A most interesting case of mine involves a 69-year-old male who came to me four months after shattering his heel bone (or calcaneus). He was trimming branches on a ladder about 6 feet high when he fell and landed right on his heel bone. He went to urgent care, where x-rays were taken, revealing no obvious fracture. He then went on to see another foot specialist, who diagnosed him with a heel fracture and treated his injury conservatively with immobilization in a walking cast boot.
After four months of immobilization, he was sent for a CT scan, which revealed a shattered heel bone within the joint, and by then it had healed in a poor position. It was decided to order a bone stimulator for the patient to help heal the fracture in the heel.
At this point, the patient came to me at Dr. Bob for a second opinion. By now he was terribly discouraged and wondered why it would take so long for his fracture to heal. Plus he was having a lot of pain when he walked, even in the walking cast boot.
Now clinically, the patient had no pain when I squeezed his heel bone, but the bone was in an inverted, or varus position. He had pain along the tendons that run along the outside of the heel, stiffness, and pain along the subtalar joint as well (the joint just below the ankle).
I decided to start from ground zero and ordered a set of x-rays, which we took in our office, which revealed obvious arthritis in his subtalar joint, as well as malalignment of the heel bone in a varus position.
After listening to his story, doing my examination, and reading his radiographs (aka x-rays) it was clear that he had initially suffered a bad injury that was not properly treated from the beginning. Now he had two bad issues that were causing him continued pain and swelling: a malunion of his heal and post-traumatic arthritis. A bone stimulator, which his prior doctor ordered, was never going to resolve this issue.
About his Malunion
In the time before he came to see me his heel fracture had healed but unfortunately in a bad position, changing his gait and putting more pressure on the outside of his foot and ankle. Neglected or poorly treated heel fractures will typically heel mal-aligned, in a varus or inverted position, leading to increased stress on the outside of the extremity.
Additionally, due to the compressive nature of the fracture, there was a loss of height, or flattening of the heel. Left untreated this can lead to limb length discrepancies and subsequent compensatory issues if not properly treated.
About his post-traumatic arthritis
Due to the intraarticular nature of the fracture – meaning that the fracture violated the joint – there were now signs of arthritis in the joint. Heel fractures that violate the joint – the subtalar joint in this case – have a high risk of subsequent arthritis. If properly reduced, the risk is lessened, but there is still a chance of arthritis. In this patient’s case, his displaced fracture within the joint was not originally reduced back into its anatomical alignment. Due to this, arthritis began developing in the subtalar joint which was due to the mal-alignment of the joint.
How we treated this condition
The surgical plan to correct this patient’s malunion was to make a wedge cut in the heel bone to reduce the varus deformity in the heel. This would make the heel more neutral and reduce the amount of stress he is putting on the outside of his heel. I would then attempt to fuse the subtalar joint, adding a bone graft in that joint to recreate some height to the heel. During the surgery, I would also remove any bone spurs, and inspect for any tendon damage to the outside tendons of the foot (peroneal tendons). The goal of the surgery was to provide a functional and stable foot for the patient to walk on. The patient agreed to proceed with this course of treatment.
Results: his recovery story
After surgery, the patient was immobilized in a cast for 2 months and then placed in a walking boot for 1 month, after seeing evidence of bone fusion of the subtalar joint, and bone cut. Physical therapy was performed for a couple of months afterward.
The patient is currently doing very well. He is walking without any pain or and the swelling he was experiencing before he came to see me was totally gone. He is very happy with the surgery and has ended up with a perfectly functional foot which pleases both him and me tremendously!
To schedule a consultation, please call (855) 557-5400 or make an appointment now.
Dr. Bob Baravarian is conveniently located in Los Angeles, near Cedars-Sinai Medical Center, providing expert foot and ankle care for patients throughout Southern California.
