visualize anatomic alignment of the subtalar joint. 

After confirming reduction of the fractures and restoration of the calcaneus with fluoroscopy, one determines the length of the nail with the use of a nail length gauge. Employing a nail holder, the surgeon inserts the appropriate size nail from the posterior calcaneus up to the posterior facet of the calcaneus. At this point, one can remove the distractor, attach a nail alignment frame to the nail holder and insert cannulated screws laterally into the nail (see fourth photo above). The surgeon then removes the nail holder and alignment frame, and closes the incisions. 

What Is The Evidence Surrounding Interlocking Nails For Calcaneal Fractures? 

Cadaveric studies show that interlocking nails are not inferior to lateral locking plates for the treatment of calcaneal fractures in regard to load to failure, stiffness and interfragmentary motion.9,10 A study by Simon and colleagues has also shown outcome scores of calcaneal fracture patients treated with a locking nail to be comparable to the outcome scores of patients treated with other techniques.11 For the 54 patients treated with a locking nail and completed the study, the average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS-AHS) was 86.5. Although six implants necessitated removal and three patients went on to secondary subtalar joint fusions, the authors reported few complications with the locking nail technique. 

In a study looking at the use of an intramedullary nail in treating joint displacement intra-articular calcaneal fractures, Fourgeaux and team obtained three-dimensional reconstruction computed tomography (CT) scans immediately postoperative, one year postoperative and at a final follow-up averaging 2.8 years.12 The CT scans demonstrated excellent or good overall reduction in 81 percent of the patients. The postoperative hindfoot valgus position of the 26 total patients based on the Meary view radiograph, was five degrees at the last follow-up. The average Bohler’s angle and crucial angle of Gissane was 32 degrees and 101 degrees respectively, at the last follow-up as well. In addition, at the final follow-up, the average AOFAS-AHS score was 79, the average visual analog pain scale rating was three and the average duration of the surgery was 69 minutes.12 This study confirms the efficacy of an intramedullary nail for intra-articular calcaneal fractures as the results are comparable to other published studies cited in this article. 

Final Thoughts 

Based on the primary author’s experiences, the use of intraosseous reduction and a locking nail for the treatment of intra-articular joint depression calcaneal fractures is an emerging technique, which has minimal soft tissue complications and fracture reduction equal to the traditional lateral extensile approach. One can perform this novel technique faster than the extensile lateral approach, thus reducing operating room time. In our experience, patients tend to return to normal shoe gear at a faster rate and patient satisfaction compares to that of other minimally invasive techniques. Although further research is necessary, the use of locking nails for the treatment of calcaneal fractures is a promising surgical technique.  

Dr. Cook is the Director of Podiatric Medical Education and the Assistant Director of the Podiatry Department at University Hospital in Newark, N.J. 

Dr. Hayashi is the Chief Resident of the Podiatric Residency Program at University Hospital in Newark, N.J. 

Surgical Pearls
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By Keith D. Cook, DPM, FACFAS and Bobbi Hayashi, DPM
References

1. O’Connell F, Mital MA, Rowe CR. Evaluation of modern management of fractures of the os calcis. Clin Orthop Relat Res. 1972;83:214- 223. 

2. Essex-Lopresti P. The mechanism, reduction technique and results in fractures of the os calcis. Br J Surg. 1952;39(157):395-419. 

3. Eastwood DM, Phipp L. Intra-articular fractures of the calcaneum: why such controversy? Injury. 1997;28(4):247-259. 

4. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Orthop Trauma. 1999;13(5):369-372. 

5. Wang Q, Chen W, Su Y, et al. Minimally invasive treatment of calcaneal fracture by percutaneous leverage, anatomic plate, and compression bolts – the clinical evaluation of cohort of 156 patients. J Trauma. 2010;69(6):1515-1522. 

6. Ding L, He Z, Xiao H, Chai L, Xue E. Risk factors for postoperative wound complications of calcaneal fractures following plate fixation. Foot Ankle Int. 2013;34(9):1238-1244. 

7. DeWall M, Henderson CE, McKinley TO, Phelps T, Dolan L, Marsh JL. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Ortho Trauma. 2010;24(8):466-472. 

8. Schuberth JM, Cobb MD, Talarico RH. Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. J Foot Ankle Surg. 2009;48(3):315- 322. 

9. Reinhardt S, Martin H, Ulmar B, et al. Interlocking nailing versus interlocking plating in intra-articular calcaneal fractures: a biomechanical study. Foot Ankle Int. 2016;37(8):891- 897. 

10. Goldzak M, Simon P, Mittlmeier T, Chaussemier M, Chiergatti R. Primary stability of an intramedullary calcaneal nail and an angular stable calcaneal plate in a biomechanical testing model of intraarticular calcaneal fracture. Injury. 2014;45(Suppl1):s49-53. 

11. Simon P, Goldzak M, Eschler A, Mittlmeier T. Reduction and internal fixation of displaced intra-articular calcaneal fractures with a locking nail: a prospective study of sixty nine cases. Int Orthop. 2015;39(10):2061-2067. 

12. Fourgeaux A, Estens J, Fabre T, Laffenetre O, Hernandes JL. Three-dimensional computed tomography analysis and functional results of calcaneal fractures treated by an intramedullary nail. Int Orthop. 2019;43(12):2839-2847. 

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