SLR - September 2019 - Hesam Naenifard
References: Lee H, Kim W, Park E, Kim J, Kim Y, Lee Y. Mid-Term Follow-Up Results of Calcaneal Reconstruction for Calcaneal Malunion. BMC Musculoskeletal Disorders. 2019 Jan 29;20(1)Scientific Literature Review
Reviewed By: Hesam Naenifard, DPM
Residency Program: Hoboken University Medical Center – Hoboken, NJ
Podiatric Relevance: Calcaneal fractures are common in the hindfoot and are caused by high energy trauma. The injury can lead to complications such as subtalar arthritis and malunion, which will result in persistent postoperative pain and low patient satisfaction. When performing surgery, it is critical to restore the calcaneal height, the articular surfaces, and to pull the calcaneus out to length and realign the calcaneus into a varus position. Calcaneal malunion, a common sequelae after surgery for a calcaneus fracture, can be detrimental to the patient’s quality of life and can cause a lot of pain for the patient. The purpose of this retrospective study was to report the mid-term follow-up clinical and radiological results of calcaneal reconstruction of calcaneal malunion.
Methods: Patients who underwent calcaneal reconstruction from 2009 to 2014 for painful nonunions were evaluated. Of the 34 patients identified, 10 patients were reviewed postoperatively at the mid-term follow-up. Inclusion criteria included diagnosis of post-calcaneus fracture malunions, history of a calcaneal fracture, open reduction internal fixation, reconstruction surgery for calcaneal malunion, postoperative follow-up of a minimum of four years and symptoms of postoperative pain. Exclusion criteria applied to patients with severe subtalar arthritis or those who underwent subtalar arthrodesis or an ostectomy. Patients were evaluated for the site of pain and range of ankle motion. Radiographic assessment included talocalcaneal height and angle, calcaneal pitch, calcaneal width, and Bohler’s angle were measured three times at each visit (pre-reconstruction, post-reconstruction, and final follow-up). Stephens and Zwipp classification at each of the visit was used to assess the severity of the injury.
Results: The study included 10 male patients with a mean age of 46.3 years. The mean interval between the first operation and the reconstruction surgery was 16.6 months. The mean follow-up period was 67.1 months after calcaneal reconstruction. There was a significant difference in talocalcaneal height, talocalcaneal angle, calcaneal pitch, calcaneal width, and Bohler angle before and after reconstruction. No significant differences were observed between reconstruction and final follow-up. Furthermore, researchers found the mean AOFAS ankle and hindfoot score improved from 66.50 pre-construction to 80.30 at the final follow-up. The mean VAS score improved from 8.60 pre-construction to 3.40 at the final follow-up.
Conclusions: The most statistically significant improvement of calcaneal reconstruction for calcaneal malunion at the mid-term follow-up was the improvement in the radiographical and clinical outcomes. The participants in this study had diffuse pain at the anterior, lateral and plantar aspects of the foot. It is critical during calcaneal reconstruction to restore the calcaneal height in order to improve the talocalcaneal relationship and increase the Achilles tendon lever arm. This further prevents tibiotalar impingement and decreases postoperative pain. The limitations within this study were the small sample size and lack of a control group can lead to a type two statistical error, where one could fail to detect an effect and thereby skew the results. Lastly, the researchers concluded that calcaneal reconstructions can be successful in the presence of calcaneal malunion.