Calcaneus malunion and nonunion

Though the debate continues between operative interventions versus conservative therapy, there is significant evidence that the deformity that results from calcaneus malunions causes significant disability for the patient. Knowledge of the fracture patterns in the original calcaneal fracture aids in both understanding the deformity of the malunion and the necessary steps for correction of the deformity. Increased heel width, subfibular impingement, tibiotalar impingement, varus/valgus deformity of the hindfoot, peroneal tendon dysfunction, and subtalar arthrosis are well established consequences of calcaneal malunion. Different surgical options have been postulated either trying to address all the deformities or concentrating on certain aspects that are most clinically pressing. The simplest form of treatment is isolated lateral wall decompression, and if applied to a patient who has minimal subtalar arthrosis and no hindfoot deformity, good results are produced. The more complex surgical interventions aim to correct the lateral ankle symptoms, subtalar arthrosis, and hindfoot varus. These surgeries result in a more functional foot but should be considered a salvage procedure because there is still considerable disability as indicated by lower functional scores on the Short Form 36 and American Orthopaedic Foot and Ankle Society hindfoot surveys. Nonunion in calcaneal fractures has limited incidence within the literature for both operative and nonoperative management. Thus, any conclusion as to why there would be such a low incidence can only be made on speculation that the vascularity of the calcaneus and ability to immobilize both the subtalar and calcaneocuboid joints allow the fracture to heal.