SLR - March 2019 - Gaston Mike Liu

Foot Function After Surgically Treated Intraarticular Calcaneal Fractures

Reference: Foot Function After Surgically Treated Intraarticular Calcaneal Fractures: Correlation of Clinical and Pedobarographic Results of 65 Patients Followed for Eight Years. Dürr C et al. J Orthop Trauma. (2018)

Scientific Literature Review

Reviewed by: Gaston Mike Liu, DPM
Residency Program: New York Presbyterian/Queens, Flushing, NY

Podiatric Relevance: Restoring calcaneal anatomy is necessary for restoring foot function after displaced intraarticular calcaneal fractures. Following calcaneal ORIF, foot function may be evaluated via patient-reported outcome measurements, patient scores and physical exam, such as range of motion, muscle force and gait examination with dynamic pedobarography. Even after perfect reduction intra-operatively, postoperative complications, such as traumatic cartilage degeneration, tendon impingement and adhesions, may lead to restricted hindfoot range of motion that predisposes the patient to posttraumatic arthritis as well as gait abnormalities. In pedobarographic studies, pressure shift from hindfoot to midfoot, with lateralization of the center of pressure and increased stress on the lateral foot column, have been described. The goal of this study was to evaluate surgically corrected displaced intra-articular calcaneal fractures that were anatomically restored and whether it would lead to less differences in pedobarography compared to the contralateral, uninjured foot.

Methods: In a retrospective single-center study, 65 patients with unilateral, calcaneal fractures treated surgically with a mean age of 53.4 years at time of follow-up and average of 8.1 years after surgery were evaluated. All patients underwent physical examination and dynamic pedobarography at time of last follow-up. Functional results were assessed with Short Form-36, the AOFAS ankle and hindfoot scale, the modified Zwipp score and the Foot Function index. Radiographs were taken and evaluated for union, Bohler angle of both feet, step-off of the posterior facet and degree of posttraumatic osteoarthritis. Pedobarography was utilized to evaluate for contact area, maximum pressure, contact time and pressure time integral. The uninjured foot served as a control.  

Results: Bohler’s angle was decreased compared to the contralateral uninjured side. Regarding dynamic pedobarography, the injured foot had significantly greater contact area at the hindfoot, midfoot and the whole foot. A significantly smaller contact area was found at the first and second metatarsal. Maximum pressure was significantly increased at the midfoot as well as metatarsals 3-5. Contact time was prolonged at the midfoot.  

Conclusions:
Displaced, intraarticular calcaneal fractures usually lead to functional restrictions due to cartilage damage, scar formation and intra-articular and extra-articular adhesions. All four clinical scores had weak correlations with the dynamic pedobarographic study utilized. Therefore, plantar pressure analysis may not add much value to established outcome scores. Patients treated with percutaneous reduction and screw fixation had excellent outcome scores and less differences in side-to-side pedobarographic measurements, and decreased scar formation and better subtalar range of motion. However, patients treated with the lateral extensile approach had increased scar formation and decreased subtalar range of motion. Therefore, the percutaneous approach may be a superior option to surgically reconstructing displaced intraarticular calcaneal fractures.

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