Background: Nonoperative management of displaced intra-articular
calcaneal fractures may result in malunion affecting the function of both the
ankle and the subtalar joint. The purpose of this study was to report the
intermediate to long-term results of a treatment protocol for calcaneal
fracture malunions.
Methods: Seventy feet (sixty-four patients) with a malunion after
nonoperative management of a displaced intra-articular calcaneal fracture were
evaluated. On the basis of the classification system of Stephens and Sanders,
type-I malunions were treated with a lateral wall exostectomy and peroneal
tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal
tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a
lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis,
and a calcaneal osteotomy. The patients were evaluated clinically and
radiographically at a minimum of twenty-four months following surgery.
Results: Forty-five feet in forty patients were available for
follow-up evaluation at a minimum of two years, with an average duration of
follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an
arthrodesis achieved union. Statistical analysis revealed no significant
difference among the types of malunion with respect to the Maryland foot
score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and
hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which
was likely due to sample size discrepancies. Forty-two (93%) of the forty-five
feet were aligned in neutral or slight valgus hindfoot alignment, and all
forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild
residual pain, and nineteen of them had pain in the lateral aspect of the
ankle. Radiographically, talocalcaneal height was significantly greater for
the type-III malunion group relative to the type-I and type-II malunion groups
(p = 0.021).
Conclusions: This treatment protocol proved to be effective in
relieving pain, reestablishing a plantigrade foot, and improving patient
function. Because of the difficulty we encountered in restoring the calcaneal
height and the talocalcaneal relationship in this group of patients with a
symptomatic calcaneal fracture malunion, we believe that patients with a
displaced intra-articular calcaneal fracture may benefit from acute operative
treatment.
Level of Evidence: Therapeutic Level III. See
Instructions to Authors for a complete description of levels of evidence.