title: Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions.
abstract: BACKGROUND
  Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions.
  
  
  METHODS
  Seventy feet (sixty-four patients) with a malunion after nonoperative management of a displaced intra-articular calcaneal fracture were evaluated. On the basis of the classification system of Stephens and Sanders, type-I malunions were treated with a lateral wall exostectomy and peroneal tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and a calcaneal osteotomy. The patients were evaluated clinically and radiographically at a minimum of twenty-four months following surgery.
  
  
  RESULTS
  Forty-five feet in forty patients were available for follow-up evaluation at a minimum of two years, with an average duration of follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an arthrodesis achieved union. Statistical analysis revealed no significant difference among the types of malunion with respect to the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which was likely due to sample size discrepancies. Forty-two (93%) of the forty-five feet were aligned in neutral or slight valgus hindfoot alignment, and all forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had pain in the lateral aspect of the ankle. Radiographically, talocalcaneal height was significantly greater for the type-III malunion group relative to the type-I and type-II malunion groups (p = 0.021).
  
  
  CONCLUSIONS
  This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment.
authors.affiliation: The Florida Orthopaedic Institute, Tampa, Florida 33606, USA. mclare@unmc.edu
authors.forename: Michael P
authors.initials: MP
authors.lastname: Clare
authors.forename: William E
authors.initials: WE
authors.lastname: Lee
authors.forename: Roy W
authors.initials: RW
authors.lastname: Sanders
mesh_terms: D000328:Adult; D000368:Aged; D000843:Ankle Joint / Q000503:physiopathology; D001174:Arthrodesis; D001864:Bone Wires; D002111:Calcaneus / Q000293:injuries*; D002985:Clinical Protocols; D005260:Female; D005593:Fracture Fixation, Internal; D017102:Fracture Healing; D017759:Fractures, Malunited / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D011859:Radiography; D016059:Range of Motion, Articular; D013380:Subtalar Joint / Q000000981:diagnostic imaging / Q000473:pathology