May the Symptomatic Subtalar Joint Be Conservatively Treated With Intra-Articular Hyaluronic Acid Injections After a Calcaneus Fracture?

Abstract

Background Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture. Methods We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection. Results Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week ( P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week ( P = .001). Conclusion For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement. Level of evidence: IV, Case series

Pharmacological treatment withcorticoid or hyaluronic acid injections into subtalar joint via lateral access v1

“…Mei-Dan and colleagues demonstrated that patients submitted to viscosupplementation with 10mg sodium hyaluronate (Euflexxa) administered weekly to the subtalar joint for 3 weeks improved the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score (AOFAS) and on Visual Analogue Scale (VAS) till 28 weeks after injection [5]. Other studies regarding the same protocol scheme showed that similar results were achieved by the use of 20mg sodium hyaluronate (Polireumin) [2] or by the combination of 20mg sodium hyaluronate (Polireumin) with 10mg of betamethasone sodium phosphate ]3]. However, isolated corticoid injection effect was limited to 4 weeks, having returned to the original parameters after 12 weeks of the first injection [3].…”

The hyaluronic acid gel promotes the formation of osteoblasts mineralized nodules and fracture callus by regulating the expression of Runx2 and osteocalcin

“…As a biomaterial, HA gel has the advantages of good biocompatibility, strong water absorption, and high viscosity, which can provide an ideal biological scaffold to provide the necessary support and growth environment for fracture healing (14,15). In addition, HA gel can also promote the proliferation, differentiation and mineralization of bone cells in a variety of ways, thereby accelerating fracture healing (16).…”