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research-article2013

FAIXXX10.1177/1071100713495381Foot & Ankle InternationalLetter to the Editor

Letter to the Editor

Subtalar Distraction Osteogenesis for Old Calcaneal Fractures Dear Editor, We read with great interest your recent publication of the article by Fan et al.2 In their retrospective study, they used external fixator to fix the subtalar joint following remove of the articular surface and subchondral bone of the posterior subtalar facet. And they concluded that this method was novel and effective for posttraumatic subtalar arthritis following intra-articular calcaneal fractures. However, there are some concerns regarding their study. First, although subtalar distraction osteogenesis with spanning external fixation could provide good clinical results, there are some disadvantages with the external fixation.2 With external fixator spanning ankle and subtalar joints, the ankle joint space could be more easily widened rather than subtalar joint, thus leading to potential injury of the ankle joint.3 Removal of the external fixator after bone fusion at an average of 4.9 months (range, 4-8 months) could result in the ankle stiffness.1 Subtalar distraction with external fixator is more prone to induce nonunion.4 In the process of distraction, lateral placement of the unilateral external fixator could cause varus deformity of the calcaneus, thus preventing the effective surgical correction of the calcaneal malunion. Second, the authors performed external fixation only to restore calcaneal height. We would like to know whether an additional calcaneal osteotomy should be considered. In our opinion, in some selected cases, calcaneal osteotomy combined with subtalar fusion can give better result. Calcaneal osteotomy can correct the residual varus malalignment, especially for Stephens–Sanders type III deformity.3 It has already been reported in the literature that a lateral wall exostectomy, bone block subtalar arthrodesis, and a calcaneal osteotomy resulted in satisfactory outcomes.1 Third, the authors stated that the subtalar fusion using subtalar distraction osteogenesis was performed at four to

Foot & Ankle International 34(11) 1606­ © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100713495381 fai.sagepub.com

eighteen months after the injury. In our opinion, in the early period, the subtalar arthritis could not be so severe that a chance should be given to reconstruct the calcaneal morphology and preserve the subtalar joint. Yu et al4 reported on 24 patients with calcaneal malunion who were treated by osteotomy and autogenous bone graft with subtalar joint salvage. They found this method was effective for selected calcaneal malunions. Fourth, we think their techniques might be more suitable for single subtalar arthritis following calcaneal fracture with only height loss rather than the classic calcaneal malunion with severe hindfoot malalignment. Sincerely, Bing Li, PhD, Da-wei Chen, PhD, Guang-rong Yu, MD, and Yun-feng Yang, PhD Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China

References 1.  Dwyer FC. Osteotomy of the calcaneum for pes cavus. J Bone Joint Surg Br. 1959;41:80-86. 2. Fan WL, Sun HZ, Wu SY, Wang AM. Subtalar distraction osteogenesis for posttraumatic arthritis following intra-articular calcaneal fractures. Foot Ankle Int. 2013;34: 398-402. 3. Stephens HM, Sanders R. Calcaneal malunions: results of a prognostic computed tomograghy classification system. Foot Ankle Int. 1996;17:395-401. 4.  Yu GR, Hu SJ, Yang YF, Zhao HM, Zhang SM. Reconstruction of calcaneal fracture malunion with osteotomy and subtalar joint salvage: technique and outcomes. Foot Ankle Int. 2013;34:726-733.

Subtalar distraction osteogenesis for old calcaneal fractures.

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