Session VIII - Reconstruction

*Intermediate to Long-Term Results of a Treatment Protocol for Calcaneal Fracture Malunions

Michael P. Clare, MD¹; William E. Lee, III, PhD; Roy W. Sanders, MD² (c,e-DePuy Ace, a Johnson & Johnson Company);

¹University of Nebraska Medical Center, Omaha, Nebraska, USA;

²Florida Orthopaedic Institute, Tampa General Hospital, Tampa, Florida, USA

Purpose: We report the intermediate- to long-term results of a treatment protocol based on the Stephens-Sanders classification for calcaneal fracture malunions.

Methods: Seventy malunions in 64 patients who had previously undergone nonoperative management of a displaced calcaneal fracture resulting in malunion were reviewed. Type I malunions underwent lateral wall exostectomy and peroneal tenolysis; type II malunions underwent a lateral wall exostectomy, peroneal tenolysis, and subtalar autograft arthrodesis; and type III malunions underwent a lateral wall exostectomy, peroneal tenolysis, subtalar autograft arthrodesis, and calcaneal osteotomy. The average patient age was 47.5 years (range, 24 to 74); the average interval between fracture and surgery was 16.4 months (range, 2 to 117).

Results: Forty-two malunions in 39 patients were available for a follow-up evaluation at a minimum of 24 months, with an average of 5.3 years (range, 24 to 151 months). Fifty-four of 59 arthrodeses (91.5%) achieved initial union; all five nonunions (8.5%) underwent revision arthrodesis and successfully healed. The average Maryland and AOFAS scores were 79.1 and 73.8, respectively. Statistical analysis revealed no difference in outcome scores between the malunion types, likely due to sample size discrepancies. Thirty-nine of 42 malunions (92.9%) were aligned in neutral or neutral-slight valgus, and all 42 malunions (100%) were plantigrade. Twenty-six of 39 (66.7 %) had mild residual pain, 19 in the lateral ankle. Radiographically, the overall average talocalcaneal height was 71.4 mm; the average lateral talocalcaneal angle was 32.2°; the average talar declination angle was 14.7°; and the average calcaneal pitch angle was 17.6°. Statistical analysis revealed significantly greater talocalcaneal height for the type III malunion group relative to the type I and type II malunion groups (P = 0.021). There was no significant difference in all other radiographic parameters between malunion groups. Twenty-five of 29 (86.2%) workers compensation patients returned to work at an average of 8.7 months after surgery; 23, however, required job retraining. Statistical analysis revealed significantly lower outcome scores in all but one of the SF-36 subscales in the workers compensation group (P <0.01 to 0.03) compared with the non-workers compensation group, however, there was no significant difference in Maryland or AOFAS scores.

Conclusions: The protocol proved effective in relieving pain, reestablishing a stable, plantigrade foot, and improving overall patient function. Patients may note mild persistent pain, however, particularly in the lateral ankle. Most workers compensation patients can expect to return to work after treatment, albeit at a lesser job. Because of the difficulty in restoring calcaneal height and the talocalcaneal relationship following a calcaneal fracture malunion, patients with displaced calcaneal fractures may derive long-term benefit from operative treatment performed acutely.

* If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options and e-consultant or employee.