[Treatment of calcaneal fractures with a locking nail (C-Nail)]. / Versorgung des Fersenbeinbruchs mit einem Verriegelungsnagel (C-Nail).

OBJECTIVE: Anatomic reconstruction of the posterior facet by primary stabilization of the calcaneal fracture with a locking nail. INDICATIONS: All intraarticular calcaneal fractures and unstable two-part fractures independent of the degree of closed/open soft tissue trauma. CONTRAINDICATIONS: High perioperative risk, soft tissue infection, beak fracture (type II fracture) and still open apophysis. SURGICAL TECHNIQUE: Anatomic reduction of the posterior facet using a sinus tarsi approach. Reduction and temporary fixation of the sustentacular, tuberosity, and anterior process fragments with 1.8-2.0 mm Kirschner wires. Thereafter, the C-Nail (calcaneus nail) is introduced with its guiding device stabilizing the sustentacular, tuberostity, and anterior process fragments through its three guiding arms with 6 or 7 locking screws. POSTOPERATIVE MANAGEMENT: Passive and active motion starts on postoperative day 2. Lymph drains help reduce swelling. Partial weightbearing with 20 kg for 6-8 weeks in the patient's own shoes is recommended. X­ray controls are done at 4 and 8 weeks as well as after 6 and 12 months. RESULTS: A total of 107 calcaneal fractures treated with the C-Nail between 2011 and 2014 were evaluated according to the AOFAS score 6 months and 1 year after surgery. The measured values were on average 93.0 (range 65-100) points at 6 months and 94.1 (range 75-100) points 12 months after the surgery. Böhler's angle with initial traumatic values of 6.2° (-30 to +13°) improved postoperatively to 31.8°, after 3 months slightly decreased to 29.6°, and after 12 months to 28.3°. There were 2 cases of superficial wound necrosis (1.9 %) and 1 case a deep infection (0.93 %) with need of early C-Nail removal.

[Operative treatment of displaced intra-articular calcaneal fractures]. / Osteosynthese dislozierter intraartikulärer Kalkaneusfrakturen.

OBJECTIVE: Anatomic reduction of displaced intra-articular calcaneal fractures with restoration of height, length, and axial alignment and reconstruction of the subtalar and calcaneocuboid joints. INDICATIONS: Displaced intra-articular calcaneal fractures with incongruity of the posterior facet of the subtalar joint, loss of height, and axial malalignment. CONTRAINDICATIONS: High perioperative risk, soft tissue infection, advanced peripheral arterial disease (stage III), neurogenic osteoarthropathy, poor patient compliance (e. g., substance abuse). SURGICAL TECHNIQUE: Extended lateral approach with the patient placed on the uninjured side. Reduction of the anatomic shape and joint surfaces according to the preoperative CT-based planning. Reduction of the medial wall and step-wise reconstruction of the posterior facet from medial to lateral. Reduction of the tuberosity and anterior process fragments to the posterior joint block and temporary fixation with Kirschner wires. Internal fixation with an anatomic lateral plate in a locking or nonlocking mode. Alternatively less invasive internal fixation with a calcaneus nail over a sinus tarsi approach for less severe fracture types. POSTOPERATIVE MANAGEMENT: The lower leg is immobilized in a brace until the wound is healed. Range of motion exercises of the ankle and subtalar joints are initiated on the second postoperative day. Patients are mobilized in their own shoe with partial weight bearing of 20 kg for 6-12 weeks depending on fracture severity and bone quality. RESULTS: Over a 4-year period, 163 patients with 184 displaced, intra-articular calcaneal fractures were treated with a lateral plate via an extended approach. In all, 102 patients with 116 fractures were followed for a mean of 8 years. A surgical revision was necessary in 4 cases (3.4%) of postoperative hematoma, 2 (1.7%) superficial and 5 (4.3%) deep infections. Of the latter, 2 patients needed a free flap for definite wound coverage, no calcanectomy or amputation was needed. Secondary subtalar fusion for symptomatic posttraumatic arthritis was performed in 9 cases (7.8%). At follow-up, the AOFAS Ankle/Hindfoot Score averaged 70.2, the Zwipp Score averaged 76.0, the German versions of the Foot Function Index and SF-36 physical component averaged 32.8 and 42.2, respectively. Scores were significantly lower with increasing fracture severity according to the Sanders and Zwipp classifications, bilateral fractures, open fractures, and with work-related injuries. With less invasive fixation using a calcaneal nail, superficial wound edge necrosis was seen in 2 of 75 cases (2.7%).

[Malignant lymphoma of the small intestine as an uncommon cause of obstructive ileus]. / Maligní lymfom tenkého streva jako méne obvyklá prícina obstrukcního ileu.

The authors draw attention to an uncommon cause of obstructive ileus in children, i.e. malignant lymphoma of the small intestine in a 10-year-old boy.