Reconstruction of calcaneal fracture malunion with osteotomy and subtalar joint salvage: technique and outcomes

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.

Staged Ilizarov distraction histogenesis and corrective reconstruction for severe malunited calcaneal fractures

PURPOSE

Severe calcaneal malunion is a clinical conundrum for the difficulty of calcaneal reconstruction without soft tissue complications. The aim of this study is to introduce the treatment strategy and preliminary results of staged Illizarov distraction histogenesis and corrective reconstruction for severe malunion of calcaneal fractures.

METHODS

From June 2014 to May 2020, 14 patients with severe calcaneal malunion treated with the staged strategy were retrospectively analyzed. At the first stage, calcaneal osteotomy and external fixation with Ilizarov frame were performed. The restoration of the approximate configuration of calcaneus and the expansion of contractural soft tissue were achieved by gradual calcaneal distraction. At the second stage, corrective reconstruction was performed and autogenous iliac crest bone graft was used. Clinical and radiographic outcomes were evaluated at final follow-up.

RESULTS

The average time of Ilizarov distraction and total fixation was 21.4 days and 41.0 days at first-stage treatment. At a mean follow-up of 33.1 months, the average American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score increased significantly from 24.0 to 72.4 (p < 0.01). And the mean visual analogue scale (VAS) score had improved remarkably from 8.2 to 2.4 (p < 0.01). Radiographs showed that talocalcaneal height, calcaneal width, calcaneal tuberosity height, hindfoot alignment angle, and talar declination angle were improved to a great extent (p < 0.01). Only one patient had minor pin site infection at first-stage treatment and one got superficial wound infection after second-stage surgery. No wound dehiscence, skin necrosis, or deep infection occurred.

CONCLUSION

Staged Ilizarov distraction histogenesis and corrective reconstruction is a safe and effective treatment strategy for reducing soft tissue complications and improving reconstruction results in surgical correction of severe calcaneal malunion.

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.

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.

Comparison and predictive factors analysis for efficacy and safety of Kirschner wire, anatomical plate fixation and cannulated screw in treating patients with open calcaneal fractures

This study aimed to compare the efficacy and safety among Kirschner wire, anatomical plate fixation and cannulated screw treatments in patients with open calcaneal fractures, and to explore the predictive factors for treatment response and complication occurrence.The 142 open calcaneal fracture patients were enrolled in this study, who received fixation procedures of Kirschner wire, anatomical plate fixation or cannulated screw on demand. Treatment efficacy was assessed by AOFAS score and occurrence of complications was recorded.No difference of AOFAS score was observed among Kirschner wire, anatomical plate fixation and cannulated screw groups (P = .792), and the numbers of patients with excellent, good, medium, and poor AOFAS score in Kirschner wire group were 16 (16.2%), 42 (42.4%), 32 (32.3%), and 9 (9.1%), which in anatomical plate fixation group were 4 (16.7%), 11 (45.8%), 7 (29.2%), and (8.3%), and in cannulated screw group were 1 (5.3%), 10 (52.6%), 6 (31.6%), and 2 (10.5%), respectively. No difference of total complication occurrence (P = .709) or specific complications including skin graft (P = .419), flap graft (P = .229), deep infection (P = .644) or amputation (P = .428) was discovered among 3 groups. Logistic regression analysis revealed that fixation options did not affect treatment response and complication occurrence (all P > .05), while higher Gustilo type correlates with decreased treatment response (P < .001) and elevated complication occurrence (P < .001) independently.Kirschner wire, anatomical plate fixation, and cannulated screw are equally efficient and tolerated in treating patients with open calcaneal fractures, and higher Gustilo type correlates with decreased treatment response and increased complication occurrence independently.

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.

Mid-term follow-up results of calcaneal reconstruction for calcaneal malunion

Background

We hypothesized that calcaneal reconstruction can relieve chronic pain due to calcaneal malunion. We report the mid-term follow-up results of calcaneal reconstruction for calcaneal malunion.

Methods

We reviewed the records of 10 male patients (10 ft) who underwent calcaneal reconstruction for calcaneal malunion between January 2009 and July 2014 at the mid-term follow-up. Talocalcaneal height and angle, calcaneal pitch, calcaneal width, Böhler angle, Stephens classification, and Zwipp classification were evaluated by three orthopedic doctors at each visit (pre-reconstruction, post-reconstruction, and at the last follow-up).

Results

The mean follow-up period was 67.1 months (range, 48–101 months). The sites of pain before reconstruction were lateral aspect (4 patients), plantar aspect (3 patients), diffuse pain (2 patients), and anterior aspect (1 patient). There was a significant difference in talocalcaneal height, talocalcaneal angle, calcaneal pitch, calcaneal width, and Böhler angle before and after reconstruction (p < 0.05). There was no significant difference between reconstruction and the last follow-up. Radiological measurement agreement was calculated to be moderate to strong (intraclass correlation coefficient: 0.659–0.988). Mean American Orthopedic Foot & Ankle Society Ankle and Hindfoot score improved from 66.50 ± 9.37 pre-reconstruction to 80.30 ± 8.52 at the last follow-up (p < 0.05). The mean visual analog scale score improved from 8.60 ± 1.43 before reconstruction to 3.40 ± 0.84 at the last follow-up (p < 0.05). Most patients were satisfied with the outcome postoperatively.

Conclusions

Our results showed substantial improvement in the clinical and radiological outcomes after calcaneal reconstruction of calcaneal malunion. This outcome was maintained until the mid-term follow-up. Therefore, calcaneal reconstruction may be a good option for the treatment of chronic pain caused by the malunion of a calcaneal fracture without severe subtalar arthritis. Further prospective studies are needed to test this theory.

Level of Evidence: Level IV, Retrospective Case Series.

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.

[Biomechanical comparison of three kinds of fixation instruments for calcaneal osteotomy]

Objective

To compare the biomechanical characteristics of self-made nickel-titanium shape memory alloy stepped plate with calcaneal plate and cannulated compression screws in fixing calcaneal osteotomy.

Methods

Calcaneal osteotomy was operated on 6 fresh-frozen lower limbs collected from donors. Then three kinds of fixation materials were applied in random, including the self-made nickel-titanium shape memory alloy stepped plate (group A), calcaneal plate (group B), and cannulated compression screws (group C). Immediately after fixation, axial loading of 20-600 N and 20 N/s in speed was introduced to record the biomechanical data including maximum displacement, elastic displacement, and maximum load. Then fatigue test was performed (5 Hz in frequency and repeat 3 000 times) and the same axial loading was introduced to collect the biomechanical data. Finally, the axial compression stiffness before and after fatigue test were calculated.

Results

There was no significant difference in the axial compression stiffness between pre- and post-fatigue test in each group ( P>0.05). However, the axial compression stiffness was significant higher in group A than that in groups B and C both before and after fatigue test ( P<0.05). No significant difference was found between group B and group C ( P>0.05).

Conclusion

Self-made nickel-titanium shape memory alloy stepped plate is better than calcaneal plate and cannulated compression screws in axial load stiffness after being used to fix calcaneal osteotomy.

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.

[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.