Treating A Patient With A Neglected Calcaneal Fracture And Severe Rearfoot Varus

These authors discuss keys to the diagnosis and treatment of a neglected calcaneal fracture in a 25-year-old patient who had suffered a traumatic fall when he was 18.

An 18-year-old male suffered a severe injury to his left lower extremity after falling from a height of approximately 15 feet. The patient suffered polytrauma including ankle, talar and calcaneal fractures. Surgeons performed immediate open reduction with internal fixation for a severe depressed talar body fracture and an isolated, displaced medial malleolus fracture. The surgeons did not address the calcaneal fracture at that time.

   Approximately six years after the initial injury, the patient sought treatment for progressively increasing pain to his hindfoot. Since the initial injury, he saw multiple foot and ankle specialists and received stirrup ankle braces, ankle/foot orthotics, anti-inflammatory medication, and other pain relievers. All modalities proved to be unsuccessful and poorly tolerated, and continued pain resulted in the patient being treated by a pain management specialist.

   Seven years after the initial injury, the patient presented to our office for surgical consultation.

What The Diagnostic Workup Revealed

Visually, the patient had a gross varus deformity, cavus foot architecture and well-healed surgical scars to the left ankle area. He had pain with palpation in the sinus tarsi area. Range of motion of the subtalar joint elicited pain and crepitus. The patient had pain-free range of motion in the ankle joint but limited dorsiflexion. A Silfverskiold test revealed a mild gastroc soleus equinus.

   We performed a Coleman test, which was developed to evaluate the driving force of the cavus foot.1 Offloading the medial column and evaluating the posterior heel determines the reducibility and root cause of the cavus foot. If the rearfoot reduces, the cavus deformity is driven by the plantarflexed first ray. If the rearfoot remains in varus position, the deformity is rearfoot-driven and rigid.

   The Coleman block test in this patient revealed a rearfoot-driven deformity and a rigid cavus foot.

   Preoperatively, we obtained extensive radiographs and advanced imaging including a full foot and ankle series, hindfoot axial and long leg axial views. Moreover, we obtained a computed tomography (CT) scan to check for possible talar avascular necrosis, ascertain bone quality and evaluate the retained prior hardware.

   Overall, the radiographic analysis indicated a global cavus structure with severe osteoarthritis of the subtalar joint and a depressed posterior facet. The subtalar joint was collapsed and in a varus alignment. The patient also had an abnormal Meary’s angle. The CT scan was negative for avascular necrosis and there was no failure of the retained hardware. The CT scan also confirmed severe degenerative changes at the subtalar joint.

Keys To Treatment

As we noted earlier, previous physicians had exhausted conservative treatment and the patient sought surgical reconstruction. Reconstruction required a possible staged procedure to address both the hindfoot and forefoot components of his deformity.

   The first stage would consist of an open gastrocnemius recession, distraction arthrodesis of the subtalar joint and a closing wedge osteotomy with translation of the calcaneus. This would allow for reconstruction of the posttraumatic affect of the subtalar joint while reducing the varus attitude of the hindfoot. The second stage, if it is necessary, would consist of a dorsiflexory osteotomy of the first ray to realign the talo first metatarsal angle.

   After reduction of the equinus deformity, we used the surgical approach outlined by Lee and colleagues for correction of the depressed posterior facet and restoration of hindfoot height. We then used a Dwyer lateral closing wedge osteotomy of the calcaneus, using the surgical approach recently described by Lamm and coworkers to reduce the varus deformity of the rearfoot.

   After we removed the lateral wedge of bone from the calcaneus, we performed a slight translation of the posterior tuber to realign the hindfoot to the leg. We placed a single 7.0 cannulated, fully threaded screw across both the osteotomy site and the arthrodesis site for stabilization. We also placed a 4.5 cannulated, fully threaded screw from the anterior process of the calcaneus into the neck of the talus for added stabilization and as an anti-rotational effect.

   The patient subsequently used a below-the-knee fiberglass cast and remained non-weightbearing for six weeks. He subsequently transitioned into a CAM walker with a gradual increase in weightbearing over the next four weeks.

   To date, the patient continues to increase his physical activity and is pain-free in the left lower extremity for the first time in seven years. The patient hopes to continue to improve and adapt to his rectus foot. To date, he has elected to hold off on the second stage of his procedure until the pain returns.

   Dr. Wobst is a Chief Resident with Florida Hospital East Orlando in Orlando, Fla.

   Dr. Reeves is a Fellow of the American College of Foot and Ankle Surgeons. He is an Attending Physician with the Florida Hospital East Orlando in Orlando, Fla. Dr. Reeves is a Diplomate of the American Board of Podiatric Surgery and is in private practice in Winter Park, Fla.

References
1. Coleman, SS., Chestnut WJ. A simple Test for hindfoot flexibility in the cavovarus foot. Clin Orthop Relat Res. 1977;123:60-62.
2. Lee MS, Tallerico V. Distraction arthrodesis of the subtalar joint using allogenic bone graft: a review of 15 cases. J Foot Ankle Surg. 2010;49(4):369-374.
3. Lamm BM, Gesheff MG, Salton HL, Dupuis TW, Zeni F. Preoperative planning and intraoperative technique for accurate realignment of the Dwyer calcaneal osteotomy. J Foot Ankle Surg. 2012;51(6):743-748.