Distraction Arthrodesis of a Neglected, Depressed Calcaneal Fracture with Chronic Pain 

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Author: Devin Bland, DPM, FACFAS, DABPM, Prestige Medical Care, Phoenix, AZ.

Dr. Devin Bland graduated from Midwestern University in 2013 and completed his surgical residency at the Carl T. Hayden Veterans Hospital in Phoenix, Arizona. He chose to further his surgical skill set by completing one of the premier lower extremity reconstruction fellowships in the country, of the American Foundation of Lower Extremity Surgery and Research. Dr. Bland holds multiple board certifications, welcomes all forms of pathology and has a special interest in Charcot Reconstruction, Total Ankle Arthroplasty, Revision Surgeries, Pediatrics, and other complex presentations. He currently practices in a multispecialty group in Phoenix, Arizona and serves as adjunct faculty at Midwestern University. Dr. Bland often precepts students and gives back to younger doctors completing their training. Dr. Bland has received many awards and recognition for his surgical ability in treating advanced and revisional pathology. He has authored textbook chapters relating to bone grafting and continues to publish leading research. One of Dr. Bland’s great joys in life is correcting pathology that has hindered a patient’s enjoyment of activity for an extended period of time or save a limb that otherwise would have ended in amputation.

INTRODUCTION

The subtalar Joint (STJ), also known as the talocalcaneal joint, is a complex articulation between the talus superiorly and the calcaneus inferiorly^1,2. It plays a major role in inversion and eversion of the foot by load transmission and movement at the hindfoot^1,2. Traumatic injury to the STJ disrupts normal hindfoot motion and thus may significantly restrict global foot function. Pain originating from the STJ might result from several pathologies, including primary arthritis, posttraumatic arthritis, congenital or acquired deformities, instability, tarsal coalition or inflammatory diseases³. Osteoarthritis can develop in a damaged and distorted STJ, and this complication is the main cause of late and prolonged disability⁴. Once conservative treatment has failed, subtalar arthrodesis using 2-3 screws is the gold standard treatment which offers pain relief for weightbearing activities. Common complications of this fusion procedure include wound infections, sensory deficits, persisting pain as well as non-union, which may require revision surgery. Wirth et al. showed that risk factors for non-union of STJ fusions are smoking or alcoholism history, diabetes, coexisting psychiatric diseases, prior ankle-fusion, persisting infections or revision surgery. Diabetes mellitus was found to be associated with higher rate of STJ revision arthrodesis, as 56% of the patients with diabetes underwent revision vs. 22% of the patients without diabetes³.

CASE HISTORY

A 54-year-old female patient, BMI of 31.3, diagnosed with type 2 diabetes. The patient suffered a traumatic 30 feet fall. She presented a four-level spinal trauma that resulted in surgical spinal fusion. She further suffered a right open calcaneal fracture that was debrided and sutured closed without surgical fixation attempt. Since the initial injury, the fracture eventually healed into a non- united, shortened, varus-positioned calcaneus since the initial injury. The patient presented chronic right foot and heel pain, leading to immobility and weight gain for the next four years.

CASE PRESENTATION

Upon meeting and assessing the patient, it was noted she had a large osseous bulge on the plantar aspect of the right heel. She had a short cadence and demonstrated an ataxic gait. She complained of pain that radiated from the plantar calcaneus along the posterior heel and extended to the Achilles aponeurosis.
CT scan was performed to evaluate the posterior facet of the STJ and prior fracture pattern. Imaging demonstrated post traumatic deformity of the calcaneus with minimal scattered regions of osseus non-union and mild STJ osteoarthritis.

WHY OSSIOfiber^® IS AN IDEAL CHOICE FOR THIS PATIENT?

Based on the patient’s medical history of diabetes, there was a great benefit in using OSSIOfiber^® implants and avoiding hardware removal procedure in the future. Posterior calcaneal screws quite often need to be removed thus the use of non-permanent implants avoids this inherent risk. Furthermore, by choosing OSSIO headless screws, the surgeon was able to gain a tailored approach to setting the hardware well below the plantar surface of the calcaneus. Many times, when using large metal screws, the patient will complain of pain and irritation during the post operative period or early weight bearing. The patient presented in this study has not complained of plantar calcaneal or insertion site pain.

Surgical Plan

Right STJ arthrodesis with callus distraction, lateral calcaneal wall decompression and tendon repair.
Leg Length Radiograph Measuring was used for operative planning of the distraction arthrodesis.

The following OSSIOfiber^® fixation implants were used: 

1. OSSIOfiber^® Cannulated Trimmable Fixation Nail (CTFN) 4.0x70mm x 1 unit
2. OSSIOfiber^® Compression Screw (CS) 4.0x60mm x 2 units 
3. OSSIOfiber^® Suture Anchor (SA) 4.75 x 2 units
4. Iliac Crest Wedges (Tricortical Blocks) by MTF Biologics

Surgical Technique

The surgeon chose to operate on the patient in two positions.

1. Initially, in a prone position, this afforded direct access to the posterior STJ. Using a Hintermann retractor, surgeon was able to measure the amount of distraction needed. Then, a Tricortical Allograft Block was fashioned and placed in the posterior facet of the STJ. Next, imaging was used to confirm block position, and the OSSIOfiber^® CTFN was inserted across the STJ from the dorsal to plantar surface. Then, two 4.0 OSSIOfiber^® CS were inserted from the posterior calcaneus to the talar neck and talar head. Both two screws and nail crossed the joint and through the tricortical block. The incision site was closed and sutured. 
2. Next, the patient was moved into a supine position, allowing access to the lateral wall of the calcaneus, Peroneus Brevis tendon, Peroneus Longus tendon, and fibula. After realignment of the anatomy, an aggressive arthroscopic ankle debridement was done, including removal of multiple exostosis from the anterior tibial plafond, which worsened over time by her impingement on ambulation during the past couple of years since the trauma. Tendon was advanced and reattached using 2 OSSIOfiber^® SA.

Post-Operative Protocol

The surgeon chose to operate on the patient in two positions.

1. Non-weight bearing: 4 weeks in a Short Leg Cast.
2. Partial weight bearing: 2 weeks in a CAM boot.
3. Full weight bearing: At 6 weeks started physical therapy
4. Comfort Shoe: At 7 weeks post op

Patient Follow-up

The surgeon noted less swelling compared to his experience with other patients treated with metal hardware for STJ fusion. No complications reported throughout the duration of the post operative healing. Once the patient started to weight bear in her CAM boot, she immediately remarked the significant pain reduction. Upon beginning ambulation in a corrected position and with lateral wall decompression, she noted the amount of improvement. The patient has not complained of plantar calcaneal or insertion site pain, a common complaint when using large metal screws.

PHYSICAL THERAPY

The patient had to complete a series of gait-training physical therapy, which was an integral part of her recovery following lateral wall decompression and repaired the Peroneal tendons. She was able to transition from passive range of motion to active range of motion as quickly as she did since she did not suffer from prolonged post-surgical edema.

Summary:

OSSIO technology offers a unique advantage by providing strong fixation while avoiding the need for hardware removal. OSSIO products afford surgeons the opportunity to correct complex pathology with less edema, quality surgical outcomes, and the assurance of not having to remove metal-based hardware. This is especially important in debilitated or high-risk patients where every additional procedure presents the risk of general surgical complications as well as retarded healing.

References

1. Rammelt, S., Bartoníček, J. & Park, K. Traumatic injury to the subtalar joint. Foot Ankle Clin. 23, 353–374 (2018).
2. Tuijthof, G., Beimers, L., GMMJ, K., Dankelman, J. & Van Dijk, C. N. Overview of subtalar arthrodesis techniques: options, pitfalls and solutions. Foot Ankle Surg. 16, 107–116 (2010).
3. Wirth, S. H. ; et al. How many screws are necessary for subtalar fusion? A retrospective study. Foot Ankle Surg. 26, 699–702 (2020).
4. Eid, M.A.M., El-Soud, M.A., Mahran, M. A. & El-Hussieni, T. F. Minimally invasive, no hardware subtalar arthrodesis with autogenous posterior iliac bone graft. Strateg. Trauma Limb Reconstr. 5, 39–45 (2010).

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