What is the step-by-step procedure for treating a calcaneal (calcaneum) fracture using cannulated compression (CC) screws?

From the Guidelines

The surgical procedure for calcaneal fracture fixation using cannulated compression (CC) screws is a complex process that requires careful planning and execution to minimize morbidity and mortality, and improve quality of life. The procedure involves several key steps, starting with positioning the patient in a lateral decubitus position with the affected foot elevated on a radiolucent platform. After standard surgical preparation and draping, a lateral approach is typically used with an L-shaped incision beginning posterior to the lateral malleolus and extending anteriorly below the peroneal tendons. The skin flap is carefully elevated to expose the lateral wall of the calcaneus while protecting the sural nerve and peroneal tendons.

Key Steps in the Procedure

• Once the fracture is exposed, anatomical reduction is achieved by elevating the depressed posterior facet fragment using a bone tamp or elevator, restoring the Böhler's angle and calcaneal height, as recommended by the guidelines for acute trauma to the ankle 1.
• Temporary K-wires are used to maintain the reduction, and after confirming proper alignment with fluoroscopy, guide wires for the CC screws are inserted from the posteroinferior calcaneal tuberosity directed anteriorly toward the calcaneocuboid joint.
• The appropriate screw length is measured, and the path is drilled, followed by the insertion of partially threaded 6.5 or 7.0 mm cannulated screws over the guide wires to provide compression across the fracture site.
• Additional screws may be placed from lateral to medial to support the sustentaculum tali or to buttress the posterior facet, and final fluoroscopic images are obtained to confirm proper hardware placement and fracture reduction.

Postoperative Care

• The wound is irrigated, a drain may be placed, and closure is performed in layers, with the patient typically kept non-weight bearing for 8-12 weeks with early range of motion exercises to prevent stiffness, as suggested by the guidelines for the acute care of severe limb trauma patients 1.
• Early definitive osteosynthesis of diaphyseal fractures, including calcaneal fractures, is recommended within the first 24 hours to reduce the incidence of local and systemic complications, unless the patient has severe visceral injuries, circulatory shock, or respiratory failure, in which case a delayed definitive osteosynthesis is probably recommended.

Important Considerations

• The technique provides stable fixation while minimizing soft tissue disruption compared to plate fixation, though it is generally reserved for simple fracture patterns rather than highly comminuted injuries.
• CT scan is a key exam in detecting massive bleeding or unstable injuries, and should be used to determine the extent of the fracture and guide the surgical approach 1.

From the Research

Step-by-Step Procedure for Fracture Calcaneum by CC Screw

• The procedure for fracture calcaneum by CC screw involves several steps, including preoperative planning, reduction, and fixation 2.
• Preoperative planning includes computed tomography (CT) analysis to classify the fracture and guide joint and calcaneal body reconstructions 2.
• The reduction of the fracture is typically achieved through a lateral approach, with the goal of restoring the anatomical shape of the calcaneus and joint surfaces 3, 4.
• Fixation is achieved with one or more screws, depending on the type and severity of the fracture 2, 4.
• The screws are typically inserted in a transverse or oblique position to stabilize the fracture and promote healing 2, 4.

Key Considerations

• The choice of approach and fixation method depends on the individual pathoanatomy of the fracture 3.
• Anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory for optimal outcomes 3, 5.
• Postoperative computed tomography (CT) can be useful in evaluating the reduction of the subtalar joint surface and predicting outcomes 6.
• Prognostic factors that can be influenced by the surgeon include anatomical reduction of the overall shape of the calcaneus and congruity of the subtalar joint 5.

Potential Complications

• Wound complications, such as infection and wound healing problems, can occur with open reduction and internal fixation 3, 5.
• Subtalar osteoarthritis and calcaneo-cuboid osteoarthritis can develop as a result of inadequate reduction and fixation 6.
• Malunions and nonunions can occur if the fracture is not adequately reduced and fixed, leading to disabling conditions 5.