Outcome of Subtalar Arthrodesis After Calcaneal Fracture

Patricia Kolodziej, MD and James A. Nunley, MD

Disclosures

J South Orthop Assoc. 2001;10(3) 

In This Article

Abstract and Introduction

Abstract

Between 1983 and 1995, we used subtalar arthrodesis to treat 16 consecutive patients for continued pain after an intra-articular calcaneal fracture. Average time to union was 3 months (2 to 4 months). Complications were minor in 4 patients, and major in 4 others. Length of follow-up in 14 patients was 55 months (range, 12 to 112 months). Hindfoot scores (clinical rating system of the American Orthopaedic Foot and Ankle Society) improved from 38 (range, 28 to 62) to 67 (range, 39 to 94). Results of medical outcome surveys indicate that patients had low scores in areas related to physical conditioning, physical role functioning, and bodily pain. We conclude that the majority of patients can have improvement with surgical reconstruction that addresses a specific problem, but pain relief is usually not complete.

Introduction

Late results of intra-articular calcaneal fractures have long been known to have poor outcomes. Pain levels may be high and rehabilitation, in an effort to return to work, may be expensive. Return to work may be difficult or in some cases impossible. Nonoperatively treated calcaneal fractures may have a spectrum of symptoms related to various components of the injury. Objective findings may include hindfoot deformity due to heel widening, valgus or varus hindfoot deformity, and loss of talar declination (hindfoot height), which may cause anterior ankle impingement and decreased Achilles tendon lever arm.[1] Articular damage that occurs at the time of fracture may result in subtalar arthrosis, calcaneal-cuboid arthrosis, and loss of subtalar motion.[2,3,4,5,6,7,8] Lateral heel pain due to lateral wall expansion may cause calcaneal fibular abutment,[9] peroneal tendon dislocation or impingement,[2,6,7,10,11,12,13,14,15,16,17,18] and sural nerve entrapment. Damage to the fat pad of the heel,[5,10,15,19,20] or a displaced tuberosity fragment may cause plantar heel pain.[5,13,18]

Clinically, patients complain of shoe wear problems, instability, or pain when walking on uneven terrain, pain on the bottom or lateral aspect of the heel, and anterior ankle pain. Even in patients treated with open reduction and internal fixation that reconstructs the normal anatomy, some of these symptoms may develop.

Numerous operative procedures have been developed to address specific symptoms in patients with previous calcaneal fractures. Most authors report on only one type of surgical procedure to determine its effectiveness for specific symptoms.[1,3,8,9,17,21,22,23] However, symptoms of old calcaneal fractures may vary widely, and individualized treatment is often necessary. We have been unable to find studies designed to evaluate outcomes in this heterogeneous group of patients who have had intra-articular calcaneal fractures. The purposes of this study were to review retrospectively a consecutive group of patients who had had a subtalar arthrodesis with additional surgical procedures as deemed necessary for the treatment of chronic foot pain after a calcaneal fracture, and to assess their long-term satisfaction and clinical outcomes.

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