Calcaneal Stress Fracture: An Adverse Event Following Total Hip and Total Knee Arthroplasty

SLR- March 2014- Keleigh Muxlow

Reference:  Takaaki; M. Takahito; M. Akihiro; N. Calcaneal Stress Fracture: An Adverse Event Following Total Hip and Total Knee Arthroplasty: A Report of Five Cases. The Journal of Bone & Joint Surgery. 2014 Jan; 96(2).

 

Reviewed by: Keleigh Muxlow, DPM
Residency Program: Botsford Hospital

Podiatric Relevance: This article is interesting to a podiatric surgeon because there has not been reported literature of calcaneal stress fractures after a total hip or total knee arthroplasty. Calcaneal stress fractures are not commonly recognized in elderly individuals and are more commonly recognized in healthy, active patients.  Although the rate of a calcaneal stress fracture in a post-operative patient is low (less than 1 percent in this six-year study), it is important to recognize the possibility in elderly patients. This is especially true in those with osteoporosis and symptoms such as acute heel pain, warmth, and erythema of the heel. The authors' purpose of this article was to discuss five occurrences of calcaneal stress fractures in patients with prior total hip and knee surgery and common presenting symptoms as well as treatment.
 

Methods: A retrospective study design specifically focusing on clinical features, imaging results, and bone mineral content of the proximal femur and distalradius were reviewed in five patients who obtained a calcaneal stress fracture after a total hip (one patient) or total knee (four patients) arthroplasty.

Results: All patients were women with an average age of 76.8 years. All calcaneal stress fractures occurred on the ipsilateral side as the arthroplasty. All patients reported with heel pain upon ambulation (stand on heel test). Four patients presented with swelling, and three patients presented with warmth. The fracture appeared radiographically at a mean of 10.2 weeks post-operatively. Symptoms subsided in a few weeks with protected weight bearing. One fracture healed in a displaced position.

Conclusions: Calcaneal stress fractures may occur more after joint replacement surgery due to additional mechanical stress on the operatively treated limb as a result of pain relief. Clinically all patients complained of heel pain and could not bear weight on the affected limb and medial-lateral squeeze test was positive. Subsequently, warmth, erythema, and swelling occurred. The common radiographic finding was an irregular sclerotic line traversing the calcaneus appearing between seven and thirty-one days after the presenting symptoms. When treating this patient population it is important to note that clinical symptoms appear prior to radiographic findings. Therefore, a high index of suspicion is necessary to make an accurate diagnosis because a calcaneal stress fracture may be often under recognized and misdiagnosed.