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Calcaneal Malunion

Approach & Management

Dr.Rajiv ShahFoot & Ankle Surgeon‘Foot and ankle orthopaedics’Vadodara, Surat, Gujarat

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Diagnosis H/o

trauma Difficulty

on walking on uneven ground

Pain sites

Deformities – heel varus/valgus

Tendons & ligaments

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Joints Heel fat pad Gait Footwear RSD &

compartment syndrome

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Radiology

Plain X-rays Weight bearing x-rays Axial view Broden view Opposite side x-rays

  

BA

GA

Normal Xray Parameters: Lateral View

• A)Talocalcaneal height• B)Talar declination

angle

• C)Lateral talocalcaneal angle

• D)Calcaneal pitch

All parameters distorted!! Axial view Lateral wall exostosis Hindfoot malalignment Calcaneal shortening

CT Scan

Degree of joint arthrosisPresence of nonunion Cystic lesionsLoss of calcaneal heightHeel wideningSubfibular impingementHindfoot malalignmentPreop planning for complex

deformities

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Treatment

Conventional methodology is to treat Calcaneus Malunion based on classification!!

1996: Stephens & Sanders

CT based –axial images

Three types

Exosectomy & peroneal tenolysis

Addition of subtalar fusion

Addition of osteotomy

Dwyer or MCO

Classification is not complete!!Classification does not cover… ProtrusionsCC arthritisNerve issuesTendon issuesDeformities

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How should one treat calcaneus malunion?

There could be many reasons of pain!Reasons very from case to case!!

Like in case of back pain find out every pain generator

Diagnostic injections in joints & nerve blocks help to identify pain generators

Beyond 3 weeks every calcaneus fracture should be treated like a case of Calcaneus Malunion!

Decison

Making

Duration

Age and activity

Arthritis

Deformity

InfectionSkin condition

Bone quality

Vascularity

Neurological status

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Treatment options available…Conservative treatment

NSAIDS Local

injections Braces & shoe

modifications

Activity modification

Calcaneal malunion: surgical

procedures

Joint salvage procedures

Revision fixation

Realignment with

osteotomy & fixation

Joint sacrificing

procedures Arthrodesis + osteotomy

Arthrodesis

Revision fixation

Calcaneus

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Operative careRevision fixation??

Pressure effects

Calcaneus

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Excision of bony prominences Decompression of tendons, ligaments & nerves

Realignment with osteotomy

Calcaneus

5 cases 3 months

post trauma

No fusion

26 cases 6 months

post trauma

4% fusion

Arthrodesis

Calcaneus

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Subtalar fusion In situPost fixation arthrodesis

With tricortical iliac crest bone graft distrction arthrodesis

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Subtalar fusion after delayed presentationDistraction subtalar fusion

Realignment with osteotomy + Fusion

Calcaneus

Corrective Osteotomy & Subtalar Arthrodesis

• For sanders type III

• Varus Dwyer: Lateral closing wedge

• Valgus Medializing calcaneal slide osteotomy

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Vertical slide osteotomy + Subtalar fusion

Case courtesy: Dr.Selene Parekh

Romash’s methodosteotomy through old fracture & distraction & arthrodesis

Case courtesy: Dr.Selene Parekh

Final fixation

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My worst case?!

Medial side: FHL impingement Lateral side– peroneal

impingement Plantar – painful plantar bump Sural & posterior tibial nerve

neuralgia Forefoot abduction on weight

bearing Hindfoot valgus with secondary

flat arch Arthritis of Subtalar & CC joint Tendoachiless tightness Claw toe deformities

1) Peroneal tenolysis with bump excision 2) Plantar bump excision 3) Medial bump excision 4) TT release5) Subtalar arthrodesis6) Calcaneal distraction for gaining height

with use of excised bony prominences7) MCO for heel valgus correction8) Iliac crest bone harvesting9) CC distraction arthrodesis10) Percutaneous triple hemisection

tendoachilles release11,12,13,14) All four lateral claw toe release

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“ Try to correct as much damage as possible in the acute phase with surgery as late salvage procedures are quite difficult with absolutely uncertain results !! ”

Sander

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That’s allThank you…