Post-calcaneus fracture reconstruction

Inter- and Intra-observer Reliability of a New Classification System for Calcaneus Fracture Malunions: The ADEINS Classification

Background

Currently, two classification systems, namely Stephens and Sanders, based on axial CT images, and Zwipp and Rammelt, which consider deformities, are used for calcaneus malunions. Existing classifications have limitations due to their pure anatomical basis, and the complexity of the problem, involving both bone and soft tissues. As a solution, the senior author proposed a novel ADIENS classification system for calcaneal malunion, based on pain generators. This study aimed to introduce and evaluate the inter- and intra-observer reliability of a new classification system for calcaneal malunions.

Methods

This retrospective cohort study included adult cases with post-traumatic calcaneus malunion. Three experienced foot and ankle surgeon volunteers underwent training session on the classification system, which classifies malunions based on A arthritis, D deformity, E exostosis, I implant issues, N nerve issues, and S soft tissue issues. Post-training, two rounds of classification exercises were conducted. Inter-rater and intra-rater agreements were determined using Gwet's AC coefficient.

Results

Out of 15 cases, 6 were of Stephen and Sanders types, and 8 were of Zwipp and Rammelt types, the rest fell out of these classifications. Inter-rater agreement for ADEINS classification was noted to be 'very good' for all six domains. Intra-observer agreements were 'very good' for four out of six domains of classification and 'fair' for two domains of classification.

Conclusion

Pain generators-based new ADEINS classification has demonstrated good intra- and inter-observer reliability and seemed user-friendly. However, results need to be replicated in a larger, multicentric cohort before wider clinical applicability.

Level of Evidence

Level IV, retrospective study.

Mid-term follow-up results of calcaneal reconstruction for calcaneal malunion

Background

We hypothesized that calcaneal reconstruction can relieve chronic pain due to calcaneal malunion. We report the mid-term follow-up results of calcaneal reconstruction for calcaneal malunion.

Methods

We reviewed the records of 10 male patients (10 ft) who underwent calcaneal reconstruction for calcaneal malunion between January 2009 and July 2014 at the mid-term follow-up. Talocalcaneal height and angle, calcaneal pitch, calcaneal width, Böhler angle, Stephens classification, and Zwipp classification were evaluated by three orthopedic doctors at each visit (pre-reconstruction, post-reconstruction, and at the last follow-up).

Results

The mean follow-up period was 67.1 months (range, 48–101 months). The sites of pain before reconstruction were lateral aspect (4 patients), plantar aspect (3 patients), diffuse pain (2 patients), and anterior aspect (1 patient). There was a significant difference in talocalcaneal height, talocalcaneal angle, calcaneal pitch, calcaneal width, and Böhler angle before and after reconstruction (p < 0.05). There was no significant difference between reconstruction and the last follow-up. Radiological measurement agreement was calculated to be moderate to strong (intraclass correlation coefficient: 0.659–0.988). Mean American Orthopedic Foot & Ankle Society Ankle and Hindfoot score improved from 66.50 ± 9.37 pre-reconstruction to 80.30 ± 8.52 at the last follow-up (p < 0.05). The mean visual analog scale score improved from 8.60 ± 1.43 before reconstruction to 3.40 ± 0.84 at the last follow-up (p < 0.05). Most patients were satisfied with the outcome postoperatively.

Conclusions

Our results showed substantial improvement in the clinical and radiological outcomes after calcaneal reconstruction of calcaneal malunion. This outcome was maintained until the mid-term follow-up. Therefore, calcaneal reconstruction may be a good option for the treatment of chronic pain caused by the malunion of a calcaneal fracture without severe subtalar arthritis. Further prospective studies are needed to test this theory.

Level of Evidence: Level IV, Retrospective Case Series.

Calcaneus fractures

Assessment and treatment of calcaneal fractures have made substantial progress over the last two decades. Open reduction and stable internal fixation without joint transfixation has been established as standard therapy for most displaced intra-articular fractures with good to excellent results in more than two-thirds of patients in larger clinical series. The use of bone grafting or bone substitutes appears unnecessary in most cases. Important prognostic factors are anatomical reduction of subtalar joint congruity and the overall shape of the calcaneus. Therefore, quality of joint reduction should be reliably proved intra-operatively either with open subtalar arthroscopy or high-resolution (3D) fluoroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days, a high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the subtalar and calcaneocuboid joints in complex fractures. In simple fracture patterns percutaneous screw fixation, supplemented by arthroscopic control if necessary, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage exploiting the full armamentarium of pedicled and free tissue transfer appears promising in improving the functional results and infection rates after open fractures. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, in situ or correctional subtalar arthrodesis and calcaneal osteotomies.

Comparative study of subtalar arthrodesis after calcaneal frature malunion with autologous bone graft or freeze-dried xenograft

Background

Calcaneal fracture malunion may evolve into arthrosis and severe foot deformities. The aim of this study was to identify differences in bony union following corrective subtalar arthrodesis with interposition of autologous tricortical bone graft or freeze-dried bovine xenograft.

Methods

We prospectively evaluated 12 patients who underwent subtalar arthrodesis, six patients received autografts and 6 received freeze-dried bovine xenografts. After a mean followup of 58 weeks, the patients were clinical assessed using AOFAS scale and the visual analog scale (VAS) for pain and for final radiographic parameters measurement. Two blind raters evaluated the length of time required for solid union of the arthrodesis and graft integration by retrospective radiographic examination.

Results

In the autograft group, AOFAS score improved from a preoperative average of 37 to 64 points postoperatively (p = 0.02) and mean VAS score improved from 4.7 to 1.9 (p = 0.028). In the xenograft group, AOFAS score improved from 38 to 74 points (p = 0.02) and VAS from 5.5 to 2.7 (p = 0.046). Solid union was achieved in all cases in the autograft group at an average of 5.3 weeks and in five cases in the xenograft group at 8.8 weeks (p = 0.077). Graft integration occurred after an average of 10.7 weeks in the autograft group and 28.8 weeks in the xenograft group (p = 0.016).

Conclusion

With the numbers available, no significant difference could be detected in the length of time required for solid union of subtalar arthrodesis between groups, although time to integration of freeze-dried bovine xenografts was statistically higher. Clinical and functional improvement was observed in both groups.

Surgical Management of Calcaneal Malunion

Calcaneal malunion is a common complication after conservative treatment or incorrect surgical treatment of calcaneal fracture. The typical pathoanatomies of calcaneal malunion are subtalar joint incongruity, loss of calcaneal height, arch collapse, varus or valgus deformity of the calcaneus, heel widening and so on. Calcaneal malunion often needs to be treated surgically. The classification of calcaneal malunion and the detailed clinical and radiographical assessment play important roles for surgical option. The main surgical methods include in situ subtalar arthrodesis, reconstruction of calcaneal thalamus and subtalar arthrodesis, calcaneal osteotomy with subtalar arthrodesis, corrective calcaneal osteotomy without subtalar arthrodesis. Each option has its different indications, advantages and disadvantages. Thus, the surgical treatment should be individualised.

Calcaneal reconstruction for the late complication of calcaneus fracture

Calcaneal fracture is the most common fracture in the tarsal bones. Treatment is difficult because the patterns of fracture are various and complications occur frequently. The purpose of this study was to evaluate the clinical results of calcaneal reconstruction for chronic complications after calcaneal fracture. rom September 2001 to November 2004, calcaneal reconstruction was performed in 24 patients (25 feet). We reviewed 21 patients (22 feet) who could be followed up >2 years postoperatively. Patients who underwent subtalar arthrodesis and simple bone resection were excluded. Patients who underwent calcaneal sliding osteotomy were included. Nineteen men and 2 women ranged in age from 27 to 54 years (mean, 44.4 years). The mean interval between the first operation and reconstructive operation was 11.2 months (range, 3-31 months). The mean follow-up period after calcaneal reconstruction was 29.8 months (range, 24-38 months). Böhler angle, calcaneal pitch, and talocalcaneal height were checked pre- and postoperatively. The most common patient report was pain on the inferior aspect of the lateral malleolus (16 patients) and calcaneal tuberosity (3 patients). All the mean values of talocalcaneal height, calcaneal pitch, and Böhler angle improved, which was statistically significant. In the postoperative period, 10 patients were very satisfied, 9 were satisfied, and 3 were not satisfied. Although pain did not completely resolve, all patients were satisfied postoperatively.