What is the step-by-step procedure for treating a right calcaneal (heel bone) fracture with Cannulated Compression (CC) screw fixation?

Surgical Procedure for Calcaneal Fracture Fixation with Cannulated Compression Screws

The surgical treatment of right calcaneal fractures using cannulated compression (CC) screw fixation involves a minimally invasive approach that provides stable fixation with reduced surgical trauma, less bleeding, and lower complication rates compared to traditional plate fixation.

Preoperative Planning

• Obtain standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) 1
• Order CT scan for detailed fracture pattern analysis and 3D reconstruction 2
• Measure key parameters:
  • Böhler's angle (normal: 20-40°)
  • Gissane's angle
  • Calcaneal height
  • Calcaneal width 3
• Classify fracture according to Sanders classification (Type II and III are most suitable for CC screw fixation) 3
• Plan screw trajectory and length based on preoperative imaging 2

Patient Positioning and Anesthesia

1. Position patient in lateral decubitus position with the affected foot uppermost
2. Apply tourniquet to the thigh
3. Administer appropriate anesthesia (general or regional) 3
4. Prepare and drape the surgical field using standard sterile technique

Surgical Procedure Steps

Step 1: Fracture Reduction

1. Make a small lateral incision (1-2 cm) over the calcaneus
2. Insert a Schanz pin or K-wire into the tuberosity fragment
3. Use the pin as a joystick to manipulate and reduce the tuberosity fragment
4. Correct varus/valgus deformity and restore calcaneal height
5. Verify reduction with fluoroscopy in lateral and axial views 4

Step 2: Provisional Fixation

1. Insert K-wires percutaneously to maintain the reduction
2. Verify articular surface reduction of the posterior facet using fluoroscopy
3. Ensure restoration of Böhler's and Gissane's angles 5

Step 3: Definitive Fixation with CC Screws

1. First screw placement:

   • Insert guide wire from the posterolateral aspect of the calcaneal tuberosity
   • Direct it anteriorly toward the sustentaculum tali (constant fragment)
   • Verify position with fluoroscopy 6
   • Measure appropriate screw length
   • Drill over the guide wire
   • Insert cannulated compression screw (6.5-7.5 mm)

2. Second screw placement:

   • Insert guide wire in a transverse position under the posterior facet
   • Direct it from lateral to medial
   • Verify position with fluoroscopy
   • Measure appropriate screw length
   • Drill over the guide wire
   • Insert cannulated compression screw 5

3. Additional screw placement (if needed):

   • For complex fractures, place a third screw from the tuberosity to the anterior process
   • Verify position with fluoroscopy 4

Step 4: Final Assessment and Closure

1. Perform final fluoroscopic assessment in multiple views
2. Verify:
   • Restoration of Böhler's angle
   • Restoration of Gissane's angle
   • Calcaneal height and width
   • Articular congruity 3
3. Remove K-wires
4. Close incisions with sutures
5. Apply sterile dressing and short leg splint

Postoperative Management

1. Elevate the extremity for 48-72 hours to minimize swelling
2. Non-weight bearing for 6-8 weeks
3. Begin early range of motion exercises at 2 weeks
4. Obtain follow-up radiographs at 3 weeks and at the end of immobilization period 1
5. Progress to partial weight bearing at 8 weeks if healing is adequate
6. Full weight bearing typically by 12 weeks
7. Proprioceptive training to prevent chronic instability 1

Advantages of CC Screw Fixation vs. Plate Fixation

• Shorter operative time (118.9 ± 43.8 minutes vs. 146.9 ± 47.6 minutes)
• Less intraoperative blood loss (38.2 ± 27.7 mL vs. 67.1 ± 58.8 mL)
• Shorter hospital stay (8.7 ± 3.9 days vs. 17.0 ± 7.9 days)
• Lower wound complication rate (6% vs. 26%) 3

Potential Complications and Management

• Screw irritation (9.3%): Remove hardware if symptomatic 4
• Subtalar osteoarthritis (5.5%): May require subtalar fusion if severe 4
• Malunion (1.8%): May require corrective osteotomy 4
• Infection (0.9-1%): Treat with appropriate antibiotics and possible hardware removal 4
• Loss of reduction: Ensure proper screw placement into the sustentaculum tali to prevent secondary displacement 5

This minimally invasive approach provides excellent outcomes with a high rate of good to excellent results (96.8% according to AOFAS score) while minimizing soft tissue complications that are common with extensile approaches 3.