SLR - December 2019 - Kevin N. Nguyen
Reference: Calcaneal Fracture Fixation Using A New Interlocking Nail Reduces Complications Compared to Standard Locking Plates - Preliminary Results After 1.6 Years. Herlyn A, Brakelmann A, Herlyn PK, Gradl G, Mittlmeier T. Injury. 2019 Jul 15. pii: S0020-1383(19)30414-0.Scientific Literature Review
Reviewed By: Kevin N. Nguyen, DPM
Residency Program: Grant Medical Center – Columbus, OH
Podiatric Relevance: The surgical repair of calcaneal fractures is a challenging task that foot and ankle surgeons face due to the incidence of posttraumatic subtalar arthritis, wound healing complications and deep infection. Open reduction and internal plate fixation through a lateral extensile approach has traditionally been the standard of care. However, the poor blood supply of the lateral soft tissue flap invariably makes this approach vulnerable to infection and healing complications. Minimally invasive interlocking nails have been recently introduced to avoid these complications while also aiming to provide comparable reduction and functional outcomes. The authors present preliminary results of a matched pairs analysis to compare the midterm outcomes of a calcaneal interlocking nail to standard locking plate fixation.
Methods: Patients matched on age, gender, Sander’s classification and soft tissue injury according to Tscherne and Oestern with displaced intraarticular calcaneal fractures were treated with either a calcaneal interlocking nail or locking plate. The matching selected 40 feet in 38 patients for analysis at 20 months. This included 20 feet treated with standard locking plate (DePuy Synthes) and was matched to 20 prospectively analyzed feet treated with interlocking nails (Calcanail, FH Ortho). Clinical and radiological evaluations including Bohler and Gissane angles, AOFAS ankle-hindfoot scores, Revised Foot Function Index (R-FFI), and visual analogue scale (VAS) were compared.
Results: The preliminary results demonstrate a significant difference in the overall complication rates seen between the groups; with the plating group having more cases of impaired wound healing, deep infections, and hardware breakage. There was no significant difference in AOFAS hind-foot, VAS, or R-FFI scores. There was a significant reduction in the length of hospital stay, duration of required partial weight bearing, and time away from work with the nailing group. There was also a smaller scar and reduced rate of hindfoot sensory disorders seen with the nail group. Patients whose calcaneal fractures were fixated with a locking plate demonstrated a more secure and stable heel strike when compared to the nailing group. This is likely due to the positioning of the through-the-heel approach of the nail. Improved ranges of motion in plantarflexion, eversion and inversion were noted in the nailing group. Significant reduction in Bohler and Gissane angles were seen with both groups. Similarly, there was a comparable loss of reduction over time seen in both groups.
Conclusions: While there was no significant difference in AOFAS hind-foot, VAS, or R-FFI scores, the minimally invasive interlocking nail demonstrates a significantly lower incidence of complications. With the nailing group, there was significantly less post-operative wound healing complications and infection rates compared to the plating group. These patients also had a shorter hospital stay and returned to work sooner than those who had plate fixation. With comparable reduction capacity, functional and radiographic outcomes, calcaneal interlocking nails may be a better option when compared to standard locking plate fixation through a lateral extensile approach. Future research with longer follow-up comparing interlocking nail outcomes to locking plate fixation as well as the less invasive sinus tarsi approach are needed to decide the practicality of interlocking nails for calcaneal fracture fixation.