results and observations in operative treatment of displaced intra...

Chir. Narzadow Ruchu Ortop. Pol., 2018; 83(4) 131-136 DOI: 10.31139/chnriop.2018.83.4.27

131© Polskie Towarzystwo Ortopedyczne i Traumatologiczne

Chirurgia Narządów Ruchu i Ortopedia Polska / Polish Orthopaedics and Traumatology

ISSN 0009-479X

Author’s address: Dawid Lisowski, Osiedle Hutnicze 6/83, 31-918 Kraków, Poland, phone: +48122578257, e-mail [email protected]

Received: 21.07.2018Accepted: 01.08.2018Published: 31.08.2018

ORIGINAL PAPER

Results and observations in operative treatment of displaced intra- articular calcaneal fractures with use of Calcanail®

Wyniki i obserwacje w leczeniu przemieszczonych śródstawowych złamań kości piętowej z użyciem gwoździa Calcanail®

Dawid Lisowski, Tomasz Sorysz

Department of Traumatology and Orthopedic Surgery of the Gabriela Narutowicz Municipal Hospital in Krakow, Poland

Abstract

Introduction. Since the introduction of the Calcanail® in 2011 more and more surgeons have been treating calcaneal fractures with use of this method. It is mainly because of its safety concerning wound healing and final outcomes comparable to ORIF. This paper is to show the intraoperative problems the surgeon may encounter beginning with this method as well as final results in comparison to more experienced operators and other methods.Material and methods. Study of eleven displaced intra-articular calcaneal fractures operated between November 2015 and April 2018 with the use of the Calcanail®. All patients were evaluated with use of the AOFAS Hindfoot score. Pain, shoe fit and look of the foot were evaluated in 11 point- VAS scale. Böhler’s angle was measured before, after operation and in 3 and 6 month-time. All intra and post-operative complications were carefully noted.Results. Average AOFAS Hindfoot score was 79.75. VAS pain 2.0, shoe fit 1.5, look of the foot 1.25. Average Böhler’s angle restoration was 17.77 with no significant decrease with time. No intra- or post-operative complications were observed. Patients with less comminuted fractures and better reduction got better final results.Conclusions. Treatment of displaced calcaneal fractures with the Calcanail® is a safe and good alternative for other procedures. Restoration of articular surface is on one hand the most difficult stage of the procedure and on the other a key to a good final outcome.

Key words: calcaneus fracture, Calcanail

Streszczenie

Wstęp. Od prowadzenia gwoździa Calcanail® w 2011 r. coraz więcej ortopedów zaopatruje złamania kości piętowej z użyciem tej techniki. Głównym powo-dem jest bezpieczeństwo metody związane z brakiem problemów dotyczących gojenia rany połączone z wynikami porównywalnymi z otwartą repozycją i wewnętrzną stabilizacją. Niniejszy artykuł ma na celu przedstawienie problemów, jakie operator może napotkać w trakcie operacji, jak i wyników uzyska-nych przez autora.Materiał i metody. Badanie obejmuje 11 przypadków przemieszczonych śródstawowych złamań kości piętowej operowanych pomiędzy listopadem 2015 i kwietniem 2018 z użyciem gwoździa Calcanail. Średni czas obserwacji wyniósł 13 miesięcy. Pacjenci byli ocenieni w skali AOFAS Hindfood. Dolegliwości bólowe, problemy z doborem obuwia i subiektywny wygląd stopy, zostały ocenione w 11 punktowej skali VAS. Zmierzono kąt Böhlera przed i po operacji oraz po 3. i 6. miesiącach po zabiegu. Wszystkie śródoperacyjne i późniejsze komplikacje zostały wnikliwie przeanalizowane.Wyniki. Średni wynik w skali AOFAS wyniósł 79,75; ból w skali VAS 2,0; problemy z doborem obuwia 2,0 oraz wygląd stopy 1,25. Średnia korekcja kąta Böh-lera wyniosła 19 stopni bez tendencji do istotnego spadku z czasem. Nie zaobserwowano istotnych komplikacji śród- i pooperacyjnych. Pacjenci, u których złamania wstępnie były mniej złożone a repozycja dokładniejsza, osiągnęli lepszy wynik końcowy.Wnioski. Leczenie przemieszczonych, śródstawowych złamań kości piętowej z użyciem gwoździa Calcanail® jest bezpieczną alternatywą dla pozostałych procedur. Odtworzenie powierzchni stawowej jest z jednej strony najtrudniejszym etapem zabiegu, z drugiej jest niezbędne do osiągnięcia dobrego osta-tecznego wyniku.

Słowa kluczowe: złamanie kości piętowej, Calcanail

Chir. Narzadow Ruchu Ortop. Pol., 2018; 83(4) 131-136



Dawid Lisowski and Tomasz Sorysz: Results and observations in operative treatment of displaced intra- articular calcaneal fractures with use of Calcanail®

ORIGINAL PAPER

Introduction

In October of 2011 Dr. M. Goldzak from Clinique de l’Union in Toulouse, France, used the Calcanail® in treatment of dis-placed intra-articular calcaneal fractures for the first time [1-5]. Since then, the method gains popularity and is increas-ingly practised. In Poland the first operation took place in March of 2013 in ZZOZ in Ostrów Wielkopolski. It was per-formed by Dr. M. Falis who is still its devoted supporter and promoter [6].

This paper is to present own results and observations in regards to the authors quoted and other operative methods.

Materials and methods

The study includes eleven patients operated on at the Szpital Miejski Specjalistyczny im. Gabriela Narutowicza in Kraków between November of 2015 and April of 2018. Ten of them were men and one was female. Average patients’ age was 46.7 years. In all eleven cases, a fracture type nail was used with no need of primary arthrodesis. There was no open fractures. Average time from injury to the operation was 12.8 days, with one case operated on after 28 days. Clinical results were evaluated in the AOFAS Hindfoot score [7]. Pain, shoe fit and look of the foot were evaluated in 11 point – VAS scale. A mean follow-up was 13 m months.

Preoperative lateral and axial radiographs and CT scans of calcaneal fractures were taken into consideration. Then they were classified due to Guy Uthéza classification into ver-tical (27.27%), horizontal with one fracture line (0%), hori-zontal with two fracture lines (0%), mixed with one fracture line (27.27%) and mixed with two fracture lines (45.46%) [5,8, 9, 10]. Böhler’s angle [11] was measured pre- and post-operatively and then again evaluated in 3 and 6 month-time. Assessment of subtalar congruency was performed accord-ing to Sanders criteria [12].

The operative technique was no different to commonly used [1,3,5,6] and in accordance with the implant’s manufac-turer’s recommendation [13]. The patient is positioned, on the side which the operated heel elevated on the support. Through 2-3 cm long incision, between the back and plantar surface of the foot, an access to the calcaneus is gained (Fig. 1).

The next stage is an introduction of the guide wire under fluoroscopy control. Its end should aim in the direction of the posterior articular surface on the lateral view and be placed centrally in the axial view (Figs. 2 and 3).

Afterwards two Steinman’s pins are inserted, one into the tallus and the other into the calcaneal tuber. On these pins the Caspar distractor is mounted. With help of the dis-tractor the correction of valgus deformity, restoration of the length and height of the calcaneus take place. It also creates space for future reposition of the articular surface. Next, with

Fig. 1. Patient’s positioning and approach to the calcaneus.

Fig. 2. Position of the guide wire in the lateral view.

Fig. 3. Position of the guide wire in the axial view

the tunnel reamer the working chamber is created, through which the reduction of the fracture takes place with the use of appropriate tools (Figs. 4 and 5).





ORIGINAL PAPER

Drilling with the tunnel reamer creates a bone graft that is used to support the articular surface during the reposition stage or later placed inside the implant. After the reposition is done, the nail is inserted, in a way that it supports the dam-aged articular surface, and locked with two locking screws (Figs. 6 and 7).

At this stage the Caspar distractor and Steinmann pins are removed and wounds closed with unabsorbable sutures. Immobilisation of the operated limb is not required. The next day the patient is ambulating with the crutches. At this time also the rehabilitation begins. Sutures are removed after 14 days. Up to 6 weeks the patients are ambulating with no full weight bearing. After 6 and 12 weeks the check up x-rays are performed.

Fig. 4. Displaced articular Surface before reposition

Fig. 5. Displaced articular Surface after reposition

Fig. 6. The lateral view after insertion and lock of the nail

Fig. 7. The axial view after insertion and lock of the nail. Proximal end of the implant is placed to support the damaged articular surfaced.

Fig. 8. Lateral and axial view of the calcaneal fracture presented in the method description.





ORIGINAL PAPER

Assessment of subtalar congruency was performed ac-cording to Sanders criteria [12]. In 3 cases, the reposition was anatomic (2 vertical fractures and 1 horizontal with one fracture line), in 6 cases, it was almost anatomic (1 vertical fracture, 2 mixed with one fracture line and 3 mixed with two fracture lines). In one case, the reposition was unsatis-factory and in one case bad. Both fractures were mixed types with 2 fracture lines. In patients with anatomic and almost anatomic type reposition average AOFAS Hindfoot score [7] was more than 80 points (84.5 and 83.25). The pain was no bigger than 2 points in VAS scale (1 point and 2 points). The patient with unsatisfactory reposition achieved 71 points in AOFAS scale and pain level 3 in VAS scale. The patient with bad reposition type achieved 59 points in AOFAS scale and pain level 4 in VAS scale (Tab. 1).

Patients with less comminuted fracture (vertical and mixed with one fracture line) achieved significantly better final score in AOFAS scale (82.5 points and 85.6 points) and VAS scale (0.5 points and 2 points). Patients with more com-plex fracture pattern (mixed with two lines) achieved 73.5 points in AOFAS scale and pain level 2.75 points in VAS scale (Tab. 2).

Table 1. Comparison of the average AOFAS Hindfoot score and VAS pain level depending on the reposition type.

reposition type AOFAS VAS

anatomic 84.5 points 1

almost anatomic 83.25 points 2

unsatisfactory 71 points 3

bad 59 points 4

Table 2. Comparison of the average AOFAS Hindfoot score and VAS pain level depending on the fracture type.

fracture type Vertical mixed with one line

mixed with two lines

AOFAS 82.5 points 85.6 points 73.5 points

VAS pain 0,5 2 2,75

No intra- or postoperative complications of importance were observed including wound healing difficulties. All the patients came back to their previous occupations in the time of 6 months. There was no necessity of implants removal or other surgical procedures.

Discussion

Average score in AOFAS scale (79.75 points) is comparable to these of Dr. M. Goldzak (86.5 points) [5] and Dr. M. Falis (82 points) [6]. The difference mostly seems to be due to the high percentage of multifragmentary fractures (mixed type with two lines – 45.46%). It is confirmed by the fact that pa-tients with that type of fracture achieved worse final result

Results

In the final follow up among 11 patients, 1 achieved very good result (9.09%), 5 good (45.45%), 4 fair (36.6%) and one poor (9.09%). Average AOFAS Hindfoot score [7] was 79.75 points (range from 59 to 92 points). Average pain level in VAS scale was 2.0. One patient claimed to be painless, in 8 the pain was moderate, in the last 2 moderate. One patient described shoe fit problems and was not satisfied with the look of the foot. Average Böhler’s angle value was 15.8 degrees preoperatively (from -17 to 28) and 34.8 degrees postoperatively (from 23 to 49). Average Böhler’s angle restoration was 19 degrees with no significant decrease with time. No intra- or post-operative complications were observed.

Fig. 9. The same fracture in 3 months check-up.





ORIGINAL PAPER

(73.5 points in AOFAS scale) in comparison to other groups, in which the outcome was higher than 80 points. Despite a small number in the study (11 cases), a direct correlation be-tween an accuracy of reposition and the final score has been noticed, which confirms the observation of Dr. M. Goldzak [5]. Compared to the open reduction and internal fixation (ORIF) with LCP plates the outcome is similar. P. Zeman in the study of 46 fractures treated with ORIF gives 34.5% very good, 51% good, 13.8% satisfactory and bad outcomes[14], but with the early complication rates at the level of 20,7%. In the case, an operation with C-nail® is performer, mean AO-FAS score is 89-94 pkt [15,16]. Although this technique re-quires opening of the fracture site, at least through the sinus tarsi approach, to perform the reduction and is connected with the risk of infection at the level of 2.8% [15,16]. It is im-portant to highlight that the extended lateral approach used in ORIF is connected with the risk of infection 18.1% up to even 33% [14,17,18,19]. In case of operation with Calcanail® technique, complications are not observed [5,6].

Intraoperatively the most difficult and time consuming stage of the procedure is an accurate reposition of the dis-placed articular surfaces. It is easier to accomplish in case of one or a few bigger pieces than several small. Often during the reposition with the use of dedicated tools the reposition is lost after the tool withdrawal. In such a situation, it is wise to use the bone graft gained during drilling to support the ar-ticular surface being reduced. Positioning the nail with prox-imal end towards the damaged articular surface in axial view enables preservation of reduction till the time of bone heal-ing occures. Qualification for the operation should be careful in case of concomitant anterior calcaneus process fracture. The author has encountered an intra - articular fracture of the calcaneus with concomitant multifragmentary fracture of the anterior calcaneal process and luxation of the subtalar joint (Figs. 10-11).

Despite of sustentaculum tali and a huge piece of cal-caneal tuber being preserved the closed reduction with the Caspar distractor mounted in both the talus-calcaneus and cuboid-calcaneus configuration has not been achieved. In this case, operative treatment required the open reduction through the sinus tarsi approach. After reduction of the sub-talar join and temporary fixation with K-wires, the anterior process of the calcaneus has been rebuild. The loss of bone has been filled with bone grafts and the fracture bridged with plate. Additionally one screw in a transverse plane has been introduced into the sustentaculum tali (Fig. 12 and 13). The calf cat has been admitted for the wound healing time and then rehabilitation has begun.

Conclusion

Treatment of the displaced intra- articular fractures of the calcaneus still remains a challenge. Development of minimal invasive techniques such as the Calcanail® technique gives

Fig. 10. Intra - articular calcaneal fracture with concomitant multifrag-mentary fracture of the anterior calcaneal process and luxation in sub-talar joint.

Fig. 11. 3D reconstruction of the fracture from X-ray – Fig. 10





ORIGINAL PAPER

an opportunity to achieve comparable results to ORIF with the minimal risk of infectious complications. The final result highly depends on the fracture pattern and the accuracy of the articular surface reposition. The application of the Calca-nail® in the treatment of displaced articular fractures of cal-caneus gives the possibility of a good and stable reduction as well as an early rehabilitation.

References

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3. Goldzak M, Mittlmeier T, Simon P.: Locked nailing for the treatment of displaced articular fractures of the calcaneus: description of a new procedure with calcanail (R). Eur J Orthop Surg Traumatol 2012; 22: 345-9.

4. Goldzak M, Gradl G, Simon P, Mittlmeier T.: Calcanail a new internal device for calcaneal fractures. Injury – Int J care injured 2011; 42: 55.

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caneum: description et anatomopathologie. Apport de la tomodensito-métrie. Rev Chir Orthop 1993; 79: 47-57.

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13. http://www.fhortho.com/products/foot-ankle/calcanail/14. Zeman P, Zeman J, Matejka J, Koudela K: Long-term results of calca-

neal fracture treatment by open reduction and internal fixation using a calcaneal locking compression plate from an extended lateral ap-proach. Acta Chir Orthop Traumatol Cech. 2008 Dec;75(6):457-64.

15. Pompach M, Carda M, Amlang M, Zwipp H: Treatment of calcaneal fractures with a locking nail (C-Nail). Oper Orthop Traumatol. 2016 Jun;28(3):218-30. doi: 10.1007/s00064-016-0441-0. Epub 2016 Apr 18.

16. Zwipp H, Paša L, Žilka L, Amlang M, Rammelt S, Pompach M: Intro-duction of a New Locking Nail for Treatment of Intraarticular Calca-neal Fractures. J Orthop Trauma. 2016 Mar;30(3).

17. Al-Mudhaffar M, Prasad CV, Mofidi A: Wound complications follow-ing operative fixation of calcaneal fractures. Injury. 2000 Jul;31(6):461-464.

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Fig. 12. Postoperative image on the lateral view..

Fig. 13. Postoperative image in the axial view.

results and observations in operative treatment of displaced intra...

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