This document discusses the diagnosis and treatment of calcaneus malunions by Dr. Rajiv Shah. It describes evaluating patients through history, physical exam, and radiology to identify pain generators and the degree of injury. Classification systems are discussed but found lacking, as each case requires understanding all reasons for pain. Treatment options include conservative care, revision fixation, realignment through osteotomy with or without fusion, joint sacrificing procedures like arthrodesis with osteotomy, and arthrodesis. Surgical planning considers multiple factors, and late or complex cases may require multiple extensive procedures to address pain, impingements, deformities and arthritis. The document emphasizes addressing injuries early through surgery to reduce difficulties of late salvage procedures.

1. Dr.Rajiv Shah
Foot & Ankle Surgeon
‘Foot and ankle orthopaedics’
Vadodara, Surat, Gujarat 1

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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

5. • 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

6. Degree of joint arthrosis
Presence of nonunion
Cystic lesions
Loss of calcaneal height
Heel widening
Subfibular impingement
Hindfoot malalignment
Preop 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…
Protrusions
CC arthritis
Nerve issues
Tendon issues
Deformities

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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!

9. Decison
Making
Duration
Age and
activity
Arthritis
Deformity
Infection
Skin
condition
Bone quality
Vascularity
Neurological
status

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Treatment options available…
Conservative
treatment
 NSAIDS
 Local
injections
 Braces & shoe
modifications
Activity modification

11. Calcaneal
malunion:
surgical
procedures
Joint salvage
procedures
Revision fixation
Realignment
with osteotomy
& fixation
Joint sacrificing
procedures Arthrodesis +
osteotomy
Arthrodesis

12. Revision fixation
Calcaneus

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Operative care
Revision fixation??

14. Pressure effects
Calcaneus

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 Excision of bony prominences
 Decompression of tendons, ligaments & nerves

16. Realignment with osteotomy
Calcaneus

17.  5 cases
 3 months
post
trauma
 No fusion
 26 cases
 6 months
post
trauma
 4% fusion

18. Arthrodesis
Calcaneus

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Subtalar fusion In situ
Post fixation
arthrodesis
With tricortical
iliac crest bone
graft distrction
arthrodesis

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Subtalar fusion after delayed presentationDistraction subtalar fusion

21. Realignment with osteotomy +
Fusion
Calcaneus

22. 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 method
osteotomy 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 release
5) Subtalar arthrodesis
6) Calcaneal distraction for gaining height with
use of excised bony prominences
7) MCO for heel valgus correction
8) Iliac crest bone harvesting
9) CC distraction arthrodesis
10) Percutaneous triple hemisection
tendoachilles release
11,12,13,14) All four lateral claw toe release

25. “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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