Malunited Calcaneal Fractures Research Articles

Multiple Reconstructive Osteotomy Treating Malunited Calcaneal Fractures Without Subtalar Joint Fusion.

Various surgical techniques have been reported in treating calcaneal malunions over the decades, while the operations on single plane were accompanied by respective limitations. The purpose of this study is to evaluate the efficacy of a novel multiple reconstructive osteotomy for treating malunited calcaneal fractures without subtalar joint fusion. From March 12, 2010, to August 17, 2017, 10 patients (10 feet) with malunited calcaneal fractures were treated with multiple reconstructive osteotomy with subtalar joint-preserving operations. All patients were treated with a corrective osteotomy, joint realignment, soft tissue balancing, and secondary internal fixation at a mean of 5.6 ± 2.41months since the initial injury. With the utilization of the multiple reconstructive osteotomy, the posterior facet was restored to preserve the subtalar joint. All patients were evaluated clinically and radiographically at a mean follow-up of 3.04 ± 1.21 years. All patients were subjectively satisfied with the treatment. The average time to union was 12.2 ± 1.11 weeks. The American Orthopedic Foot and Ankle (AOFAS) ankle and hind foot score was 86.3 ± 4.45 (t=27.64, P < 0.0001, paired t-test), which was significantly higher than the preoperative assessment. Postoperative radiographic assessment revealed great improvement in Böhler's angle (from 25.4° to 86.3°), talocalcaneal height (65.15-72.68 mm) and Calcaneus-talus angle (from 34.46° to 39.7°). One patient had mild discomfort after a 1-h brisk walk. One patient was suspected to have early posttraumatic arthritis of the subtalar joint based upon radiographic evidence during the follow-up, but the patients could walk normally for a long time without pain. Multiple reconstructive osteotomy is an effective way to restore the calcaneal morphology and preserve the subtalar joint for selected calcaneal malunion.

Calcaneal Malunions Management and Types of Surgical Correction

Category: Hindfoot; Ankle Introduction/Purpose: Number of fractures of the calcaneus amounts to 1-5.7% of all fractures of skeleton bones according to various authors. Moreover, these figures correspond to 50% of all fractures of feet bones. Consequences of calcaneus malunion leads to early disability, arthrosis, pain syndrome, disorder of the entire low extremity axis of motion alongside cosmetic defects and shoe wearing discomfort. Purpose of the study: classification of calcaneal malunions based on a geometrically normal position and dimensions of hindfoot in order to develop optimal type of treatment for multicomponent calcaneal deformity. Methods: Twelve patients with post traumatic deformed hindfoot after malunited calcaneal fractures and as a result varus and valgus deformity, subtalar arthritis, pain syndrome, shoe wear discomfort at different stages after trauma (from 1 to 10 years) were examined, underwent surgical alignment of calcaneus and were followed up for 24 months. All cases were assessed clinically using the American Orthopaedic Foot &amp; Ankle Society (AOFAS) and visual analog scale (VAS); radiologically by measuring hindfoot varus/valgus, talus tilt, Meary's angle, and hight of calcaneal. Results: It was found a significant improvement in AOFAS (55.2 preoperatively to 78.8 after 24 months) and VAS (65 preoperatively to 30.1). Moreover, our study revealed a significant improvement in the radiographic measurements including hindfoot varus/valgus, the talar inclination, Meary's angle, and hight of calcaneus. Conclusion: The elimination of angular hindfoot varus or valgus deformation, exostectomy of the lateral wall and subtalar fusion, as well as the use of a tricortical autograft for distarction arthrodesis at III-V type Zwipp and Rammelt classification, resulted in reduced pain, improved function, cosmetic results and shoe wearing.

Malunited calcaneal fracture: the role and technique of osteotomy-a systematic review.

The research is aimed to introduce various corrective osteotomies utilized in treating calcaneal malunions in published papers, to further analyze the results, and to summarize recommended indications. The relevant research screening was conducted on the following search engines: the Cochrane Library, Web of Science, PubMed, Embase, Medline, and Academic Search Premier. Key words input included "calcaneal/calcaneus", "malunion," and "malunited fracture(s)" with Boolean operators "AND" and "OR." The inclusion criteria were researches containing surgical procedures treating calcaneal malunion with corrective osteotomy and published in the English language. For included research article, such information was extracted and analyzed: the type of calcaneal malunion, the time from initial injury to corrective surgery, the method of osteotomy, outcomes of each osteotomy (score systems, Bohler angle, talocalcaneal height and width of calcaneus, etc.), the function of the affected limb, post-operative complications, and patients' satisfaction. For included review, descriptive, commentary, or indicative sentences about corrective osteotomy were highlighted, analyzed, and summarized. Ten research articles (170 patients with 184 feet) and ninereviews were included in this review, presenting seventypes of corrective osteotomies (lateral wall exostectomy, Dwyer osteotomy, lateral wedge opening osteotomy, Romash osteotomy, tongue osteotomy, sagittal resection osteotomy, and modified Dwyer osteotomy). A different corrective osteotomy with/without arthrodesis is recommended to be utilized based on the classification of the malunion and the condition of the cartilage in treating malunited calcaneal fractures. With adequate postoperative care and rehabilitation, the results of treatment could be associated with patients' satisfaction and good function.

Is Distraction Bone Block Arthrodesis better than Subtalar Arthrodesis for Malunited Calcaneal Fractures with Subtalar Arthritis? A Retrospective Case Series

To compare the clinicoradiological outcome between in situ and distraction bone block arthrodesis in patients with malunited calcaneal fracture. Patients presenting with painful subtalar joint arthritis between January 2015 and March 2018 were included after thorough clinical and radiological evaluation. In situ group I had 22 patients and distraction group II had 14. All patients were evaluated at final follow-up for functional outcome with American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and radiological parameters including talocalcaneal height (TCH), calcaneal pitch (CP), lateral talocalcaneal angle (LTCA), and talar declination angle (TDA). Mean follow-up was 19.26 months for in situ and 12.91 months for distraction group. AOFAS ankle-hindfoot score improved postoperative in both groups, but the difference between the groups was not significant ( p value = 0.371). Statistically significant improvement was observed in radiological parameters of talocalcaneal height ( p value = 0.006), calcaneal pitch ( p value = 0.025), lateral talocalcaneal angle ( p value = 0.078), and talar declination angle( p value = 0.02) in the distraction group. Distraction arthrodesis restores hindfoot radiological parameters better compared to the in situ group; however, there is no significant difference in functional outcome between the groups. Sundararajan SR, Ramakanth R, Shreeram V, et al. Is Distraction Bone Block Arthrodesis better than Subtalar Arthrodesis for Malunited Calcaneal Fractures with Subtalar Arthritis? A Retrospective Case Series. J Foot Ankle Surg (Asia Pacific) 2021;8(1):3–7.

Corrective osteotomy and partial tarsal arthrodesis in two greyhounds with calcaneal malunion

To describe the clinical presentation and outcome of two greyhounds with calcaneal malunions that were treated with corrective osteotomy and partial tarsal arthrodesis. Short case series. Two adult racing greyhounds. Varus and recurvatum deformity of the calcaneus was ascribed to malunion of prior calcaneal fracture with concomitant central bone fracture that had been sustained during racing in both dogs. Both dogs exhibited severe, weight-bearing lameness and had radiographic evidence of moderate to severe osteoarthritis of the proximal intertarsal joint. A closing wedge corrective osteotomy and partial tarsal arthrodesis were performed with a 2.7-mm locking compression plate and cancellous autograft. Calcaneal morphology and alignment of the common calcaneal tendon seemed restored postoperatively. The implant was removed in one dog, while the other dog experienced no postoperative complications. Lameness improved in both dogs, although residual intermittent lameness after heavy exercise was reported by owners of both dogs 1 year after surgery. Overall, owner satisfaction and outcome were considered good-to-excellent in both dogs. Corrective osteotomy and partial tarsal arthrodesis for treatment of malunited calcaneal fractures may be considered in dogs with clinical signs related to calcaneal malunion.

Calcaneal Fractures - Should We or Should We not Operate?

The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.

Treatment of Malunited Calcaneal Fracture With Posttraumatic Subtalar Osteoarthritis Using Lateral Endoscopic Calcaneoplasty With Posterior Arthroscopic Subtalar Arthrodesis

Malunion of calcaneal fractures is a common complication after improper nonoperative treatment. It may develop into posttraumatic subtalar osteoarthritis, lateral calcaneal wall prominence, and severe foot deformities. This Technical Note reports the technical aspects of lateral endoscopic calcaneoplasty with posterior arthroscopic subtalar arthrodesis for the treatment of malunited calcaneal fracture with lateral calcaneal wall prominence and posttraumatic subtalar osteoarthritis. This technique was chosen because it can reduce the risk of wound complication compared with a conventional lateral extensile approach. This Technical Note describes the use of the technique in a patient with prone position. This offers the advantages of easier access to the lateral surface of the calcaneus and posterior facet of the subtalar joint, and is less invasive to the soft tissue envelope on the lateral side of the foot. Moreover, the concomitant bone void area of the subtalar joint can be dealt with by an arthroscopic procedure.

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Subtalar Distraction Arthrodesis with Fresh Frozen Femoral Neck Allograft: A Retrospective Case Series.

Subtalar joint distraction arthrodesis has been well reported with use of structural iliac crest or local autologous bone graft for malunited calcaneal fractures. Early reports for structural allograft did not yield good, consistent results, leading to a subsequent lack of recommendation in previous literature. Newer studies have had promising results utilizing femoral allograft as an alternative to autogenous bone graft. We performed a retrospective chart review on 10 patients (12 feet) undergoing subtalar joint distraction arthrodesis with femoral neck allograft for malunited calcaneal fractures. The primary aim of this study was to report on successful union rates and, in addition, outline any consistent complications. Twelve of the 12 procedures (100%) yielded successful fusion with a mean final follow-up of 7.7 months (range = 2.2-35.1 months). The mean increase in talocalcaneal height was 4 mm (range = 2-6 mm). The overall complication rate was 16.6%, including one superficial wound complication that healed uneventfully and one hardware removal. In conclusion, the current study reports a 100% successful fusion rate with interpositional structural femoral neck allograft in treatment for malunited calcaneal fractures. Therapeutic, Level IV: Case series.

Lateral Wall Decompression for Malunited Calcaneal Fractures

ABSTRACT Aim The purpose of this case series is to reintroduce Kashiwagi decompression as a viable treatment option for malunited calcaneal fractures, delineate the operative technique, and discuss its advantages. Materials and methods From August 2004 to May 2013, 18 patients with Sanders type I malunited calcaneal fractures with lateral heel pain and impingement were treated with the lateral wall decompression technique. The functional outcome was assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. Results Eleven patients were males and seven were females, with an average age of 48.4 years. Ten patients had left feet fracture and eight had right feet fracture. Among all the 18 patients with a ‘poor’ score at baseline, 2 (11.11%) scored ‘excellent’, 11 (61.11%) scored ‘good’ and 3 (16.67%) scored ‘fair’ during postoperative evaluation. The average time to return to daily activities was 10.2 weeks (8–12.5 weeks). Conclusion Lateral wall osteotomy and decompression effectively addresses the pathology in cases of lateral abutment due to a malunited calcaneal fracture. This technique has advantages of ensuring a reliable resolution with good clinical outcomes and produces fewer postoperative complications. Clinical significance Malunion is a common complication with calcaneal fracture. It affects normal function. In malunited calcaneal fractures, the lateral wall of the calcaneum forms a lateral wall exostosis that causes both subfibular impingement and peroneal tendinopathy or displacement. There is need for a viable treatment option for malunions with lateral wall exostosis after calcaneal fractures. This study describes a surgical technique as a solution for the above. How to cite this article Agarwala S, Sobti AS. Lateral Wall Decompression for Malunited Calcaneal Fractures. J Foot Ankle Surg (Asia-Pacific) 2015;2(2):80-85.

Medial displacement calcaneal osteotomy using minimally invasive technique.

Medial displacement calcaneal osteotomy is a common procedure often used as part of pes planovalgus deformity correction. Traditionally the osteotomy is performed using a direct lateral or extended lateral approach, which may carry the risk of wound problems, infection and neurovascular injury. The authors describe a minimally invasive technique to perform the osteotomy and achieve the desired correction. The article illustrates our experience and learning curve with the use of this technique as an option for calcaneal osteotomy. We retrospectively reviewed the records of a sequential series of patients since 2011 whose calcaneal osteotomies were performed by 2 surgeons, after cadaveric training using a minimally invasive operative approach. Prior to 2011, similar surgeries, performed by the senior authors, were undertaken using a direct lateral approach. Thirty cases were identified; 29 had tibialis posterior reconstruction coupled with calcaneal osteotomy for acquired flexible planovalgus deformity and 1 patient had surgery for a malunited calcaneal fracture. Radiological and clinical union occurred in all 30 cases (100%). The radiographs of all cases were reviewed by a specialist musculoskeletal radiologist. There were no neurovascular or wound complications. All patients had restoration of neutral hindfoot alignment. One patient required screw removal after union, resolving all symptoms. This series suggests that minimally invasive calcaneal osteotomy surgery can achieve excellent union rates aiding correction of deformity with no observed neurovascular or soft tissue complications. For surgeons experienced in open surgery, there is a short learning curve after appropriate training.

Joint-preserving osteotomy for calcanean malunions

Calcaneal malunions lead to a considerable loss of global foot function through the loss of the physiological hindfoot lever arm, bony and soft tissue impingement, and involvement of the subtalar joint. In the majority of cases correction of the malunion has to be combined with subtalar fusion because of a rapid development of posttraumatic subtalar arthritis. Joint-preserving corrective osteotomy may be considered in carefully selected patients with intact joint cartilage, sufficient bone quality, and good patient compliance. This is the case in extra-articular malunion and intra-articular malunion with displacement of the complete posterior facet of the subtalar joint. While respecting the criteria for indications, overall good functional results could be achieved in two clinical studies on this subject. Only 1 of the 26 reported patients required a secondary subtalar fusion. In case of development of subtalar arthritis a secondary in situ fusion of the subtalar joint can be performed on a corrected hindfoot with good prospects. In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.

Subtalar distraction bone-block fusion for the management of malunited calcaneal fractures

Aim of the workTheaim of this study was to evaluate the results of subtalar distraction bone-block fusion for the management of subtalar arthritis due to malunited calcaneal fractures.Patients and methodsSubtalar distraction bone-block fusion was performed for the management of malunited calcaneal fractures in 20 patients (20 feet) between May 2006 and December 2009 at the Orthopedic Department, Faculty of Medicine, Zagazig University. The mean age of the patients was 30 years. Patients included 15 men and five women. Each patient completed a standardized questionnaire, based on the hindfoot-scoring system of the American Orthopedic Foot and Ankle Society, which was reviewed both clinically and radiologically. No staples or screws were used for fixation of the graft taken from the iliac bone.ResultsAll patients showed solid fusion at the end of follow-up. The mean hindfoot score (maximum of 94 points) increased from 22.0 points preoperatively to 75.7 points at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 22 and 5.2° preoperatively, which improved to 26.2 and 8.0°, respectively, at the final follow-up. The mean talocalcaneal height increased from 65.5 mm before operation to 71.0 mm at the final follow-up. Three patients had sural nerve neuralgia and one patient had superficial infection at the graft donor site.ConclusionSubtalar distraction bone-block fusion can be used for the treatment of subtalar arthritis resulting from malunited calcaneal fractures to restore heel height and normal position of the talus, as well as to relieve pain resulting from arthritis, without the use of screws or staples to fix the graft, yielding similar results to those of techniques using screws or staples to fix the graft.

Plantar Exostosis in a Malunited Calcaneal Fracture: A rare complication

Plantar Exostosis in a Malunited Calcaneal Fracture: A rare complication

Malunited calcaneal fracture fragments causing tarsal tunnel syndrome: A rare cause

This is a report of tarsal tunnel syndrome (TTS) due to a specific malunited calcaneal fracture fragment in a 46-year-old man. He was treated non-operatively for extra-articular calcaneal fracture. Four months later he presented with pain, tingling and hypoaesthesia over the medial aspect of the heel. He had a positive Tinel's sign and a positive dorsiflexion-eversion test. Radiography revealed malunited calcaneal fracture along medial wall producing bony prominence. The tarsal tunnel was surgically decompressed by excising the malunited fragments. The branches of the posterior tibial nerve were stretched over these fragments intra-operatively. There was symptomatic improvement with surgical excision of the fragment, however, the hypoesthesia did not resolve completely. Appropriate initial treatment will help to prevent this complication.

Complications of intra-articular fractures of the calcaneus.

Most complications of calcaneal fractures are due to the combination of the dynamic nature and the mechanism of the injury itself. Complications are usually secondary to three integral parts of this complex fracture pattern: 1) fracture and depression of the subtalar joint, 2) loss of the height of the calcaneal body with varus rotation, and 3) expansion of the lateral wall of the calcaneus. Other complications occur with less frequency. This article describes the complications and sequelae of old, malunited intra-articular calcaneal fractures in relation to the nature and the components of these unique fractures.

Foot function after subtalar distraction bone-block arthrodesis. A prospective study.

Subtalar distraction bone-block arthrodesis for malunited calcaneal fractures was performed in 31 patients (26 men, five women), with a mean age of 38.5 years. The mean time from injury to arthrodesis was 36 months. There were no cases of nonunion. One patient had an early dislocation of the bone block requiring a repeat arthrodesis, and one had a soft-tissue infection. The mean AOFAS hindfoot score improved significantly from 23.5 before operation to 73.2 at a mean follow-up of 33 months (p > 0.001). Compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Dynamic pedobarography revealed a return to normal of the pressure distribution during roll-over and a more energetic gait. The distribution of local transfer of load correlated well with the AOFAS score. The amount of correction of the heel height correlated with a normal pattern of pressure transfer on the heel (p < 0.05).

Reconstructive Osteotomy of the Calcaneus With Subtalar Arthrodesis for Malunited Calcaneal Fractures

A technique of dealing with the late complications of malunited calcaneal fractures is based on the philosophy of reversing the deformity associated with late complications. The primary fracture is a shearing fracture that runs obliquely down the length of the calcaneus from superolateral to inferomedial and anterolateral to posteromedial. This permits the tuberosity of the calcaneus to translate laterally and proximally, and often splits the posterior facet. The complications of malunion are loss of height of the heel with concomitant dorsiflexion of the talus, widening of the heel, lateral impingement of the peroneal tendons and the distal fibula, and subtalar posttraumatic arthritis. The primary fracture deformity contributes directly to the late complications. The reconstructive osteotomy recreates the primary fracture. This permits repositioning of the tuberosity that narrows the heel, alleviates impingement, and returns height to the heel. The subtalar arthrodesis alleviates the symptoms of posttraumatic arthritis. The reconstruction is not dependent on cortical bone grafts for stability. The clinical series involved ten feet with an average follow-up period of 14 months. Two were revisions of previous triple arthrodeses. Results were satisfactory in nine feet.