Joint-preserving osteotomy for malunited intra-articular calcaneal fractures

Three-Plane Calcaneal Osteotomy With Joint Preservation vs Subtalar Arthrodesis to Treat Painful Calcaneal Fracture Malunions

BACKGROUND

Calcaneal fracture malunion (CFM) commonly occurs with multiple pathologic changes and progressive pain and difficulty walking. The purpose of this study was to propose a modified 3-plane joint-preserving osteotomy for the treatment of CFM with subtalar joint incongruence, and to compare its efficacy to subtalar arthrodesis.

METHODS

A retrospective comparative analysis of the data of 56 patients with CFM admitted from January 2017 to December 2022 was performed. Twenty-six patients were in the osteotomy group and 30 in the arthrodesis group. Computed tomographic (CT) scans were used for measurement of the intraarticular steps. Radiologic parameters, visual analog scale (VAS) score for pain, 12-Item Short Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores were compared between the 2 groups of patients to assess the outcome preoperatively and at last follow-up, which averaged 22.6 ± 3.6 months and 27.6 ± 3.6 months for the osteotomy and arthrodesis groups, respectively.

RESULTS

Improvements in pain, function, and overall quality of life were obtained in both groups compared with the preoperative values at last follow-up. The VAS and SF-12 scores were similar between the groups at the last follow-up. In the osteotomy group, the average CT scan-measured intraarticular step-offs were significantly reduced from 3.7 ± 1.2 mm to 0.9 ± 0.3 mm. The osteotomy group showed improvement in pronation and supination range of motion (ROM) of the feet (P < .01). The correction of the ankle height and Meary angle were slightly better in the osteotomy group.

CONCLUSION

In this short-term follow-up study, good results were achieved in both joint-preserving osteotomy and subtalar arthrodesis groups for the treatment of CFM with subtalar joint incongruence. The osteotomy group preserved the subtalar joint and achieved improvements in pronation and supination ROM.

Finite element analysis of restoring length with multiple internal fixations in calcaneal body fracture

Calcaneal body fractures are often associated with varying degrees of shortening deformities. Restoring calcaneal length is crucial for the functional prognosis of the foot. Through finite element analysis, this study compared the biomechanical effects of multiple fixation schemes for calcaneal fractures. We delineated and assembled the finite element model of the Sanders type II calcaneal fracture and four internal fixation simulations (namely distraction screw, lag screw, frame locking plate, and T-shaped locking plate). Different axial forces (350, 700, and 1400 N) were then applied to simulate various postures. We then compared the inner and outer shortening distances (D1 and D2, respectively), equivalent von Mises stress, and maximum von Mises stress of the calcaneus. In the individual model, with an increase in the pressure, D1, D2, and the maximum von Mises stress gradually increased. At 1400 N, D1 and D2 for the internal fixation schemes were as follows: distraction screw (0.03 mm, 0.1 mm) < T-shaped locking plate (0.45 mm, 0.26 mm) < frame locking plate (0.50 mm, 0.26 mm) < lag screw (0.66 mm, 0.64 mm). The maximum von Mises stress values for the internal fixation methods were as follows: lag screw (491.0 MPa) < distraction screw (663.1 MPa) < frame locking plate (772.7 MPa) < T-shaped locking plate (931.8 MPa). In patients with calcaneal body fractures, the distraction screw is a potential therapeutic option for resisting calcaneal shortening.

Multiple Reconstructive Osteotomy Treating Malunited Calcaneal Fractures Without Subtalar Joint Fusion

OBJECTIVE

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.

METHODS

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 ± 2.41 months 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.

RESULTS

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.

CONCLUSION

Multiple reconstructive osteotomy is an effective way to restore the calcaneal morphology and preserve the subtalar joint for selected calcaneal malunion.

Management of the Subtalar Joint Following Calcaneal Fracture Malunion

Subtalar joint arthrosis is common following intra-articular calcaneus fractures. The appropriate management of pain secondary to posttraumatic arthritis depends on the status of the remaining posterior facet articular cartilage, the magnitude of any residual joint displacement and distortions in the overall morphology of the calcaneus. In select circumstances, joint-preserving surgical techniques may be considered including lateral wall exostectomy, far lateral posterior facet joint debridement, and intra-articular osteotomies. When the subtalar joint is not salvageable, some form of arthrodesis procedure is pursued. Occasionally, an extra-articular osteotomy may be necessary in combination with arthrodesis to correct deformity.

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.

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

PURPOSE

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.

METHODS

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.

RESULTS

Ten research articles (170 patients with 184 feet) and nine reviews were included in this review, presenting seven types of corrective osteotomies (lateral wall exostectomy, Dwyer osteotomy, lateral wedge opening osteotomy, Romash osteotomy, tongue osteotomy, sagittal resection osteotomy, and modified Dwyer osteotomy).

CONCLUSION

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.

Recognition, Treatment, and Outcome of Calcaneal Fracture-Dislocation

BACKGROUND

Calcaneal fracture-dislocations are rare but potentially disabling injuries that are regularly overlooked at first presentation. To date, only about 50 cases have been reported in the literature.

METHODS

Over a period of 8 years, 10 patients (average age 61.7 years) with acute fracture-dislocations of the calcaneus were treated at 2 level 1 trauma centers. The calcaneocuboid joint was involved in 9 patients. There was a concomitant fracture of the lateral talar process and of the tip of the distal fibula in 7 patients each. Open reduction and internal fixation was performed in 9 of 10 patients via an oblique lateral dislocation approach. One patient underwent primary subtalar fusion. All patients were seen for clinical and radiographic follow-up at an average of 3 years using patient-reported outcome scores.

RESULTS

Anatomic fixation was achieved in all patients as judged by postoperative computed tomographic imaging. In the 9 patients treated with internal fixation, the Foot Function Index averaged 12.8, the EuroQol 5D score averaged 0.89 and the visual analog scale score for patient satisfaction averaged 79.3 at final follow-up. Signs of mild subtalar arthritis were seen in 6 patients. No secondary subtalar fusions were needed.

CONCLUSION

When recognized and treated early, prognosis of calcaneal fracture-dislocation was favorable. A dislocation approach starting over the distal fibula, continuing over the sinus tarsi, and extending toward the calcaneocuboid joint allowed for adequate visualization of the subtalar joint and treatment of all components of the injury.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Managing Severely Malunited Calcaneal Fractures and Fracture-Dislocations

Severe calcaneal malunions are debilitating conditions owing to substantial hindfoot deformity with subtalar arthritis and soft tissue imbalance. Type III malunions are best treated with a subtalar distraction bone block fusion. Additional osteotomies may be required for severe varus or superior displacement of the calcaneal tuberosity. Type IV malunions result from malunited calcaneal fracture-dislocations and require a 3-dimensional corrective osteotomy. Type V malunions warrant additional ankle debridement and reconstruction of the calcaneal shape to provide support for the talus in the ankle mortise. Accompanying soft tissue procedures include Achilles tendon lengthening, peroneal tendon release, and rerouting behind the lateral malleolus.

Late Treatment of Displaced Intra-Articular Calcaneus Fractures: Successful Management With Anatomic Reduction

INTRODUCTION

The aim of this study was to evaluate the results of displaced intra-articular calcaneus fractures treated more than 25 days after injury by open reduction and internal fixation (ORIF) using a lateral extensile surgical approach.

METHODS

Twenty patients identified by retrospective review of our trauma database were treated with ORIF for a displaced intra-articular calcaneus fracture more than 25 days after injury. OTA/AO 82-B and 82-C fracture patterns were included. All had ORIF by a lateral extensile approach. Bohler's angle was measured on injury radiographs, after operative fixation and the final follow-up and compared with the Bohler's angle of the contralateral uninjured extremity. Patients completed a Musculoskeletal Function Assessment (MFA) to evaluate the functional outcome.

RESULTS

The mean number of days from injury to fixation was 33.4 days (range, 26-58 days). A total of 18/20 patients were available for follow-up (mean 26.1 months; range 12.5-100 months). Eleven injuries were joint depression (82-C), and 7 injuries were tongue type (82-B) fracture patterns. The reason for delayed presentation was delayed transfer to our institution (11 patients), hemodynamic instability from polytrauma (2 patients), excessive fracture blisters (2 patients), and sepsis (1 patient). Bohler's angle at the time of injury was a mean of 10.9 degrees, which corrected to a mean of 33.3 after operative fixation but decreased to a mean of 28.1 at the time of the final follow-up. The mean Bohler angle was 32.3 on the contralateral uninjured side. The mean MFA score was 16.5 (range, 1-34). There were no wound infections or subtalar arthrodesis procedures performed.

CONCLUSIONS

ORIF by a lateral extensile approach is a safe and viable option for patients presenting in a delayed fashion with a displaced intraarticular calcaneus fracture. Marked improvement in the Bohler angle, acceptable functional outcome, and low complication rates can be expected when surgery is performed by an experienced surgeon.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hindfoot Injuries: How to Avoid Posttraumatic Varus Deformity?

Posttraumatic hindfoot varus may result from nonoperative treatment or inadequate reduction and fixation of talar and calcaneal fractures. Adequate visualization of the talar neck via bilateral approaches is essential in avoiding malreduction. In cases of medial comminution of the talar neck, lag screws must be avoided and the use of single or double plates should be considered. A Schanz screw introduced into the calcaneal tuberosity is instrumental in realigning shortening, varus, or valgus deformity of the heel. Special attention should be paid to addressing impaction of the medial facet of both the talus and calcaneus to avoid hindfoot varus.

The Effectiveness of Surgical Interventions in the Management of Malunited Calcaneal Fractures: A Systematic Review

Nonoperative management may result in calcaneal malunion with consequences of pain, deformity, and functional limitation. The aim of this review was to proffer an evidence-based scientific account of the effectiveness of contemporary surgical procedures in the management of malunited calcaneal fractures after initial conservative management. This systematic review included studies that evaluated the surgical procedures in the management of calcaneal malunion and systematically searched studies published between January 2005 and June 2016. The search was conducted using the following search engines: the Cochrane Library, Web of Science, PubMed/ MEDLINE, EMBASE, CINAHL, Academic Search Premier, and Open Grey. Methodologic assessment was conducted using the Cochrane Risk of Bias In nonrandomized Studies- of Interventions assessment tool version 7. Ten observational studies (212 patients) were included in this review. Five articles explored various means of achieving subtalar arthrodesis, 2 articles evaluated joint-sparing osteotomies, 1 examined corrective osteotomy for extra-articular os calcis malunion, and 2 articles explored combined procedures based on the Stephen and Sanders calcaneal malunion classification. Clinical and methodologic heterogeneity did not allow quantitative pooling of results. The overall risk of bias was considered moderate in 7 studies and 3 were considered at high risk of bias. The inability for any study to be considered at low risk of bias in this review might be mainly attributed to the lack of a valid and reliable outcome measure for the assessment of foot and ankle conditions. There is clear evidence that appropriately indicated procedures are effective in terms of pain alleviation, correction of deformity, and improved function. However, long-term outcomes may improve the acceptability to joint-preserving osteotomies, subtalar arthrodesis with the VIRA implant and subtalar distraction osteogenesis.

The lateral malleolar bony fleck classified by size and pathoanatomy: The IOFAS classification

BACKGROUND

This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs.

METHODS

Twenty-four patients had a lateral malleolar bony fleck on anteroposterior ankle radiographs, either in isolation or associated with other hindfoot injuries. We studied size of the bony flecks, presence or absence of peroneal tendon dislocation and pathoanatomy on CT scans.

RESULTS

In 11 patients, a small bony fleck lies within the superior peroneal retinaculum and contiguous periosteum, which are stripped off the lateral fibula (Class II lesions). Tendons dislocate into the subperiosteal pouch thus formed, resembling Class I lesions without associated bony avulsion. Treatment for Class II is same as for Class I injuries. In 8 patients with a big bony fleck, tendons dislocate into the fracture site and SPR is intact (Class III lesions). In Class IV lesions, observed in 5 patients with 2-part calcaneal fracture/dislocation, SPR remains intact and peroneal tendons are not dislocated. The invariably large fleck results from the displacing lateral calcaneal fragment abutting against the fibula, whereas the dislocating tendons cause the bony avulsions in Classes II and III.

CONCLUSIONS

Due to pathoanatomical differences, surgical approach and natural history of neglected lesions differ depending on size of the bony fleck. The SPR must not be incised in case of big Class III flecks.

Peroneal Tendon Instability in Intra-Articular Calcaneus Fractures: A Retrospective Comparative Study and a New Surgical Technique

OBJECTIVE

To compare the prevalence of peroneal tendon instability as determined by intraoperative evaluation versus preoperative computed tomography (CT) scans, and to identify specific risk factors that correlate with tendon instability.

DESIGN

Retrospective comparative study.

SETTING

Level 1 trauma hospital.

PATIENTS

Patients with operatively treated intra-articular calcaneus fractures managed between January 1, 2002 and December 31, 2012 were reviewed for evidence of peroneal tendon instability. Of 254 fractures, 155 intra-articular calcaneus fractures met inclusion criteria and were available for final analysis.

INTERVENTION

Operative notes were reviewed to confirm intraoperative testing for superior peroneal retinaculum (SPR) integrity and peroneal tendon stability. Preoperative CT scan and plain radiographs were evaluated for presence of peroneal tendon dislocation, fibular fracture or "fleck" sign, excessive lateral wall displacement, and/or calcaneal fracture-dislocation.

MAIN OUTCOME MEASURES

Peroneal tendon stability was determined with intraoperative assessment of the intact SPR and its confluence with the peroneal tendon sheath. The incidence of peroneal tendon instability on intraoperative assessment was compared with preoperatively identified tendon dislocation on CT scan. Prevalence of peroneal tendon dislocation was determined using each diagnostic method. Risk factors for tendon instability were identified using a multivariate regression model.

RESULTS

There was significantly higher prevalence of peroneal tendon instability as determined by preoperative imaging (30%; n = 47/155) compared with intraoperative retinaculum testing (11.6%; n = 18/155) (P < 0.001). Intraoperative tendon instability was significantly associated with increased fracture classification severity, fibular fracture/"fleck" sign, and fracture-dislocation.

CONCLUSIONS

Intraoperative evaluation of the SPR should be used in conjunction with preoperative imaging for diagnosis of peroneal instability in the setting of operatively treated, intra-articular calcaneus fractures.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Joint-Preserving Osteotomies for Malaligned Intraarticular Calcaneal Fractures

Intraarticular calcaneal fracture treatments that result in malalignment often require reconstructive surgery. Seven cases are used to demonstrate the intricacies of reconstructive case management. Reestablishment of calcaneal height, length, orientation, and position relative to the other tarsals is necessary to reestablish appropriate foot function. Inherent or acquired gastrocnemius equinus should be treated with recession to reduce destructive forces on the reconstruction.

Corrective Osteotomies for Malunited Tongue-Type Calcaneal Fractures

Displaced tongue-type fractures of the calcaneus can lead to severe pain and disability if not treated appropriately. Failure to reduce articular displacement may require subtalar joint arthrodesis with subsequent loss of function. The subtalar joint is crucial for normal foot and ankle function. In selected cases, if the malunited joint is still in good condition, it is preserved by corrective osteotomy. A joint-preserving osteotomy with axial realignment is a treatment option for malunited tongue-type calcaneal fractures encountered early on, before the development of subtalar arthrosis in carefully selected patients.

Incidence and recognition of peroneal tendon dislocation associated with calcaneal fractures

BACKGROUND

Questions abound regarding natural history and medicolegal implications of untreated peroneal tendon dislocation (PTD) associated with calcaneal fractures.

METHODS

We retrospectively analyzed CT scans and anteroposterior ankle radiographs of 79 consecutive calcaneal fractures presenting over 4 years at a single institution.

RESULTS

Nineteen patients (24%) had associated PTD, which was initially missed in 10 (53%). Bony fleck was present in 11 (13.75%). Soft tissue swelling at lateral malleolar level, present on radiographs of 18 tendon dislocators (95%), raises likelihood of PTD with increasing specificity the greater the swelling. In 6 patients, surgeons failed to identify on CT spontaneously relocated tendons that then peeped around the posterolateral fibula, a finding not appreciable on 3-dimensional volume-rendering.

CONCLUSIONS

Despite a significant association of PTD with calcaneal fractures, it still passes unrecognized all too frequently. Anatomical fracture fixation does not guarantee stable tendon reposition. Further studies are required to elucidate functional outcome of untreated PTD.

[Joint-preserving osteotomy for calcanean malunions]

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.

[Operative treatment of displaced intra-articular calcaneal fractures]

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%).

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.