Calcaneal locking intramedullary nailing versus extensile lateral plating for displaced intra‑articular calcaneal fractures: a propensity‑weighted cohort study focusing on perioperative soft‑tissue burden and early recovery trajectories

BACKGROUND: Displaced intra-articular calcaneal fractures (DIACFs) are among the most challenging hindfoot injuries and are often associated with persistent disability, reduced quality of life, and treatment-related complications [1, 2]. Although extensile lateral open reduction and plate fixation can restore calcaneal anatomy, it is accompanied by substantial soft-tissue morbidity [3-6]. Locking intramedullary nailing (IMN) is less invasive, yet comparative studies often emphasize overall complication rates and long-term functional scores, with limited quantification of perioperative soft-tissue management burden and early recovery trajectories [9, 10]. METHODS: We performed a retrospective cohort study comparing locking IMN with extensile lateral plating (ORIF) in adults with DIACFs. The primary outcomes were (1) a Soft‑Tissue Burden Index (STBI) incorporating drain utilization, postoperative drainage volume, wound leakage duration, dressing changes, aspiration for hematoma/seroma, and soft‑tissue reintervention; and (2) early recovery trajectories using repeated pain scores (VAS) and patient‑reported outcomes (Foot Function Index, FFI) at prespecified time points (2, 6, and 12 weeks; 6 and 12 months). Confounding was addressed using inverse probability of treatment weighting (IPTW) [13-15, 17]. RESULTS: Ninety patients were included (IMN n = 28; ORIF n = 62). After IPTW, baseline covariates were balanced. IMN demonstrated a lower STBI than ORIF (weighted mean 1.3 ± 1.1 vs. 3.5 ± 1.4; p < 0.001), driven by reduced drain utilization (3/28 [11%] vs. 59/62 [95%]; p < 0.001) and fewer dressing changes within 14 days (2.2 ± 1.5 vs. 6.4 ± 3.1; p < 0.001). Early recovery favored IMN, with lower VAS at 6 weeks (2.5 ± 1.2 vs. 3.7 ± 1.4; p < 0.001) and 12 weeks (1.7 ± 1.0 vs. 2.4 ± 1.2; p = 0.020), and better FFI at 6 weeks (52.3 ± 14.7 vs. 63.1 ± 15.4; p < 0.001) and 12 weeks (34.4 ± 12.3 vs. 43.2 ± 13.1; p = 0.003). Time to full weight bearing was shorter in IMN (10.7 ± 2.3 vs. 12.9 ± 2.6 weeks; p = 0.004). Twelve‑month functional outcomes were similar (FFI 16.8 ± 8.6 vs. 18.2 ± 9.4; p = 0.520). Wound‑related complications were lower in IMN (1/28 [4%] vs. 12/62 [19%]; p = 0.048). CONCLUSIONS: Locking IMN showed lower perioperative soft‑tissue burden and faster early recovery compared with extensile lateral plating, while maintaining similar mid‑term outcomes.