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Plantar Exostosis in a Malunited Calcaneal Fracture: A rare complication

by Asif Sultan1   ,Tahir Ahmad Dar ,Mohd Iqbal Wani1 ,
Mubashir Maqbool Wani1 , Samina Shafi2

The Foot and Ankle Online Journal 3 (11): 2

Calcaneal fractures are very common and are associated with many complications irrespective of the treatment method chosen. We present a case of malunited calcaneal fracture with a rare complication of an exostosis in the middle 3rd of the plantar surface of calcaneus which clinically produced a large bony swelling on the sole of the foot causing pain and abnormal gait .This type of plantar calcaneal exostosis to our knowledge has not been previously reported. The patient was managed operatively by exostectomy with subtalar arthrodesis and had a good result at 2 years follow-up.

Key words: Calcaneus, fracture, complications, plantar exostosis, exostectomy, subtalar arthrodesis.

Accepted: October, 2010
Published: November, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0311.0002

The calcaneus is the most frequently fractured tarsal bone, with calcaneal fractures accounting for 65% of all tarsal injuries and approximately 2% of all fractures. [1] Most of these fractures occur in male industrial workers and lead to significant economic impact because of long-term disability. [1] Even though recent studies have shown better results with surgical treatment [2-5] and less invasive stabilization systems [3-5], the treatment of calcaneal fractures remains controversial because of the suboptimal results of treatment and the incidence of complications associated with both conservative and surgical methods. [6-9]

On reviewing the literature for the treatment of symptomatic, malunited calcaneal fractures, the general consensus suggests that resection of impinging bone with isolated subtalar arthrodesis for subtalar joint arthritis yields the best long term results. [10-23] Moreover, some surgeons also do endoscopic calcaneal ostectomies for calcaneofibular impingement with good results. [15]

We present a case of mismanaged, malunited calcaneal fracture in a young male laborer who had an unusual and rare complication of large exostosis on plantar surface of the middle portion of the calcaneus, which to our knowledge has not been reported. The patient presented with bony swelling on the sole of the foot with a painful limp and was managed operatively by excision of the exostosis with subtalar arthrodesis. The patient was symptom free after a 2 year follow-up.

Case report

A 19 year-old male, manual laborer, living in tribal hilly area presented to us with pain in left rearfoot with prominent swelling on the plantar surface and anterior part of the heel. He had difficulty in walking for the last year. He had suffered a crushing injury to his left foot while at work in his native place when a heavy stone fell on his left foot from the antero-lateral aspect.

He had sustained a crushed wound over the left foot which was accompanied by severe pain and the inability to walk. He was managed locally, only for wound care and had no proper medical or orthopedic consultation. This injury healed in 4 weeks, but he still was unable to walk for another two months. After three months of sustained injury, the patient began to walk with a limp and also had noticed hard swelling under the heel. He had always had difficulty in walking afterwards due to pain in the hind foot on weight bearing and abnormal prominence under the heel.

On clinical examination the patient’s left foot had an irregular scar of 4 cm over the anterolateral aspect of the foot. Range of motion at the subtalar joint was restricted and painful with increased heel width and no varus or valgus deformity of heel. There was a prominent bony projection on the plantar surface over the anterior aspect of heel which was tender to touch, with thick, firm, and hypertrophic overlying skin. This region of skin was having major contact with the ground during stance phase, and was associated with an antalgic gait style. Radiographic evaluation showed malunited calcaneal fracture with reduced Bohler’s angle, subtalar arthritis, minimally increased heel width and a large exostosis on the plantar surface of calcaneus. (Fig.1A and 1B) The patient was managed operatively under spinal anesthesia. A lateral approach with sharp dissection to raise a full thickness flap from skin to periosteum was performed. A large plantar exostosis was excised along with associated surrounding bursa. There was no cartilaginous cap on the exostosis. Subtalar arthrodesis was performed after denuding cartilage from both the articular surfaces of the calcaneus and talus. The exostosis was used as graft material and fixed with two staples and a short leg cast was applied after closure. (Fig. 2) Sutures were removed after 3 weeks and a short leg cast was reapplied for 3 months with non-weight bearing for 6 weeks and partial weight bearing for another 6 weeks. There were no post operative complications. At 2 years follow-up the patient was pain free with no limp and had a good subtalar fusion. (Fig.3) The patient had returned to his pre-injury employment as manual laborer and the result was deemed good.


Figure 1A and 1B Lateral (A) and axial (B) view radiographs showing large plantar exostosis, loss of Bohler’s angle and subtalar arthritis with normal tibiotalar alignment.

Figure 2 Immediate post operative lateral radiograph after removal of exostosis and subtalar arthrodesis.

Figure 3 Lateral radiograph at 2 years follow-up showing subtalar fusion with staples in-situ.


Complications of calcaneal fractures occur in the acute and late stages and after operative or non-operative treatment. [1,2,6-9,17,18] Acute complications include swelling, fracture blisters, and compartment syndromes. Late complications include arthritis, malunion, lateral exostosis, calcaneofibular abutment, tendon impingement, heel pad problems and reflex sympathetic dystrophy. Complications from non-operative treatment include arthritis, pain, malunion, and stiffness. Complications associated with operative treatment include wound dehiscence, infection, arthritis, stiffness, and iatrogenic nerve and tendon injury. [2] Heel pad pain is the second most common site of pain after pain over lateral aspect of heel after a calcaneal fracture [2] and have thinning with increased mobility of the pad, and a softer, less firm heel pad compared to the normal side. This pain has been attributed to crushing of the heel pad during injury. This was not the cause of pain in our patient as his heel pad was more firm, harder, thickened, and less mobile than the normal side.

Lateral exostosis usually develops after malunion of calcaneal fractures and is a very common complication. Heel exostosis (bony calcaneal spurs) sometimes develop after injury and may also cause chronic heel pain. These develop from the undersurface of the calcaneus in patients with injuries to the plantar cortex. These are as a consequence of proliferative bony changes at the origin of planter fascia. In our patient, the plantar exostosis was on the plantar surface of calcaneus in the middle third of the calcaneus, well anterior to the origin of plantar fascia, thus being a rare inferior surface exostosis rather than heel exostosis. We hypothesize that severe crushing force anteriorly and laterally caused collapse of the calcaneal body to the middle, also fracturing the inferior cortex and taking a large bony fragment plantarly which developed into large bony exostosis.

Post-traumatic arthritis after intra-articular calcaneal fractures may affect the subtalar or calcaneocuboid joint. It may develop either due to articular surface depression or may occur due to secondary cartilage damage from the initial trauma. Subtalar joint arthritis causes pain on weight bearing, aggravated by varus or valgus stressing of the subtalar joint without significant tenderness to the lateral aspect of heel with or without radiological evidence. [2]

In our patient, operative intervention was performed using a lateral approach as both inferior wall exostectomy (resection of exostosis)[10] and isolated subtalar arthrodesis [11-13] were performed using a single incision. This was indicated for painful subtalar arthritis with normal heel height and normal tibiotalar alignment. (Fig.1) Our result was good with pain free arthrodesis of the subtalar joint. [23] This procedure of isolated subtalar arthrodesis has been well documented with good results, [11-14, 23] and is consistent with our case.

Conflict of interest

There is no conflict of interest related to this article


Written informed consent was obtained from the patient’s guardian for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


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Address correspondence to: Asif Sultan , Government Hospital for Bone and Joint Surgery. Barzullah, Srinagar, India 190005.

 Government Hospital for Bone and Joint Surgery, Barzullah. Srinagar, India 190005.
2  Resident Government Medical College, Srinagar, India 190005

© The Foot and Ankle Online Journal, 2010

Technical Tip: A Simple Method for Proper Placement of an Intramedullary Nail Entry Point for Tibiotalocalcaneal or Tibiocalcaneal Arthrodesis

by Ronald Belczyk, DPM 1 , Wenjay Sung, DPM 2, Dane K. Wukich, MD 3

The Foot & Ankle Journal 1 (9): 4

The purpose of this article is to report on a technical tip when performing tibiotalocalcaneal or tibiocalcaneal arthrodesis. Technical faults of this arthrodesis may include malpositioning of the IM nail that can potentiate complications such as nonunion, delayed union, malunion, screw fracture, painful hardware, fracture of the intramedullary nail, tibial fracture, wound healing complications, and nerve damage. This article will present important information to aid the surgeon in preventing malpositioning of an IM nail and will provide a simple clinical pearl for perioperative incisional planning using image intensification.

Key words: Tibiotalocalcaneal fusion, tibiocalcaneal fusion, IM nail, intramedullary rod, complications

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: July 2008
Published: September 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0109.0004

Several authors have reported the use of intramedullary (IM) nails in ankle and hindfoot arthrodesis with varying rates of success and complications. [1, 5, 7, 12] Since intramedullary nailing involves arthrodeses of the ankle and hindfoot, accurate entry point placement is a critical step with this procedure. Although many technical pearls of initial guide-wire placement have been described in the literature, we have nonetheless seen complications arising from malpositioning. [1-3]

This manuscript reviews potential complications associated with intramedullary nailing, in particular to malpositioning of the retrograde nail. We present two cases that presented with continued pain upon ambulation after attempted tibiotalocalcaneal fusions. Their nonunion and failure of fixation was related in part due to malpositioning of the intramedullary nail. This article further reviews several authors’ recommendations for determining the ideal entry point for the insertion of an intramedullary nail for tibiotalocalcaneal fusion. Many of these studies recommend a guide wire entry point based on anatomical landmarks and preoperative radiographic findings.

Lastly, this article will describe a simple method of perioperative incisional planning by using image intensification.

Potential complications

Potential complications associated with this type of procedure include: nonunion, delayed union, malunion, screw fracture, painful hardware, fracture of the intramedullary nail, tibial fracture, wound healing complications, and nerve damage. [4-10]  Table 1 summarizes complications encountered by several foot and ankle surgeons.

Table 1  Reported complications of IM nailing. 

In addition to those complications listed in table 1, we present two cases with improperly placed intramedullary nails. Figures 2 and 3b are calcaneal axial radiographs which reveal malpositioning of an intramedullary nail.

Case 1

A 56 year old female with hypothyroidism, diabetes, peripheral neuropathy and a significant history of tobacco use presented to our service with severe pain in the medial aspect of her foot. She had sustained an ankle fracture five years prior and underwent open reduction internal fixation, subsequently developing a valgus deformity of her ankle and Charcot neuroarthropathy. Her ankle and hindfoot deformity was treated with a tibiotalocaneal fusion using a retrograde intramedullary nail. At the time of IM nail removal, movement was seen through the subtalar joint. (Figs.1ab, Fig.2)


Figure 1a  Case 1:  Anteroposterior (AP) ankle radiographs showing an intramedullary nail for a tibiotalocalcaneal arthrodesis.

Figure 1b  Case 1:  Lateral ankle radiographs showing placement of  intramedullary nail for the tibiotalocalcaneal arthrodesis.

Figure 2  Case 1:  Calcaneal Axial radiograph demonstrating malpositioning of the IM nail through the hindfoot with the insertion site too medial.

Case 2

A 66 year old male with rheumatoid arthritis, diabetes and peripheral neuropathy presented with significant pain upon ambulation. He related a history of a talus fracture that went on to Charcot neuroarthropathy of the ankle and hindfoot. He underwent a tibiotalocalcaneal fusion with intramedullary nail two years prior to our initial consultation. Figures 3abc demonstrate the patient’s initial presenting radiographs. The radiographs reveal distal migration of the IM nail. A computerized tomography (CT) scan showed a nonunion of the tibiocalcaneal joint. Laboratory data revealed no clinical signs of infection. Revisional arthrodesis was performed using circular ring fixation and external bone stimulation.


Figure 3abc  Case 2:  AP (a), axial (b) and Lateral (c)  radiographs of the ankle demonstrate an attempted tibiocalcaneal fusion with an intramedullary nail with broken calcaneal screw and distal migration of the nail.

Recommendations for determining guide wire entry point

Accurate guide wire placement is critical prior to reaming and inserting a retrograde intramedullary nail for tibiotalocalcaneal or tibiocalcaneal fusion. The guide wire is typically placed into the central medial aspect of the calcaneus and centered in the medullary canal of the tibia. Because the longitudinal bisection of the calcaneus is lateral relative to the alignment of the tibia in a normal anatomic structure, it is usually necessary to medially translate the talus and calcaneus.

This will allow insertion of a straight nail from the calcaneus into the central portion of the tibia. [11]

The foot placement should be 90 degrees with respect to the lower leg, maintaining the heel in neutral position with 10-15 degrees of external rotation. Blunt dissection is carried down to the bone to avoid any neurovascular structures. [13]

A number of authors have described the anatomical placement of the IM nail. Table 2 summarizes several author recommendations for determining the proper entry point. The surgical approach to placement of the IM nail is described in terms of measurement from specific landmarks and anatomical structures.

Table 2  Several recommendations for determining proper IM nail entry points.

Our technique uses perioperative imaging to determine the placement of the IM nail. Using intraoperative C-arm visualization, the long axis of the tibia on lateral view is used to determine the tibial location along the plantar entry point of the foot. The IM nail is simply placed along the lateral leg just above the border of the fibula. A marking pen is then used to draw a horizontally placed line along the plantar aspect of the foot. This corresponds to the central tibial component for IM nail placement.

The IM nail should visually appear to go directly through the lateral process of the talus on lateral view.

The second vertical or longitudinal bisecting line is made with the calcaneal axial view perioperatively. The IM nail is placed directly against the plantar heel on axial view. The line corresponds to the valgus or varus rotation of the calcaneus. The marking pen is then used to draw a longitudinal bisecting line. The center of the bisecting line represents the ideal entry point for the IM nail. Here, no measurements are required, and the landmarks to determine the ideal entry point correspond to radiographic anatomical structures. Figures 4-7 show a stepwise approach for perioperative incisional planning. The entry point is based on lateral ankle and calcaneal axial views utilizing C-arm visualization.


Figure 4abc  Preoperatively, a line is made on the ankle which is consistent with a line that bisects the tibia and goes through the lateral talar process.

Figure 5  The mark on the lateral aspect of the ankle is then continued transversely on the plantar surface of the foot.  A guide-wire or metallic marker, in this case a threaded rod, is then placed against the plantar aspect of the foot along the center of the heel. 

Figure 6   Using image intensification, a calcaneal axial view is taken and a line bisecting the calcaneus is then marked on the plantar skin.

Figure 7   The center of the two intersecting lines is the ideal entry point.


In summary, ideal incisional placement permits accurate insertion, good screw purchase, and avoids neurovascular damage. (Fig. 8ab)


Figure 8 ab Lateral ankle (a), calcaneal axial (b) radiographs demonstrate a tibiotalocalcaneal fusion with a properly placed intramedullary nail.

Although fixed angled devices are being popularized as being able to purchase a greater amount of calcaneus and not having to medially translate the talus to align the tibia and calcaneus, clearly intraoperative errors can lead to postoperative complications as presented in this article. A simple, accurate, and reproducible method of determining the proper entry point as described in this article is invaluable to the foot and ankle surgeon performing tibiotalocalcaneal or tibiocalcaneal fusion with intramedullary devices. Currently there are retrograde devices approved for use that have a valgus orientation built into the nail.

The valgus nail such as the T2 Ankle arthrodesis nail (Stryker, Kalamazoo, MI) or the Hindfoot Arthrodesis Nail-EX (Synthes, West Chester, PA) can facilitate proper entry site placement, however, we recommend the above technique to guide proper placement. Proper placement of the device in the calcaneus improves fixation with the distal interlocking screws whether they be transverse or axial in nature.


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Address correspondence to: Dane Wukich, MD. UPMC Comprehensive Foot and Ankle Center. Roesch-Taylor Bldg Ste 7300. 2100 Jane St. Pittsburgh, PA 15203. Phone: 412-586-1546 Fax: 412-586-1544
Email: wukichdk@upmc.edu

PGY-4, Fellow, Foot and Ankle Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15203.
Resident, Foot and Ankle Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15203.
Chief, Foot and Ankle Division, University of Pittsburgh Medical Center Department of Orthopedic Surgery and Assistant Professor, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 15203.

© The Foot & Ankle Journal, 2008