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

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Author(s): 
Garrett Wobst, DPM, and Christopher Reeves, DPM, FACFAS

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.

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Dwight L. Bates, DPMsays: June 6, 2013 at 6:25 pm

Great case! Intra-op photos would be appreciated.

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