Description of patient (type of occupation, indication of age, intensity of sport):
57-year-old patient with history of comminuted calcaneal fracture. The patient is diabetic, compliant and the diabetes is controlled.
History and previous treatment:
The calcaneal fracture was operated with a plate. Due to an infection the plate was removed. A heel ulcer was treated with an offloading brace and was cured. He lost his big toe due to gangrene. Since more than 4 years the wounds are healed.
He has pain with every step and can not walk long distances.
Right foot and ankle: Swelling and deformity of the hindfoot. Good ankle ROM. Subtalar joint stiff. No skin lesions. Loss of big toe. Good sensation and blood supply.
[Picture 1 - 3]
Right foot and ankle: non union after calcaneal fracture and subtalar OA.
Additional investigation (CT/MRI):
[Picture 4 + 5]
CT shows nonunion of a calcaneal fracture with massive bone loss and subtalar OA.
Nonunion calcaneal fracture and subtalar OA right ankle.
Question(s) to this case:
What would you do?
1) Conservative treatment?
2) Operative Treatment with fusion and bone grafting?
If yes, which technique would you prefer?
I would go for scopic arthrodesis of the subtalar joint. Careful preoperative planning, to judge if the calcaneus indeed is divided into 2 fragments. If so, try to use 2 screws for the posterior main fragment and at least 1 screw for the anterior fragment. If possible, also use 2 screws for the anterior part.