Archives of Orthopaedic and Trauma Surgery (2022) 142:1911–1922
Use ofintramedullary locking nail fordisplaced intraarticular fractures
ofthecalcaneus: what istheevidence?
AlessioBernasconi1,2 · PaolinoIorio1· YaserGhani2· MiltiadisArgyropoulos2· ShelainPatel2· AlexejBarg3,4·
FrancescoSmeraglia1· GiovanniBalato1· MatthewWelck2
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
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
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
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 . 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 . No published reports
* Alessio Bernasconi
Extended author information available on the last page of the article