| As the largest tarsal bone in the human body, calcaneus plays an important role in supporting weight and during walking. Calcaneal fractures are commonly seen in clinical practice, most of which are high-energy injuries, and more than 70% of which are intra-articular fractures. Improper post-fracture treatment leads to malunion and various complications like ankle and subtalar joint stiffness, which impact patients’ work and life. Without an agreed and effective treatment at present, malunions after calcaneal fractures are mainly treated by surgeries, most of which are arthrodesis, significantly affecting patients’ foot function. With the improvement of people’s living standards, more attention paid to the treatment of calcaneal fracture, and the progress in imaging, internal fixation and other technologies, there have been fewer and fewer serious malunions after calcaneal fractures in clinical practice. Although ankle and subtalar joint stiffness after calcaneal fracture receives more attention, there are still only a few reports on the pathogenesis and treatment of ankle and subtalar joint stiffness, and the treatment outcomes are largely different. In this study, after the patients with ankle and subtalar joint stiffness after calcaneal fracture were classified by Stephens and Sanders CT classification, those with ankle and subtalar joint stiffness induced by Type I and Type II malunions were treated by surgery with their subtalar joints preserved, and studied in the follow-up so as to determine the surgical outcomes in hope of finding proper treatment for ankle and subtalar joint stiffness.Objective:For patients with type I and type II malunion after calcaneal fracture according to Sanders CT classification, extension or release of peroneal tendons and subtalar joint release were used to treat ankle and subtalar jointstiffness after calcaneal fracture. By comparing the preoperative and postoperative calcaneal varus and valgus angulation, plantar flexion and dorsal flexion angles of ankle joint, hindfoot AOFAS function scores and visual analogue scale(VAS) and observing the postoperative curative effects in the follow-up, giving a theoretical basis of pathological mechanism and treatments of ankle and subtalar joint stiffness after calcaneal fractures.Methods:42 cases(60 feet) with ankle and subtalar joint stiffness after calcaneal fractures were selected, who were admitted in the third hospital of He bei medical university between February 2012 and October 2014. The male is 34 cases(52 feet)with the average age is 30(range,18-55),and female is 8(8 feet)with the average age is 35(range,20-46). Injury reasons include high falling injury(36 feet), traffic accident injury(14 feet),crushing accident(10 feet). 38 feet were given conservative treatment(manipulative reduction and plaster fixation, bed rest) while 22 feet were given surgical treatment(lateral fixation with plate and hollow screw). The time of weight loading after injury was from 2 to 4 months with an average of 3.3 months, while the interval from fracture to surgery was 6-37 months with an average of 15 months. All the cases were selected based on inclusion criteria and exclusion criteria. Each foot was given X-ray and CT scan before operation and measured calcaneal varus and valgus angulation as well as plantar flexion and dorsal flexion angles of ankle joint. Then record every patient’s hindfoot AOFAS function scores and visual analogue scale(VAS). Calcaneal fracture malunions were classified by Stephens and Sanders CT classification. For patients with type I or type II, extension or lysisof peroneal tendonsand subtalar jointl release were given via lateral calcaneal incision. Manipulation release was given during the operation to further increase the mobility. The patients were followed up and at 6 months and 12 months after operation measured the calcaneal varus and valgus angulation as well as plantar flexion and dorsal expansion angles of ankle joint. Hindfoot AOFAS function scores and visual analogue scale(VAS)scores were also assessed. SPSS 21.0 was used for statistical analysis to compare preoperative data and data at postoperative 6 months as well as data at postoperative 6 months and 12 months, so as to assess clinical curative effects of operation. P<0.05 referred to significant difference.Results:42 cases(60 feet) were included and followed up for 13-27 months with an average of 16 months. 1 foot came about postoperative hemorrhage on incision and local necrosis on skin edge. Some sutures was removed at early time and the patient’s incision was given an adequate drainage, at last the incision healed well. 1 foot appeared necrosis on skin edge of incision. The soft tissue was exposed after excision of eschar. The patient was given VSD treatment and the result was well. 1 patient’s valgus activity and obviously decreased, due to inadequate exercise after operation. The patient was given functional exercise and became better than before. The rest of the patients had increased range of varus and valgus activity and relived pain. No case appeared complication such as re-fracture, and could be involved in normal work and life.The observation indexes before the operation and 6 months after the operation were compared. The results were: varus mobility(t=-34.790, P=0.000<0.05),valgus mobility(t=-19.363,P=0.000<0.05), plantar flexion of ankle joint(t=-1.973, P=0.0.053>0.05),dorsal flexion angles of ankle joint(t=-1.918,P=0.060>0.05),VAS scores(t=28.796, P=0.000<0.05), and AOFAS scores(t=-42.249, P=0.000<0.05). Before operation, 4 feet were fair and 56 feet were poor; while 6 months after operation, 11 feet were excellent, 46 feet were good and 3 feet were fair, with the excellent and good rate of 95.0%.The observation indexes of 6 months and 12 months after the operation were also compared. The results were: varus mobility(t=-0.753, P=0.454), valgus mobility(t=0.055, P=0.956), plantar flexion of ankle joint(t=-0.406, P=0.686), dorsal flexion angles of ankle joint(t=0.335,P=0.739), VAS scores(t=1.926, P=0.059), and AOFAS scores(t=0.947, P=0.347).Conclusions:1 There are statistical differences between preoperation and 6 months postoperation on calcaneal varus and valgus angulation, AOFAS function scores and VAS scores; but there are no statistical differences between preoperative and postoperative plantar flexion and dorsal flexion angles of ankle joint. And there are no statistical differences between 6 postoperation and 12 months postoperation.2. Ankle and subtalar joint stiffness are influenced by a variety of factors which is including peroneal muscle spasms, peroneal tendon adhesion, expansion of calcaneal lateral wall, narrowing clearance of subtalar joints, uneven articular surface or not fully recovered articular surface, and poor occlusion of joints. Malunion of calcaneal fracture of type I and type II has little effect on ankle joint stiffness.3. Extension or release of peroneal tendons and subtalar joint release can treat ankle and subtalar joint stiffness caused by malunion of type I or II calcaneal fracture effectively. They can alleviate the patients’ pain, and retain joint mobility and improve the quality of life of patients. Subtalar joint sparing surgery is selected according to the patients’ condition, preoperative examination, patients’ symptoms and the requirement for foot function. |
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