Use of intramedullary locking nail for displaced intraarticular fractures of the calcaneus: what is the evidence?

Abstract

Introduction
Intramedullary locking devices (ILDs) have recently been advocated as a minimally invasive approach to manage displaced intraarticular calcaneal fractures (DIACFs), to minimise complications and improve outcomes. We reviewed clinical and biomechanical studies dealing with commercially available devices to identify their characteristics, efficacy and safety.

Methods
Following a PRISMA checklist, Medline, Scopus and EMBASE databases were searched to identify studies reporting the use of ILDs for treating DIACFs. Biomechanical studies were first evaluated. Cohort studies were then reviewed for demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations. The modified Coleman Methodology Score (CMS) was used to assess the quality of studies.

Results
Eleven studies were identified which investigated two devices (Calcanail®, C-Nail®). Three biomechanical studies proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Eight clinical studies (321 feet, 308 patients) demonstrated a positive clinical and radiographic outcome at 16-months average follow-up. Metalware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications, while soft tissue issues (wound necrosis, delayed healing, infection) were reported in 3–5% of cases. Conversion to subtalar fusion was necessary in up to 6% of cases. Four (50%) out of 8 studies were authored by implant designers and in 5 (62%) relevant conflicts of interest were disclosed. Mean (± standard deviation) CMS was 59 ± 9.8, indicating moderate quality.

Conclusions
Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short-term follow-up, enabling restoration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment symptoms are common complications although wound complications are less frequent than after open lateral approaches. The quality of evidence provided so far is moderate and potentially biased by the conflict of interest, raising concerns about the generalisability of results.

Level of evidence
Level V – Review of Level III to V studies.

Full text

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Archives of Orthopaedic and Trauma Surgery (2022) 142:1911–1922
https://doi.org/10.1007/s00402-021-03944-7
TRAUMA SURGERY
Use ofintramedullary locking nail fordisplaced intraarticular fractures
ofthecalcaneus: what istheevidence?
AlessioBernasconi1,2 · PaolinoIorio1· YaserGhani2· MiltiadisArgyropoulos2· ShelainPatel2· AlexejBarg3,4·
FrancescoSmeraglia1· GiovanniBalato1· MatthewWelck2
Received: 3 March 2021 / Accepted: 3 May 2021 / Published online: 11 May 2021
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021
Abstract
Introduction Intramedullary locking devices (ILDs) have recently been advocated as a minimally invasive approach to man-
age displaced intraarticular calcaneal fractures (DIACFs), to minimise complications and improve outcomes. We reviewed
clinical and biomechanical studies dealing with commercially available devices to identify their characteristics, efficacy
and safety.
Methods Following a PRISMA checklist, Medline, Scopus and EMBASE databases were searched to identify studies report-
ing the use of ILDs for treating DIACFs. Biomechanical studies were first evaluated. Cohort studies were then reviewed for
demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations.
The modified Coleman Methodology Score (CMS) was used to assess the quality of studies.
Results Eleven studies were identified which investigated two devices (Calcanail®, C-Nail®). Three biomechanical studies
proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Eight clinical studies
(321 feet, 308 patients) demonstrated a positive clinical and radiographic outcome at 16-months average follow-up. Metal-
ware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications,
while soft tissue issues (wound necrosis, delayed healing, infection) were reported in 3–5% of cases. Conversion to subtalar
fusion was necessary in up to 6% of cases. Four (50%) out of 8 studies were authored by implant designers and in 5 (62%)
relevant conflicts of interest were disclosed. Mean (± standard deviation) CMS was 59 ± 9.8, indicating moderate quality.
Conclusions Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short-term follow-up, enabling resto-
ration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment
symptoms are common complications although wound complications are less frequent than after open lateral approaches.
The quality of evidence provided so far is moderate and potentially biased by the conflict of interest, raising concerns about
the generalisability of results.
Level of evidence Level V – Review of Level III to V studies.
Keywords Calcaneus· Fracture· Displaced· Subtalar· Nail· Calcanail
Introduction
Calcaneal fractures are the most frequent tarsal bony injury
and account for 1% to 4% of all adult fractures [1, 2]. Intra-
articular extension is present in 60% to 80% of cases with
joint incongruity associated with functional impairment [1,
2]. Adequate restoration of the articular surface can lead
to satisfactory long-term clinical results [3–6] and surgical
goals are thus focused on re-establishing the height and
length of the calcaneus and reconstructing the posterior
articular facet in particular [7]. The best treatment of the
displaced intraarticular calcaneal fracture (DIACF) is still
debated [1, 8–10]. Lateral approaches are associated with
complications including hematoma, skin necrosis, soft tissue
infection, and osteitis in up to 35% of cases [5, 11–15]. This
has generated interest in percutaneous reduction and fixation
techniques [16–19], which may reduce these risks.
Gussenbauer reported the use of an intramedullary nail
to fix calcaneal fractures as early as 1888 although no out-
comes are available for review [20]. No published reports
* Alessio Bernasconi
alebernas@gmail.com
Extended author information available on the last page of the article
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