The evolution of primary subtalar arthrodesis for displaced intra-articular calcaneal fractures: A historical review.

BACKGROUND: Primary subtalar arthrodesis has been advocated for the treatment of severe displaced intra-articular calcaneal fractures for more than a century. Although the procedure remains a valuable option in carefully selected patients, its historical evolution has never been comprehensively reviewed. This study aimed to describe the development of primary subtalar arthrodesis from its introduction in 1911 to contemporary practice and to evaluate how indications, surgical techniques, and reported outcomes have evolved over time.

METHODS: A comprehensive search of PubMed and Embase was performed without date restrictions, supplemented by backward and forward citation tracking. Publications describing acute primary subtalar or triple arthrodesis for calcaneal fractures were included. Studies were grouped into four historical eras based on publication volume, treatment philosophy, and technical developments. Data regarding indications, operative techniques, timing, and clinical outcomes were extracted descriptively.

RESULTS: The concept of primary subtalar arthrodesis was first introduced by Van Stockum in 1911, who recognized the subtalar joint as the principal source of persistent pain after severe calcaneal fractures. Early reports regarded arthrodesis primarily as a salvage procedure when anatomical reconstruction was considered impossible. During the 1950s-1970s, the concept evolved into reconstructive primary arthrodesis, emphasizing restoration of calcaneal morphology before fusion. Following the introduction of computed tomography and modern open reduction techniques, publications on primary arthrodesis virtually disappeared between 1980 and 1994, reflecting renewed confidence in joint-preserving reconstruction. Since the mid-1990s, primary arthrodesis has re-emerged as a selective treatment for irreparable posterior facet injuries. Although most studies reported favorable union rates and functional outcomes, comparative studies have demonstrated little difference in patient-reported outcomes between reconstruction alone and reconstructive primary arthrodesis, highlighting the importance of appropriate patient selection rather than routine use.

CONCLUSIONS: Over more than a century, primary subtalar arthrodesis has evolved from a salvage procedure into a reconstructive strategy reserved for carefully selected patients with irreparable subtalar joint injury. Contemporary evidence suggests that the success of primary arthrodesis depends less on the procedure itself than on identifying the patients most likely to benefit. Future research should focus on validating objective fracture- and patient-related selection criteria.