SLR - November 2019 - Anne-Louise Smith
Reference: Wang B, Zhang X, Huo Y, Liu W, Wang W, Shao X. Calcaneal Lengthening for Partial Traumatic Loss of The Calcaneus. Injury. 2019 Mar;50(3):796-803.Scientific Literature Review
Reviewed By: Anne-Louise Smith, DPM
Residency Program: SUNY Downstate Medical Center – Brooklyn, NY
Podiatric Relevance: Partial traumatic loss of calcaneus has debilitating consequences on the foot as it is essential for efficient gait and biomechanics. Current treatments include single stage lengthening which is limited as it allows less than 1 centimeter elongation and, in most cases, is insufficient to restore normal biomechanics. The fibula-flexor hallucis longus osteomuscular flap is a complex, technically difficult procedure involving a high risk of failure. This is the first study that introduce and assess the effectiveness of the Illizarov lengthening technique in order to allow greater calcaneal lengthening than the existing techniques.
Methods: Calcaneal lengthening was performed on 15 patients who sustained partial traumatic calcaneal loss, between 10 and 35 percent, with Gustillo Anderson type III or IV injuries. Surgical technique consisted of reinsertion of Achilles tendon, one or two wound VAC applications followed by resurfacing with fasciocutaneus flap. Calcaneal lengthening with four-ring Illisarov frame was performed three months after wound healing. Evaluation of outcomes was done by comparing contralateral calcaneal pitch, hindfoot alignment, calcaneal lengthening and ankle ROM. Clinical outcome was measured with AOFAS score.
Results: Mean loss of calcaneus was 27 percent (range 19-35 percent), and mean amount of lengthening was 28 percent (range 19-38 percent). Calcaneal lengthening duration was a mean of 157 days (range 111-226 days) was performed in three periods; latency, distraction and consolidation. Mean follow-up duration was 25 months (range 24-27 months). Calcaneal pitch reached 100 percent of contralateral site and hindfoot alignment reached 75 percent. Ankle Dorsiflexion and plantarflexion reached 96 percent and 98 percent respectively as compared to the other foot. The average AOFAS score was 88 (range 71-100). There were eight excellent, six good and one fair result. Two pin tract infections were resolved by local care.
Conclusions: There was a statistically significant difference between the calcaneal length pre- and post-lengthening, which represents a great outcome since this technique allows 3-4 centimeter lengthening as compared to the single stage lengthening which allows up to 1 centimeter. In addition, the affected feet had no difference of calcaneal pitch, hindfoot alignment, dorsiflexion and plantarflexion of the ankle after 25 months as compared to the contralateral foot. Hence, patient could return to a normal gait without assistance with normal shoe gear. This study is limited by its retrospective design, its small sample size, the lack of comparison group and the fact that it can be applied to calcaneal loss between 10-35 percent. It would be interesting to follow this study for long term functional outcomes and to assess radiographic osteoarthritis changes.