Calcaneal V-shaped osteotomy combined with subtalar arthrodesis for Stephens <b>Ⅱ</b> and <b>Ⅲ</b> calcaneal fractures malunion_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

TIAN Haodong , WANG Xinwen , LU Jun , LIU Peilong , LI Yi , ZHAO Hongmou ,  LIANG Xiaojun

Department of Foot and Ankle Surgery, Honghui Hospital Affiliated to Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P. R. China;

Corresponding author：

LIANG Xiaojun, Email: liangjun33369@163.com

Keywords：

Calcaneal fracture; malunion; traumatic subtalar arthritis; subtalar arthrodesis; osteotomy

DOI：

10.7507/1002-1892.202211082

Video：

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Objective To investigate the effectiveness of calcaneal V-shaped osteotomy combined with subtalar arthrodesis in the treatment of Stephens Ⅱand Ⅲ calcaneal fracture malunion. Methods The clinical data of 24 patients with severe calcaneal fracture malunion treated by calcaneal V-shaped osteotomy combined with subtalar arthrodesis between January 2017 and December 2021 were retrospectively analyzed. There were 20 males and 4 females with an average age of 42.8 years (range, 33-60 years). Conservative treatment of calcaneal fracture failed in 19 cases and operation failed in 5 cases. Stephens classification of calcaneal fracture malunion was type Ⅱ in 14 cases, and type Ⅲ in 10 cases. Preoperative Böhler angle of calcaneus was 4.0°-13.5° (mean, 8.6°), Gissane angle was 100°-152° (mean, 119.3°). The time from injury to operation was 6-14 months (mean, 9.7 months). American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analogue scale (VAS) score were used to evaluate the effectiveness before operation and at last follow-up. Bone healing was observed and the healing time was recorded. The talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were measured. Results Necrosis of the cuticle edge of the incision occurred in 3 cases, which were cured by dressing change and oral administration of antibiotic therapy. The other incisions healed by first intention. All the 24 patients were followed up 12-23 months, with an average of 17.1 months. The foot shape of the patients recovered well, the shoes were restored to the size before injury, and there was no anterior ankle impingement. Bone union was achieved in all patients, and the healing time ranged from 12 to 18 weeks, with an average of 14.1 weeks. At last follow-up, no adjacent joint degeneration occurred in all patients; 5 patients had mild foot pain during walking, which had no significant impact on daily life and work; no patient needed revision surgery. The AOFAS ankle and hindfoot score was significantly higher than that before operation (P<0.001), the results were excellent in 16 cases, good in 4 cases, and poor in 4 cases, and the excellent and good rate was 83.3%. The VAS score, talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were significantly improved after operation (P<0.001). Conclusion Calcaneal V-shaped osteotomy combined with subtalar arthrodesis can effectively relieve hindfoot pain, correct talocalcaneal height, restore talus inclination angle, and reduce the risk of nonunion after subtalar arthrodesis.

Citation： TIAN Haodong, WANG Xinwen, LU Jun, LIU Peilong, LI Yi, ZHAO Hongmou, LIANG Xiaojun. Calcaneal V-shaped osteotomy combined with subtalar arthrodesis for Stephens Ⅱ and Ⅲ calcaneal fractures malunion. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(3): 296-301. doi: 10.7507/1002-1892.202211082 Copy

1.	Vosoughi AR, Borazjani R, Ghasemi N, et al. Different types and epidemiological patterns of calcaneal fractures based on reviewing CT images of 957 fractures. Foot Ankle Surg, 2022, 28(1): 88-92.
2.	Thompson MJ, Roukis TS. Management of calcaneal fracture malunion with bone block distraction arthrodesis: A systematic review and meta-analysis. Clin Podiatr Med Surg, 2019, 36(2): 307-321.
3.	Yu GR, Hu SJ, Yang YF, et al. Reconstruction of calcaneal fracture malunion with osteotomy and subtalar joint salvage: technique and outcomes. Foot Ankle Int, 2013, 34(5): 726-733.
4.	Carr JB, Hansen ST, Benirschke SK. Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle, 1988, 9(2): 81-86.
5.	Kassem MS, Elgeidi A, Badran M, et al. Sagittal resection osteotomy with bone block distraction subtalar fusion for treatment of malunited calcaneal fractures. J Foot Ankle Surg, 2019, 58(4): 739-747.
6.	Rammelt S, Grass R, Zwipp H. Joint-preserving osteotomy for malunited intra-articular calcaneal fractures. J Orthop Trauma, 2013, 27(10): e234-e238.
7.	Clare MP, Lee WE, Sanders RW. Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. J Bone Joint Surg (Am), 2005, 87(5): 963-973.
8.	Farouk A, Ibrahim A, Abd-Ella MM, et al. Effect of subtalar fusion and calcaneal osteotomy on function, pain, and gait mechanics for calcaneal malunion. Foot Ankle Int, 2019, 40(9): 1094-1103.
9.	Fletcher AN, Liles JL, Steele JJ, et al. Systematic review of subtalar distraction arthrodesis for the treatment of subtalar arthritis. Foot Ankle Int, 2020, 41(4): 437-448.
10.	Huang PJ, Fu YC, Cheng YM, et al. Subtalar arthrodesis for late sequelae of calcaneal fractures: fusion in situ versus fusion with sliding corrective osteotomy. Foot Ankle Int, 1999, 20(3): 166-170.
11.	Kim HN, Park YU, Kim BS, et al. Rotational osteotomy and subtalar arthrodesis for subtalar arthritis with calcaneal malunion: A technical note. Foot Ankle Int, 2021, 42(10): 1340-1346.
12.	杨锁平, 侯晓进, 孟泽祖, 等. 距下关节融合并跟骨关节外截骨矫形术治疗陈旧性跟骨关节内骨折. 中国骨与关节损伤杂志, 2020, 35(8): 808-811.
13.	郭宝磊, 侯宝贤, 赵春丽, 等. Illizarov牵拉与截骨融合分期治疗跟骨骨折畸形愈合. 中国矫形外科杂志, 2021, 29(14): 1319-1322.
14.	Stephens HM, Sanders R. Calcaneal malunions: results of a prognostic computed tomography classification system. Foot Ankle Int, 1996, 17(7): 395-401.
15.	Harnroongroj T, Harnroongroj T, Suntharapa T, et al. The new intra-articular calcaneal fracture classification system in term of sustentacular fragment configurations and incorporation of posterior calcaneal facet fractures with fracture components of the calcaneal body. Acta Orthop Traumatol Turc, 2016, 50(5): 519-526.
16.	Schindler C, Schirm A, Zdravkovic V, et al. Outcomes of intra-articular calcaneal fractures: surgical treatment of 114 consecutive cases at a maximum care trauma center. BMC Musculoskelet Disord, 2021, 22(1): 234. doi: 10.1186/s12891-021-04088-w.
17.	Lee HS, Kim WJ, Park ES, et al. Mid-term follow-up results of calcaneal reconstruction for calcaneal malunion. BMC Musculoskelet Disord, 2019, 20(1): 43. doi: 10.1186/s12891-019-2419-1.
18.	Konovalchuk N, Sorokin E, Fomichev V, et al. Is there a borderline value in the radiological findings of patients with calcaneal malunion that may help to select an appropriate treatment option? Foot Ankle Int, 2022, 43(1): 42-48.
19.	Zhang T, Chen W, Yu G, et al. A novel method of simultaneous in situ decompression of lateral calcaneal bulge and subtalar arthrodesis via a single incision for malunion after calcaneal fractures. Orthop Surg, 2020, 12(3): 827-835.
20.	Mann RA, Baumgarten M. Subtalar fusion for isolated subtalar disorders. Preliminary report. Clin Orthop Relat Res, 1988, (226): 260-265.
21.	El-Hawary A, Kandil YR, Ahmed M, et al. Distraction subtalar arthrodesis for calcaneal malunion: comparison of local versus iliac bone graft. Bone Joint J, 2019, 101-B(5): 596-602.
22.	Chung HJ, Bae SY, Choo JW. Mid-term follow up results of subtalar distraction arthrodesis using a double bone-block for calcaneal malunion. Yonsei Med J, 2014, 55(4): 1087-1094.
23.	Myerson M, Quill GE. Late complications of fractures of the calcaneus. J Bone Joint Surg (Am), 1993, 75(3): 331-341.
24.	Lee MS, Tallerico V. Distraction arthrodesis of the subtalar joint using allogeneic bone graft: a review of 15 cases. J Foot Ankle Surg, 2010, 49(4): 369-374.
25.	Woo SH, Goh TS, Ahn TY, et al. Subtalar distraction arthrodesis for calcaneal malunion-comparison of structural freeze-dried versus autologous iliac bone graft. Injury, 2021, 52(4): 1048-1053.
26.	Pollard JD, Schuberth JM. Posterior bone block distraction arthrodesis of the subtalar joint: a review of 22 cases. J Foot Ankle Surg, 2008, 47(3): 191-198.

1. Vosoughi AR, Borazjani R, Ghasemi N, et al. Different types and epidemiological patterns of calcaneal fractures based on reviewing CT images of 957 fractures. Foot Ankle Surg, 2022, 28(1): 88-92.
2. Thompson MJ, Roukis TS. Management of calcaneal fracture malunion with bone block distraction arthrodesis: A systematic review and meta-analysis. Clin Podiatr Med Surg, 2019, 36(2): 307-321.
3. Yu GR, Hu SJ, Yang YF, et al. Reconstruction of calcaneal fracture malunion with osteotomy and subtalar joint salvage: technique and outcomes. Foot Ankle Int, 2013, 34(5): 726-733.
4. Carr JB, Hansen ST, Benirschke SK. Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle, 1988, 9(2): 81-86.
5. Kassem MS, Elgeidi A, Badran M, et al. Sagittal resection osteotomy with bone block distraction subtalar fusion for treatment of malunited calcaneal fractures. J Foot Ankle Surg, 2019, 58(4): 739-747.
6. Rammelt S, Grass R, Zwipp H. Joint-preserving osteotomy for malunited intra-articular calcaneal fractures. J Orthop Trauma, 2013, 27(10): e234-e238.
7. Clare MP, Lee WE, Sanders RW. Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. J Bone Joint Surg (Am), 2005, 87(5): 963-973.
8. Farouk A, Ibrahim A, Abd-Ella MM, et al. Effect of subtalar fusion and calcaneal osteotomy on function, pain, and gait mechanics for calcaneal malunion. Foot Ankle Int, 2019, 40(9): 1094-1103.
9. Fletcher AN, Liles JL, Steele JJ, et al. Systematic review of subtalar distraction arthrodesis for the treatment of subtalar arthritis. Foot Ankle Int, 2020, 41(4): 437-448.
10. Huang PJ, Fu YC, Cheng YM, et al. Subtalar arthrodesis for late sequelae of calcaneal fractures: fusion in situ versus fusion with sliding corrective osteotomy. Foot Ankle Int, 1999, 20(3): 166-170.
11. Kim HN, Park YU, Kim BS, et al. Rotational osteotomy and subtalar arthrodesis for subtalar arthritis with calcaneal malunion: A technical note. Foot Ankle Int, 2021, 42(10): 1340-1346.
12. 杨锁平, 侯晓进, 孟泽祖, 等. 距下关节融合并跟骨关节外截骨矫形术治疗陈旧性跟骨关节内骨折. 中国骨与关节损伤杂志, 2020, 35(8): 808-811.
13. 郭宝磊, 侯宝贤, 赵春丽, 等. Illizarov牵拉与截骨融合分期治疗跟骨骨折畸形愈合. 中国矫形外科杂志, 2021, 29(14): 1319-1322.
14. Stephens HM, Sanders R. Calcaneal malunions: results of a prognostic computed tomography classification system. Foot Ankle Int, 1996, 17(7): 395-401.
15. Harnroongroj T, Harnroongroj T, Suntharapa T, et al. The new intra-articular calcaneal fracture classification system in term of sustentacular fragment configurations and incorporation of posterior calcaneal facet fractures with fracture components of the calcaneal body. Acta Orthop Traumatol Turc, 2016, 50(5): 519-526.
16. Schindler C, Schirm A, Zdravkovic V, et al. Outcomes of intra-articular calcaneal fractures: surgical treatment of 114 consecutive cases at a maximum care trauma center. BMC Musculoskelet Disord, 2021, 22(1): 234. doi: 10.1186/s12891-021-04088-w.
17. Lee HS, Kim WJ, Park ES, et al. Mid-term follow-up results of calcaneal reconstruction for calcaneal malunion. BMC Musculoskelet Disord, 2019, 20(1): 43. doi: 10.1186/s12891-019-2419-1.
18. Konovalchuk N, Sorokin E, Fomichev V, et al. Is there a borderline value in the radiological findings of patients with calcaneal malunion that may help to select an appropriate treatment option? Foot Ankle Int, 2022, 43(1): 42-48.
19. Zhang T, Chen W, Yu G, et al. A novel method of simultaneous in situ decompression of lateral calcaneal bulge and subtalar arthrodesis via a single incision for malunion after calcaneal fractures. Orthop Surg, 2020, 12(3): 827-835.
20. Mann RA, Baumgarten M. Subtalar fusion for isolated subtalar disorders. Preliminary report. Clin Orthop Relat Res, 1988, (226): 260-265.
21. El-Hawary A, Kandil YR, Ahmed M, et al. Distraction subtalar arthrodesis for calcaneal malunion: comparison of local versus iliac bone graft. Bone Joint J, 2019, 101-B(5): 596-602.
22. Chung HJ, Bae SY, Choo JW. Mid-term follow up results of subtalar distraction arthrodesis using a double bone-block for calcaneal malunion. Yonsei Med J, 2014, 55(4): 1087-1094.
23. Myerson M, Quill GE. Late complications of fractures of the calcaneus. J Bone Joint Surg (Am), 1993, 75(3): 331-341.
24. Lee MS, Tallerico V. Distraction arthrodesis of the subtalar joint using allogeneic bone graft: a review of 15 cases. J Foot Ankle Surg, 2010, 49(4): 369-374.
25. Woo SH, Goh TS, Ahn TY, et al. Subtalar distraction arthrodesis for calcaneal malunion-comparison of structural freeze-dried versus autologous iliac bone graft. Injury, 2021, 52(4): 1048-1053.
26. Pollard JD, Schuberth JM. Posterior bone block distraction arthrodesis of the subtalar joint: a review of 22 cases. J Foot Ankle Surg, 2008, 47(3): 191-198.

Chinese Journal of Reparative and Reconstructive Surgery

Calcaneal V-shaped osteotomy combined with subtalar arthrodesis for Stephens Ⅱ and Ⅲ calcaneal fractures malunion

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