Is There a Borderline Value in the Radiological Findings of Patients With Calcaneal Malunion That May Help to Select an Appropriate Treatment Option?

Background: Despite the constant evolution of technological support, operative techniques, and rehabilitation techniques after conservative treatment and operative treatment, a considerable number of patients with calcaneal fractures have constant pain, frequently resulting in loss of occupation. There are numerous options for the operative treatment of painful calcaneal malunion; however, very few publications suggest specific radiological measurements for pre- and postoperative planning—even fewer have statistically analyzed how these radiological measurements affect clinical outcomes. Methods: We performed a retrospective study of 100 patients after operative treatment of calcaneal malunion to determine the correlation between radiological measurements and clinical outcomes. Data were used to create an algorithm that would help to choose between in situ subtalar arthrodesis and complex reconstructive operations. The algorithm was then used to treat 27 prospective patients. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) were used for clinical assessment, whereas standard weightbearing anteroposterior (AP), lateral (LAT) ankle x-rays, and long axial hindfoot view were used for radiological assessment. Results: The talar declination angle was positively correlated with clinical outcome. Patients with talar declination angles less than 6.5 degrees showed worse results in AOFAS score than patients with a greater angle did (57.3 ± 15.3 and 81 ± 15.6, respectively). Conclusion: The combination of subtalar arthrodesis with distraction bone block or calcaneal osteotomy in patients with calcaneal malunion and a talar declination angle less than 6.5 degrees showed better results than isolated in situ arthrodesis. Level of Evidence Level III, retrospective cohort study, case series.

Effect of Subtalar Fusion and Calcaneal Osteotomy on Function, Pain, and Gait Mechanics for Calcaneal Malunion

Background: Calcaneal malunion is a common complication of nonoperative management of calcaneal fracture, which leads to a disruption of the biomechanics of the lower extremity, pain, and permanent disability. Our aim was to evaluate pain, function, and gait after combined subtalar joint fusion, calcaneal osteotomy, and lateral wall exostectomy for patients with neglected calcaneal fractures with malunion. Methods: Eighteen patients with malunited calcaneal fractures, varus deformity, and subtalar arthritis were operated upon and then followed up for 18 months. All cases were assessed clinically using the American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS); radiologically by measuring the talar inclination, talocalcaneal and talus-first metatarsal angles, and talocalcaneal height; and biomechanically by measuring the stride duration, step width, comfortable speed, and ground reaction forces in relation to the body weight. Results: A significant improvement in AOFAS (59.8 preoperatively to 80.2 after 18 months) and VAS (61.1 preoperatively to 29.4) was found. Also, our study revealed a significant improvement in the radiographic measurements including the valgus angle, the talocalcaneal angle, the talocalcaneal height, and the talar inclination angle. The gait analysis found that the maximum loading force in the push-off phase and comfortable speed yielded a significant improvement postoperatively. However, no significant differences between the preoperative data and the final follow-up in terms of the step width, stride duration, maximum peak force during loading phase, and minimum peak force during midstance phase were found. Conclusion: The combination of valgus calcaneal osteotomy, lateral wall exostectomy, and subtalar fusion resulted in pain reduction, improved function, and better gait. However, the limited bone stock for the graft used in the subtalar fusion made use of this technique in severely reduced height unadvisable. Level of Evidence: Level IV, case series.

Distraction subtalar arthrodesis for calcaneal malunion

Aims We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity. Patients and Methods We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44). Results The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group. Conclusion Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602.

Mid-term follow up results of Calcaneal Reconstruction for the Late Complication of Calcaneus Fracture

Category: Trauma Introduction/Purpose: Calcaneal fracture is the most common fracture in hindfoot. The treatment is challenging, because of various patterns of fractures and high complication rates which leads to high level of dysfunction and low satisfaction of the patients. There are many previous studies reporting various methods about treatment of calcaneal malunion, such as subtalar arthrodesis, corrective osteotomy and corrective osteotomy with subtalar arthrodesis. However, there are no mid-term clinical results reporting about lateral ostectomy and sliding osteotomy, which is called calcaneal reconstruction. The purpose of this study is to evaluate the mid-term clinical and radiologic results of calcaneal reconstruction in the patients who have chronic complications after calcaneal fracture. Methods: Between January 2009 to May 2014, 196 patients (257 feet) were treated by calcaneal fracture. 34 patients (37 feet) underwent calcaneal reconstruction because of the dysfunction and the pain caused by malunion. Inclusion criteria were those whom underwent calcaneal reconstruction and able to be followed up at least 4 years postoperatively. The patients who had severe subtalar arthritis or whom underwent subtalar arthrodesis or simple bone resection were excluded. We reviewed 10 patients (10 feet) postoperatively and at mid-term follow up. Radiologic results including Böhler angle, calcaneal pitch, talocalcaneal height, talar inclination, talocalcaneal angle, talo-1st metatarsal angle, calcaneal width were measured and clinical results including AOFAS Ankle-Hindfoot scale and VAS score were checked preoperative, postoperatively and at the last follow up. The satisfaction of the patient was checked by survey. Results: The mean interval between the first operation and reconstructive operation was 16.6 months. The mean follow-up period after calcaneal reconstruction was 67.1 months. The most common symptom of the patient were pain on the inferior aspect of the lateral malleolus (4 patients) and heel area (3 patients). After calcaneal reconstruction, all the mean values of talocalcaneal height, calcaneal pitch, and Böhler angle were improved, which was statistically significant, respectively. In the postoperative period, 3 patients were very satisfied, 5 were satisfied, and 2 were not satisfied. The results maintained till mid-term follow up. Also, AOFAS and VAS score were improved comparing pre-reconstruction and mid-term follow up. Although the pain did not completely resolved, most of the patients were satisfied postoperatively. Conclusion: In patients without severe subtalar arthritis, the known main causes of the pain in calcaneal malunion are the loss of calcaneal height and hindfoot widening rather than subtalar arthritis. Our results showed signigficant clinical and radiological results by calcaneal reconstruction. And the outcome maintained till mid-term follow up. Calcaneal reconstruction can be a good choice for chronic pain which is caused by malunion of calcaneal fracture without severe subtalar arthritis.