Interlocking Nail Fixation for the Treatment of Displaced Intra-Articular Calcaneal Fractures.

introductionLess invasive restoration of joint congruity and calcaneal shape in displaced intra-articular calcaneal fractures via a sinus tarsi approach followed by percutaneous internal fixation with an interlocking nail results in a low rate of soft-tissue complications and good short-term outcomes INDICATIONS & CONTRAINDICATIONS: STEP 1 PATIENT PLACEMENT: Place the patient in the lateral decubitus position, supporting the involved extremity with a soft radiolucent pillow, flex the contralateral knee, check with fluoroscopy before draping, and obtain lateral radiographs. STEP 2 INCISION: Use a sinus tarsi approach for control of the articular reduction. STEP 3 PERCUTANEOUS MANIPULATION OF THE MAIN FRAGMENTS: Percutaneously manipulate the main fragments to facilitate reduction of the main tuberosity fragment toward the sustentacular fragment and subsequent joint reduction. STEP 4 JOINT REDUCTION WITH DIRECT MANIPULATION OF THE MAIN FRAGMENTS THROUGH THE SINUS TARSI APPROACH: Reduce the joint with direct manipulation of the main fragments through the sinus tarsi approach. STEP 5 JOINT FIXATION WITH SCREWS: Check the congruency of the posterior subtalar joint facet, stabilize the posterior facet with 2 screws, reduce the tuberosity against the joint block and anterior process, and temporarily fix with Kirschner wires. STEP 6 INTRODUCTION OF THE INTRAMEDULLARY NAIL: Make a 10-mm vertical incision below the attachment of the Achilles tendon, direct the guidewire toward the center of the calcaneocuboid joint, place the guidewire centrally within the calcaneal body, ream over the guidewire, and introduce the intramedullary nail with the attached aiming device. STEP 7 LOCKING OF THE NAIL: Use the aiming device to position the proximal Kirschner wire into the sustentacular fragment, place the nail so that it hits the sustentaculum tali properly, insert a second Kirschner wire through the other hole of the guiding arm, exchange the wires after drilling for locking screws, apply an end cap to extend the length of nail, if needed, and then verify proper reduction and implant position fluoroscopically. STEP 8 POSTOPERATIVE MANAGEMENT: Manage the patient with continuous passive motion and active range-of-motion exercises of the ankle beginning on postoperative day 2 and allow partial weight-bearing of 20 kg for 6 to 10 weeks.

resultsRecently, we reported on 103 patients with 106 intra-articular calcaneal fractures treated with the C-Nail by 4 senior surgeons from February 2011 to October 2013 PITFALLS & CHALLENGES: