Sequelae of intra-articular calcaneal fractures: patterns and management

Purpose of the study We reviewed retrospectively 24 feet with sequelae of transtalar process fractures of the calcaneum in order to identify the lesion pattern and determine optimal management options, both for acute and sequelar lesions. Material and methods There were fourteen men and nine women, mean age 42 years (19-73). Twenty-three had subtalar osteoarthritis, eight had calcaneocuboid osteoarthritis, and fifteen had lateral submalleolar conflicts. There were twelve fibular tendon dislocations or fissurations, three tarsal tunnel syndromes, and two plantar splinters. Prior to treatment, all patients complained of pain. Preoperatively, walking distance was less than 500 m for thirteen patients, 2000-3000 m for four, and greater than 3000 m for five. Mean subtalar joint motion was 30% (0-100%) compared with the healthy side and mean frontal misalignment of the rear foot was 6° vaigus. Physical examination, podoscopy and x-rays were obtained in all patients. The Kitaoka score was noted. Result Mean follow-up was 36 months (24-72). Sequelae were treated with a single procedure or with combinations: subtalar arthrodesis (n = 23) including one in association with calcaneocuboid arthrodesis, tension on fibular tendons (n = 7), neurolysis of the posterior tibial nerve (n = 3), resection of plantar splinters (n = 2), resection of the lateral shell (n = 14), and osteotomy (n = 2) to lower the greater tubercle of the calcaneum because of pain when wearing shoes. The mean Kitaoka function score was 31.7/100 (14-79) preoperatively. After treatment, the mean score was 81.7/100 (31-94), giving a 73.2% gain. The outcome was considered good in sixteen feet, fair in six, and poor in two. Mean walking distance was greater than 3000 m for 18 patients. Mean frontal misalignment of the rear foot under loading was 4.5° valgus and the podoscopy demonstrated flat foot in thirteen patients. Three subtalar arthrodesis required revision for nonhealing. Discussion Initial treatment of a fracture, particularly an articular fracture, of the calcaneum must avoid disabling postoperative pain and shoe wearing problems. These sequelae basically concern: subtalar and calcaneocuboid arthritis, lateral submalleolar conflict, fibular tendon injury, plantar splinters, tarsal tunnel syndrome, loss of height, and misalignment of the rear foot. At the sequelar stage, the physical examination is primordial to confirm the lesion and search for any complication which could develop later postoperatively when walking distance becomes longer. For nine patients with residual pain, four resulted from lesions which were missed at the preoperative physical examination. Arthrodesis of the subtalar joint should be preferred over realignment of the rear foot and can be associated with the treatment of conflicts. This management scheme allows treating during a single operative time all sequelae, thus limiting recovery time. A scan of the ankle and foot with or without opacification of the fibular tendons is needed to confirm the physical examination which, for us, remains the key to successful surgery.