A Guide To Intramedullary Fixation For Calcaneal Fractures

Given the painful nature of displaced intra-articular calcaneal fractures and the variety of complications associated with open primary repair, this author takes a closer look at the potential of ligamentotaxis through percutaneous external fixation and intramedullary locked nail fixation.

Displaced intra-articular calcaneal fractures are life-changing events for most patients, resulting in permanent pain, swelling and stiffness.¹ Surgeon experience does matter since centers with fewer than one surgical repair of displaced intra-articular calcaneal fractures per month have a five times greater infection rate and 3.3 times greater subtalar arthrodesis rate than those centers with more than one case per month.²

Unfortunately, it is not practical to require surgeons managing displaced intra-articular calcaneal fractures to have surgical expertise and mastery of the latest techniques including non-operative management, open reduction with internal fixation (ORIF), percutaneous and minimally invasive reduction and fixation methods as well as primary subtalar arthrodesis techniques.^3,4 Although the optimal management of displaced intra-articular calcaneal fractures remains elusive, especially in those patients with bilateral involvement, one should ideally tailor treatment options to the fracture’s unique characteristics and the individual patient requirements.

A dilemma exists about the long-term benefit of open primary operative intervention, even in experienced hands, given the high incidence of post-traumatic osteoarthritis, symptomatic hindfoot stiffness, retro-peroneal tendon adhesions, wound dehiscence and infection due to the extensive soft tissue trauma inherent with these injuries.⁵ Although anatomical reduction of the articular surface of the subtalar joint posterior facet is of significant importance, perfect anatomic reduction does not guarantee an improved clinical outcome due to the development of avascular necrosis of the periarticular fragments.^2,4,5 In a study of six cadavers, Barrick and colleagues demonstrated that the subtalar joint tolerates articular incongruity of 2 to 3 mm well without step off.⁶

Furthermore, researchers have demonstrated that restoration of normal calcaneal morphology restores normal kinematic and contact stress in the subtalar joint complex, and facilitates less complex secondary surgical intervention than a malunited calcaneus.^7–9 Specifically, Qiang and colleagues, in a study of 156 patients, found that restored Böhler’s and Gissane’s angles correspond to better American Orthopaedic Foot and Ankle Society (AOFAS) scores.⁷ Radnay and colleagues studied 69 patients with 75 displaced intra-articular calcaneal fractures and painful posttraumatic subtalar arthritis.⁹ The authors found those who had initial ORIF followed by in situ subtalar fusion had improved functional outcomes and fewer wound complications in comparison to patients who had subtalar distraction arthrodesis after initial conservative care and development of a painful malunion.

It is clear that incision breakdown with deep infection and sural nerve injury following open surgical approaches are devastating complications that surgeons cannot easily resolve.^4,10 Ideally, management of displaced intra-articular calcaneal fractures will include preservation of the vascular supply to all soft tissues and osseous fragments involved, employ minimally invasive traction capable of restoring calcaneal morphology using ligamentotaxis/tendinotaxis along with indirect joint surface reduction techniques, and finally the ability to deliver minimally invasive but rigid internal fixation.^11-16  

Recent literature supports the use of percutaneous external fixation distractor-assisted ligamentotaxis/tendinotaxis to restore calcaneal morphology, intraosseous indirect subtalar joint surface reduction and stabilization with a rigid, locked intramedullary nail contained within the calcaneus.^17-21 Representative implants that by and large incorporate these features include the Calcanail (FH Orthopedics), C-Nail (Medin) and Vira Calcaneal System (Biomet Spain Orthopaedics). Of these, the Calcanail is the only implant available in the United States for clinical use.

Key Pointers On The Surgical Technique

Perform the Calcanail procedure with the patient in the prone position under general anesthesia. Apply a well-padded thigh tourniquet to the operative lower extremity for hemostasis but do not routinely inflate the tourniquet. Under intraoperative C-arm image intensification, drive a guide wire with a stopper into the posterior tuberosity. Maintain alignment on the lateral view with the critical angle of Gissane and on the axial view with the middle of the calcaneal tuberosity axis, which parallels any varus deformity present.

Place a 3.2 mm bicortical Kirschner wire through the positioning square, perpendicular to the guide wire. Then place a second 3.2 mm bicortical Kirschner wire perpendicular to the talar neck. Place a distraction device over the Kirschner wires in the calcaneus and talus. Turn the large thumbscrew to gradually open and distract the subtalar joint until the calcaneal tuber is out of varus and medially translated, and the length and height have been restored.

Place a hollow trephine over the guide wire and advance it under image intensification to just beneath the subchondral bone of the posterior facet. Remove the trephine, which now contains the cylindrical bone graft, which you will save for later use. Proceed to reduce the posterior facet fragments. Using the inferior surfaces of the talus as a template, place a combination of straight, curved and spatula-shaped tamps through the working chamber created by the trephine.

Although the next step depends on the fracture pattern, most commonly, one first elevates the medial constant fragment and then addresses the lateral and central fragments. Employ image intensification to track the reduction until the subtalar joint line is congruent. Measure the length of the 10 mm diameter fracture nail with available lengths being 45, 50 and 55 mm. After selecting the correct length, pack the oblong window with the previously harvested autogenous bone graft from the trephine. Then introduce the nail through the working chamber and lock the nail by placing two bicortical, threaded locking screws through the alignment frame targeting device. One can place an optional oblique screw through the oblong window to increase rotational stability. The placement of independent screws outside the nail is an option as well. After placing the interlocking screws, remove the distractor and insert an end cap to facilitate removal if necessary.

Place the patient in a well-padded sterile dressing from toes to knee with the addition of a posterior splint to maintain the foot at 90 degrees to the lower leg. Patients wear a dressing until the skin incision has healed, which routinely occurs at the two-week visit. They will subsequently use a non-articulated immobilization boot and begin range of motion. Patients remain non-weightbearing for six weeks followed by a gradual return to full weightbearing and transition to shoe gear with serial surveillance radiographs assessing osseous healing.

In the case of non-reconstructable damage to the posterior facet of the subtalar joint or late symptomatic post-traumatic degenerative disease, one can employ the same approach and instrumentation to perform a primary arthrodesis of the subtalar joint with the 65, 75 or 85 mm long and 12 mm diameter Calcanail with a minimally invasive sinus tarsi, or a posterior endoscopic approach for joint preparation.

What The Research And Surgeon Experience Reveal

One biomechanical cadaver dry bone study demonstrated the Calcanail being three times stiffer and having a significantly higher load to failure than a locked perimeter calcaneal plate.²² Böhler’s angle was preserved in all of the Calcanail specimens but in only half of the plated specimens included in this study. Another biomechanical fresh-frozen cadaver bone study demonstrated that the Calcanail had no difference in load to failure, stiffness or interfragmentary motion in comparison to a modern anatomic locked perimeter calcaneal plate.²³

Goldzak and colleagues found the Calcanail’s creation of a working channel provides significant bone autograft and can facilitate intrafocal reduction of the displaced articular surface.¹⁷

Simon and colleagues conducted a prospective, non-randomized clinical study of 69 displaced intra-articular calcaneal fractures treated with the Calcanail.18 At a mean of 12.3 months, researchers evaluated 54 patients due to five patients being lost to follow-up and 10 patients having subtalar arthrodesis with the Calcanail fusion nail (six primary and four secondary fusions). Böhler’s angle increased from a mean of 6.7 to 30.4 degrees at six months and 84 percent of patients had no intra-articular posterior facet step-off based on computed tomography (CT) scans performed at three months. No patient had malunion, ankle motion was preserved in 52 (96 percent) patients and only five (9 percent) patients had less than 25 percent normal subtalar motion. Two patients developed sural nerve hypoesthesia that resolved spontaneously at six and eight months respectively. Six (11 percent) patients required hardware removal due to technical errors, including four locking screws that were too long and one nail that was too long.

Of note, the surgeons in this study encountered no wound healing problems or infections.¹⁸ At a mean follow-up of 12.3 months, 51 (94 percent) patients had a normal gait without a limp, 49 (91 percent) patients walked with mild or no difficulty, 45 (83 percent) patients had mild or no pain, and 37 (69 percent) patients reported no functional limitations.

Similarly, Falis and Pyszel conducted a prospective, non-randomized clinical study of 18 displaced intra-articular calcaneal fractures treated with the Calcanail at a mean follow-up of 12-months.¹⁹ Böhler’s angle increased from a mean of -3 degrees to 29 degrees at final follow-up and 89 percent had near or fully anatomic articular surface alignment based on postoperative CT scans. Two patients had implant-related problems with one requiring removal of the implant. No nerve injury, wound healing or infection-related complications occurred.

While the Calcanail offers several advantages over other forms of fixation, it is not without inherent limitations. There is a learning curve as the operative technique requires experience with percutaneous, minimally invasive and open approaches to achieve consistent near anatomic reductions, and incorporates maneuvers unfamiliar to most foot and ankle surgeons.

The surgeon places the initial guide wire free hand but one must ensure careful placement as all the subsequent steps depend on this wire. Heavy reliance on intraoperative image intensification, including repeated lateral, axial and Broden’s views, can lengthen operative time and the prone position can be disorienting for surgeons used to a lateral decubitus position. Even the inventor/consultant surgeons who were experienced with the device had patients with unacceptable joint reduction requiring secondary arthrodesis and technical errors resulting in the need for hardware removal.^18,19 Lastly, with surgical expenses under greater scrutiny, more literature is needed to better study the cost-benefit analysis of this device.

In Conclusion

Although one cannot reverse soft tissue and osseous damage from the initial calcaneal fracture injury, with the use of minimally invasive reduction techniques and stout internal fixation, the surgeon can limit further destruction and restore anatomic alignment. The surgeon can also limit iatrogenic damage to the bone, articular cartilage and soft tissue structures.

While not definitive, biomechanical cadaveric and prospective, non-randomized clinical studies have demonstrated that percutaneous external fixation distractor-assisted ligamentotaxis/tendinotaxis can reliably restore calcaneal morphology, and achieve near anatomic intraosseous reduction of the calcaneal posterior facet fragments through indirect manipulation techniques and rigid internal fixation provided with a locked intramedullary Calcanail contained within the calcaneus.

Despite the lack of robust literature, the existing studies on the use of the Calcanail offer promising results, including no documented wound healing problems or infectious complications, and may also allow for earlier operative intervention than other approaches. However, there is a clear need for non-inventor/consultant surgeon prospective data to better assess outcomes of calcaneal fracture management with intraosseous reduction and internal locked nail fixation.

Dr. Roukis is attending staff in the Orthopaedic Center at the Gundersen Health System in La Crosse, Wis. He is a Past President and Fellow of the American College of Foot and Ankle Surgeons. Dr. Roukis has disclosed that he is a consultant for DePuy Synthes, FH Orthopedics, Integra and Novastep. He receives royalties from CrossRoads Extremity Systems, Novastep and Stryker Orthopaedics.

References

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Editor’s note: For related articles, see “Point-Counterpoint: Is Open Repair More Effective Than Percutaneous Ex Fix For Calcaneal Fractures?” in the January 2017 issue of Podiatry Today or “Point-Counterpoint: Is It Time To Retire Internal Fixation For Calcaneal Fractures?” in the August 2017 issue.