PRIMARY SUBTALAR ARTHRODESIS FOR THE TREATMENT OF COMMINUTED CALCANEAL FRACTURES
October 31st, 1995
Barbara D. Buch, MD, Mark S. Myerson, MD,
and Stuart D. Miller, MD
Abstract
We retrospectively evaluated the results of primary subtalar arthrodesis for the treatment of severely comminuted calcaneal fractures. Of 108 patients with 112 calcaneal fractures treated at our institution between 1989 and 1992, 16 (15%) underwent primary subtalar arthrodesis through an extensile lateral approach. The calcaneal height and width were restored with standard fixation techniques and then arthrodesis was performed with bone graft and fixation by 7.0-mm cannulated cancellous screws. Fourteen patients (12 males, 2 females; mean age, 40 years) were available for examination at a mean of 26 months (range, 12 to 54 months) after surgery.
Arthrodesis, evidenced by radiographic bony bridging across the arthrodesis site, was present in all patients between 8 and 12 weeks. Minor wound complications occurred in three patients. Of the 12 patients employed before the injury, 11 returned to their original occupations at a mean of 8.8 months after injury (range, 1 month to 3 years). The mean AOFAS 100-point clinical rating scale score, evaluating pain, function, and alignment, was 72.4 points (range, 48 to 88 points). We concluded that primary subtalar arthrodesis is indicated as part of the management of comminuted displaced articular calcaneal fractures, yielding results that allowed 11 of 12 formerly employed patients to return to work.
Introduction
The calcaneus is the most frequently fractured tarsal bone and comprises 2% of all fractures.12 Approximately three-quarters of these calcaneal fractures are intraarticular13 and treatment for these fractures is controversial. Choices range from nonoperative modalities21 to open reduction/internal fixation and primary fusion. The results of operative versus nonoperative treatments have been difficult to compare owing to varying methods of classification, treatment, and evaluation of these injuries.8,27,32,36 Paley and Hall32 correlated unsatisfactory results with residual calcaneal deformity and fracture comminution. Using a classification incorporating computed tomography, Crosby and Fitzgibbons8 found poor results after closed treatment of comminuted intraarticular fractures. A number of advocates for open reduction and internal fixation of these calcaneal fractures have published varying results.3,12,17,19,22,35 All authors agree that the management of markedly comminuted articular fractures is difficult, with results worsening as comminution and displacement increase.32,35,36 Due to the technical difficulty of restoring joint congruency and to the attendant cartilage damage, primary subtalar arthrodesis has been advocated.11,16,18 However, restoration of precise hindfoot anatomy was not emphasized, and the results of their treatments varied considerably.11,16,18,40
This paper reviews our experience with primary subtalar arthrodesis for the management of severely comminuted articular fractures of the calcaneus associated with substantial chondral damage.
Materials and Methods
Patient Population
Between 1989 and 1993, 108 patients with 112 calcaneal fractures were treated at our institution. All patients were evaluated after injury in a standardized manner with plain radiographs and computed tomography (CT) scans in the coronal and axial projections using 2-mm bone cuts (Fig. 1A). Nine patients (nine fractures) were treated with nonoperative methods, 83 patients (83 fractures) were treated with open reduction and internal fixation, and 16 patients (20 fractures) were treated with open reduction, internal fixation, and primary subtalar arthrodesis. The indication for performing the arthrodesis was marked comminution with substantial displacement and/or severe cartilaginous damage of the posterior facet. Two of the 16 patients were unavailable for follow-up examination (one patient was incarcerated; the other died from causes unrelated to his injury). Although four (#2, 6, 11, and 13) of the remaining 14 patients sustained bilateral calcaneal fractures, only one fracture in each of these patients was treated with primary arthrodesis. The opposite foot was treated with open reduction and internal fixation in three (#6, 11, and 13) and nonoperatively with early range of motion in one (#2). Therefore, our study group consisted of 14 patients (12 males, 2 females) with 14 fractures.
These 14 patients had an average age of 40 years (range, 24 to 68 years). Their calcaneal fractures (10 right, four left) were the results of falls from a height (10) or motor vehicle accidents (4). Seven of the 14 patients had other injuries associated with their calcaneal fractures, including one vertebral crush injury (#3), one vertebral burst fracture (#11), one zygoma fracture (#11), one radial head fracture (#6), one ankle sprain (#10), four ankle fractures (#7, 8, 9, and 10), and two chest injuries (#8 and 9); these injuries were treated independently of the calcaneal fractures.
The decision to perform an open reduction and arthrodesis was made preoperatively in eight (Table 1, patients # 2, 4, 5, 7, 8, 10, 13, and 14) and intraoperatively in six patients. Utilizing the classification system reported by Crosby and Fitzgibbons in 1990,8 there were two type-II fractures (#1 and 12), and seven type-III fractures (#3, 4, 5, 6, 9, 11, and 14). Due to extensive comminution, we were unable to classify the remaining five fractures (#2, 7, 8, 10, and 13) according to this system.
Surgical Procedures
The time from injury to referral to our institution averaged 12 days (range, 1 to 41 days), and the time from injury to surgery averaged 14 days (range, 2 to 43 days). At our initial evaluation, 12 patients were noted to have marked swelling of the foot; they were admitted to the hospital for application of an intermittent compression foot pump device (AV Impulse System, Kendall Co., Mansfield, MA)to reduce swelling.29 Two patients did not require the use of the foot pump. In all 14 patients, surgery was performed once swelling had diminished to the point of skin wrinkling. The average time from hospital admission to surgery was 1.5 days (range, 0 to 4 days).
With the patient in the lateral decubitus position and a thigh tourniquet in place, an extensile lateral approach to the calcaneus was used as previously described28,36 to reduce the fracture in a sequential stepwise and standard manner, restoring the height and width of the calcaneus. When the calcaneocuboid joint was involved in the fracture pattern, an attempt was made to secure an appropriate reduction and fixation of this joint as well. The reduction was secured with 3.5-mm cortical screws and one or more H-plates (Synthes, Paoli, PA). At this stage, a final decision was made regarding the need for arthrodesis, based on chondral loss and comminution, particularly of the posterior facet.
After open reduction and internal fixation, subtalar fusion was performed. Iliac crest bone graft was routinely used; however, the type of graft harvested depended on the magnitude of the defect remaining after fracture reduction. If most or all of the posterior facet was severely damaged, a corresponding matched-sized tricortical iliac crest graft was harvested to fill the defect. If there was predominantly chondral loss without substantial bone fragmentation, only cancellous bone graft was used. Cancellous bone graft was also packed into the sinus tarsi in all feet regardless of the method of fusion obtained. In six patients (#6, 7, 8, 10, 13, and 14), a tricortical bone block graft was harvested; the defect in the remaining eight patients was filled with cancellous graft.
The undersurface of the talus was denuded of cartilage with a flexible chisel, and a high-speed burr was used to obtain bleeding bone surfaces. It was not as easy to denude the calcaneus of the remaining cartilage, since there was a tendency to fragment small pieces of bone. However, the difficulty was lessened if secure fixation of the posterior facet and tuberosity was first obtained. If small bone fragments were present, then only a burr was used to denude the articular surface and subchondral bone. Particular attention was paid to obtaining both an extra- and intraarticular arthrodesis by carefully denuding the cortical bone in the sinus tarsi corresponding to the neck of the talus and calcaneus.
A 2-mm guide pin was then inserted from plantar to dorsal across the talocalcaneal articulation. In all patients, a cannulated 7-mm screw was used to secure the arthrodesis (Fig. 1B). We found that fluoroscopic imaging was very helpful for this step, since the guide wire could be redirected if necessary. If a tricortical bone block was used, then the guide pin was intentionally inserted directly through the graft (Fig. 1C). We did not use a compression screw, nor is compression across the joint recommended, since the bone surfaces are too tenuous to tolerate this form of fixation. For this reason, a fully threaded cannulated screw was typically used. If a partially threaded screw was used across the subtalar joint, care was taken to not compress the joint, which could cause later collapse of the height of the hindfoot. We relied, therefore, on broad bleeding cancellous bone surfaces, rather than compression fixation, to achieve arthrodesis. We did not find it necessary to use two screws to control rotation of the subtalar joint as has been previously recommended for a subtalar bone block fusion.5
The wound was closed over a suction drain, and a posterior plaster splint was incorporated into the bandage. Prophylactic cephalosporin intravenous antibiotics were used for 24 hours after the drain was removed. At 2 weeks after surgery, the sutures or staples were removed, and (if the wound was clean and dry) a posterior splint was applied. The patient then commenced early range of motion exercises of the affected extremity, including the foot and ankle. Graduated protected weight-bearing was permitted, depending on associated injuries, the appearance of the radiographs, and the presence of pain, warmth, and swelling of the foot and ankle, individualized to patient comfort and the therapist's estimation of gait.
Each patient completed a detailed questionnaire, underwent a physical examination, and had bilateral anteroposterior (AP) lateral and axial radiographs of the foot taken while bearing weight. The questionnaire surveyed pre- and postoperative employment, salary, activity, and postoperative rehabilitation, pain, and medications. The physical examination included range of motion in dorsiflexion and in plantarflexion, hindfoot stability and motion, and overall alignment. The radiographs were measured for eight parameters: talocalcaneal height, distance from the cuboid to the floor, distance from the navicular to the floor, calcaneal pitch, angle between the talus and first metatarsal in the AP and lateral planes, angle between the talus and calcaneus, and the talar declination angle (Fig. 2).
Results
The decision to allow patients to begin weight-bearing was determined by associated injuries, the presence of warmth and swelling of the foot and ankle, and the appearance of the radiographs. If no warmth or swelling was present, and bony bridging across the arthrodesis site was visible, 50% partial protected weight-bearing was commenced. The average time that patients were non-weight-bearing on the affected extremity was 8.6 weeks (range, 5 to 12 weeks). Patients with bilateral fractures (#2, 6, 11, and 13) began weight-bearing at an average of 3 weeks later than did patients with unilateral injury (range, 2 to 6 weeks). Once partial weight-bearing began, a prefabricated hinged range-of-motion walker boot was used in eight patients and a firm surgical shoe was used in the remaining six. We used a hinged boot for patients who had not regained ankle dorsiflexion, or if an equinus contracture was present. The hinge was set in these patients to allow full dorsiflexion, with a block to plantarflexion. When partial weight-bearing was begun, patients were encouraged to ambulate in a swimming pool where practical.
All patients, including the four patients with bilateral calcaneal fractures, were able to bear full weight on the affected extremity by an average of 11.5 weeks (range, 10 to 14 weeks). Despite radiographic evidence of fusion, four patients continued to experience minimal discomfort at 12 weeks after surgery; two patients (#11 and 14) were given polypropylene ankle foot orthoses and two (#4 and 8) were given an ankle brace (Aircast, Summit, NJ). One patient (#5) used compression stockings for 4 months to control dependent edema.
Thirteen patients used a formal rehabilitation and physical therapy program; one patient (#3) performed these exercises at home. Postoperative therapy averaged 9 weeks (range, 4 to 28 weeks). The physical therapy sessions emphasized lower extremity strengthening, range of motion exercises of the ankle, midfoot, and forefoot joints, and diminution of soft-tissue swelling and contracture.
Examination
The patients were examined at an average of 26 months (range, 12 to 54 months) after surgery. All examinations and measurements were performed by the same physician and recorded using the AOFAS 100-point hindfoot and ankle scale20 to assess postoperative activity and mobility. This scale allots 40 points for pain, 50 points for function, and 10 points for alignment. The maximum possible score in this population was 94 since no patient had any functional inversion or eversion.
Postoperative Data
There were four postoperative wound complications (patient #1, 5, 9, and 14). Three were minor and were successfully treated with local wound care at home by the patient; the fourth patient (#1) required a split-thickness skin graft (10 x 12 mm) to cover the wound. One patient (#7) complained of a stiff first metatarsophalangeal joint after inactivity in the cast, and was later treated with a flexor tendon release. Two patients (#9 and 10) developed fixed forefoot contracture (manifested as fixed claw toe deformity), most likely secondary to myoneural ischemia after a compartment syndrome at the time of their fracture.26,37 Three patients (#4, 5, and 11) complained of plantar heel pain, all of whom were treated with cushioned heel supports. One of these patients (# 11) did not obtain satisfactory relief using shoe modifications and required a cane for ambulatory support. This, however, could have been due to his other serious injuries. Of the 14 patients, nine (#1, 2, 4, 7, 9, 11, 12, 13, 14) experienced focal pain under the posterior heel related to the screw head and subsequently underwent screw removal in the office under local anesthesia. Screws were placed from the posterior calcaneus into the talus (instead of from the talus into the calcaneus) in an effort to achieve a better bone purchase. The consequence of this stronger fixation was a relatively high rate of screw removal.
The duration of postoperative narcotic analgesic use averaged 3.8 weeks (range, 10 days to 1 year). The patient (#11) who used analgesia for 1 year was a multitrauma victim with bilateral calcaneal fractures, a vertebral fracture requiring arthrodesis, and soft-tissue injuries. Eight patients were using no pain medications at the time of this study, five were using acetaminophen or nonsteroidal antiinflammatory drugs, and one (case 8), a multitrauma patient, was occasionally using a mild narcotic analgesic (propoxyphene hydrochloride).
Radiographic Findings
Radiographic union was present in all patients between 8 and 12 weeks after surgery (Fig. 3). Patients were examined at 2, 6, and 12 weeks and 6, 9, and 12 months after surgery. The final follow-up for this study was an average of 26 months (12 to 54 months after surgery). Table 2 summarizes the means for the eight radiographic measurements. The mean talocalcaneal height for the feet treated with primary arthrodesis was only 2 mm less than the opposite foot, including those who underwent open reduction and internal fixation for bilateral fractures (Table 3; Fig. 4). Nine patients had radiographic evidence of some degree of calcaneocuboid arthritis. Two other patients had evidence of spontaneous calcaneocuboid fusion without arthritis.
Examination and Activity
The total AOFAS scores averaged 72.4 points of a possible total 94 in this population (range, 48 to 88 points). Three patients reported no pain, seven had mild pain, three had moderate pain, and one reported moderate to severe pain. All four of the patients with bilateral calcaneal fractures reported less pain in the foot treated with a primary arthrodesis than in the foot treated with open reduction and internal fixation or nonoperative treatment. Two patients were able to walk more than six city blocks without pain, nine were able to walk six city blocks but reported some pain with longer distances, two were able to walk four to six blocks, and one was able to walk only one to three blocks before tiring and experiencing pain. When traversing uneven surfaces, six patients reported severe difficulty (sometimes avoiding them altogether), five patients had moderate difficulty, one had moderate to severe difficulty, and two reported no difficulty. Three patients had marked gait abnormality, six had some degree of abnormal gait that did not affect ambulation, two had mild abnormalities, and three had no gait disturbance. Nine patients reported that their injury limited their activities of daily living (two only mildly) and five reported no limitations. All 14 patients reported limited recreational activities secondary to their injuries; for three patients, this limitation was severe.
All 14 patients had normal functional sagittal motion, a stable hindfoot, and good ankle-hindfoot alignment. For patients with unilateral fractures, normal sagittal tibiotalar joint motion was defined as within 5o of the opposite ankle; for those with bilateral fractures, the "normal" ranges were a minimum of 20o of dorsiflexion and 30o of plantarflexion. The mean ankle dorsiflexion was 6 and 12o and the mean plantarflexion was 50 and 61o for the feet with and without primary subtalar arthrodesis, respectively. (One patient did not have plantarflexion measured.) Hindfoot stability was defined as the absence of reported "giving way" by the patient, and no findings of instability of the ankle to either an anterior drawer or varus stress that was manually applied. Hindfoot alignment was defined as good if the position of the calcaneus on the axial hindfoot radiograph was within 5o of the opposite foot, but this parameter was not applied when bilateral injuries were sustained.
Return to Work
At the time of injury, 12 patients had been employed, one was retired, and one was unemployed. At the time of the last follow-up examination, 12 patients had returned to work, one (case 11) remained on workman's compensation benefits (but planned to return to work within 2 months), and one was still retired. The patients returned to work at an average of 8.9 months (range, 1 to 11 months). Seven patients had some change in their employment status (#1, 2, 6, 8, 10, 11, and 13): one was laid off from his job but found similar employment at a lower wage (#13), one moved from a field position to one in management (#2), three went on workman's compensation (#6, 8, and 11), and the previously unemployed patient found a job after rehabilitation (#10). Patients #6 and 8 subsequently returned to their previous professions but in a limited capacity. Of the 12 patients (including one previously unemployed) returning to work, nine reported they had to modify their duties, work more slowly, and do less than before their injury. Six patients had salary changes: four had slight increases and two had slight decreases. One patient remained on workman's compensation.
Statistical Analysis
According to separate paired t-test analyses of the radiographic measurements, no statistically significant difference existed between the subtalar arthrodesis foot and the contralateral foot in terms of: 1) talocalcaneal height, 2) distance from the cuboid to the floor, 3) distance from the navicular to the floor, 4) calcaneal pitch, or 5) the talus-first metatarsal joint angle (AP and lateral views). However, both the talus-calcaneus angle (lateral view) and the talar declination angle on the subtalar arthrodesis foot were significantly different from that on the opposite foot (p < 0.05). Although the mean AOFAS scores for the subgroups of patients with bilateral fractures, with multiple injuries, or on workman's compensation were slightly lower than that of the overall group, these differences were not statistically significant using unpaired t-tests (p > 0.05) [SPSS+ Statistical Software Package (SPSS Inc. Chicago, IL)].
Discussion
Calcaneal fractures often occur in young to middle-aged industrial workers.10 The natural history and morbidity of these injuries is well documented.30 In 1926 Conn6 reported that the "end results are incredibly bad" for calcaneal fractures and in 1942 Bankart1 wrote that "the result of treatment of crush fractures of the os calcis are rotten . . . ." Later, Barnard and Odegard2, specifically addressing intraarticular fractures, stated that "it appears hopeless, as well as technically impossible, to restore accurately a normal articular surface to a subtalar joint that has been disrupted" and Paley and Hall32 echoed the difficulty in their paper entitled "Calcaneal Fracture Controversies. Can We Put Humpty Dumpty Together Again?". Once reduction is achieved, holding the position can be difficult; McLaughlin24 compared it to "nailing a custard pie to the wall."
The extensive soft-tissue injury and multiple areas of articular involvement make outcome results difficult to verify. One study found slightly better results after closed treatment than after accurate open reduction and internal fixation.24 Another study found better clinical results with conservative treatment than with primary arthrodesis.23 The criteria for open reduction vary, as does the choice of operative approach.25,28,36,44
The inability to compare fractures has frustrated physicians trying to organize evaluation of results. Using a classification scheme that elaborated on previous work by Soeur and Remey38 and Crosby and Fitzgibbons,8 Sanders et al.36 concluded that "Type IV fractures [highly comminuted 4-(or more)-part articular fractures] are so severe that even the most experienced surgeon may find it difficult to piece these fragments together. Knowing this in advance will allow the surgeon and patient to prepare for the possibly of primary fusion." We were unable to classify all the fractures treated in our patients according to the scheme of Crosby and Fitzgibbons.8 There were five severely comminuted fractures (patients #2, 7, 8, 10, and 13) that would be classified as Type IV injuries according to the classification system of Sanders et al.36
We do not recommend a strict adherence to an operative protocol based on the radiographic appearance. For example, of the 14 patients in this study, seven had a Crosby type-II fracture. The initial operative plan of open reduction and internal fixation was modified intraoperatively to include a primary arthrodesis due to greater actual chondral loss than indicated by radiographic studies.
Subtalar arthrodesis as definitive treatment for intraarticular calcaneal fractures was practiced in the early 1900s.41,43 Gallie's technique, using a posterior approach, had good results but did not address the heel varus.14 Dick11 advocated primary fusion posteriorly and attempted to reduce the fracture; he felt that early fusion was warranted to prevent development of "pain patterns" that would hinder later recovery. Harris18 concurred with the approach of primary fusion, warning that joint fragments were often avascular and contributed to later subtalar arthritis, a sentiment echoed by Wilson.42 Pennal and Yadav33 injected a note of urgency into the decision-making process: three-quarters of primary subtalar fusions had good results but less than half of the patients who underwent a subtalar arthrodesis as a secondary procedure had satisfactory results. Noble and McQuillan31 had encouraging results (90% returned to work in 6 months) with a similar posterior method without attempting to reduce the fracture. Carr et al.5 reported encouraging results using distraction bone block technique for late treatment of the complications of articular calcaneal fractures. Care was taken to correct talocalcaneal height and axial heel position. Myerson and Quill27 reported that the distraction bone block arthrodesis restored calf and foot muscle relationships and facilitated decompression of the peroneal tendons.
In the discussion following Gallie's 1943 subastragalar arthrodesis report, Conn7 advocated triple arthrodesis instead of isolated fusion; the controversy continues today. Some authors advocate triple arthrodesis,9,15,40 whereas data in other reports support subtalar arthrodesis as adequate if calcaneal anatomy is restored.4,18 One study of later reconstruction found that primary subtalar arthrodesis had better results, in terms of returning to work, than triple arthrodesis.27
The subtalar joint motion is decreased even after anatomical reduction and internal fixation. The data regarding this motion are somewhat difficult to interpret in light of the great variety of calcaneal fractures treated and lack of standardization in grading. The motion in the subtalar joint relieves rotational forces on the ankle during walking;34 thus, the ankle is more susceptible to developing secondary degenerative arthritis without subtalar joint motion.22
The residual effects of complete obliteration of subtalar motion are uncertain. With subtalar fusion, the ankle suffers a 10 to 25% average loss of motion and a 25 to 50% loss of midtarsal movement.16 Thompson39 found no marked impairment in ankle joint motion in 52/53 patients. Another study40 found no substantial impairment of ankle motion except in one patient who developed a talar neck exostosis after triple arthrodesis. Indeed, there may be some beneficial effects from subtalar arthrodesis on ankle function. The restored height and narrowed heel relieve the lateral impingement associated with fracture malunion and reestablish the relationship of the talus and calcaneus to each other, as well as to the midtarsus and to the ankle.35 An attempt was made to restore the calcaneal pitch as well; this often required the use of the bone block technique to reestablish more normal anatomic relationships.27 Restoration of calcaneal height lifts the malleoli from the counter of the shoe, thereby allowing the patient more flexibility in shoewear.5 As with many articular fractures, residual arthrosis of the calcaneocuboid joint was often radiographically present but seldom symptomatic. The late effects of decreased subtalar motion on this joint, especially after fractures of the calcaneus, have yet to be resolved.
In the current study, all patients regained normal functional range of motion of the ankle, probably contributing to the encouraging overall results (Fig. 1D). The reason for the persistence of mild hindfoot discomfort in four patients with successful fusion is unclear; perhaps soft-tissue impingement or persistent soft-tissue injuries contributed to the pain.
Results of the current study demonstrate that primary subtalar arthrodesis yields results comparable to those of other methods: our techniques resulted in uniformly successful arthrodesis, good restoration of the relation of calcaneal anatomy to the remainder of the foot and the leg, and good return to work rate. Twelve patients (including the one previously unemployed) returned to work at an average of 8.8 months after surgery.
Thus, primary subtalar arthrodesis for the treatment of comminuted calcaneal fractures in combination with open reduction and internal fixation is a reasonable treatment alternative. Although this procedure may be technically challenging, we feel the benefits of restoring normal heel height and width and arthrodesing a severely injured subtalar joint warrant this treatment of these complex fractures.
References
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44. Zwipp, H., Tscherne, H., Thermann, H., and Weber, T. Osteosynthesis of displaced intraarticular fractures of the calcaneus. Results in 123 cases. Clin. Orthop., 290:76-86, 1993.
Figure Legends
Fig. 1. Patient #14. A, computed tomography axial view demonstrating comminution and displacement of the articular surface. B, intraoperative lateral radiograph with femoral distractor device in place and subsequent placement of subtalar stabilizing screw. K-wires are shown here inserted into the fibula and talus for the purpose of soft-tissue retraction only. C, early postoperative lateral view showing tricortical bone graft in place. D, late postoperative lateral view after removal of painful hardware with radiographic healing and good clinical result.
Fig. 2. Radiographic measurements: A, talocalcaneal height; B, cuboid to floor distance (the distance from the most inferior aspect of the cuboid to the floor on a weight-bearing lateral radiograph); C, navicular to floor distance (the distance from the most inferior aspect of the navicular to the floor on a weight-bearing lateral radiograph); D, calcaneal pitch angle; E, talus-calcaneal angle; F, talus-first metatarsal angle; G, talus declination angle.
Fig. 3. Patient #10. A, lateral postoperative view demonstrating reconstruction of talocalcaneal height and angle. B, axial heel view shows restoration of appropriate heel width, comparable to the uninjured side.
Fig. 4. Patient #11. A, lateral preoperative view demonstrates comminuted calcaneal fracture with loss of talocalcaneal height. B, lateral intraoperative radiograph showing reconstruction of calcaneal height and architecture with preliminary positioning of plate. C, postoperative lateral view shows excellent healing of calcaneal fracture, distraction arthrodesis, and restoration of normal hindfoot alignment.
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