Early Full Weight-Bearing After Calcaneal Fracture Using a Heel-Unloader Orthosis: Equivalent Radiographic Outcomes Compared to Traditional Cast Treatment.

Background Standard treatment of calcaneal fractures involves prolonged immobilization with partial weight-bearing, risking ankle stiffness and lower-leg deconditioning. The heel-unloader enables early full weight-bearing by redirecting axial load from the hindfoot to the midfoot, forefoot, and lower leg. This study compares radiologic and clinical outcomes of heel-unloader vs conventional cast immobilisation. Methods We retrospectively analyzed 101 calcaneal fractures treated with cast immobilization and partial weight-bearing or a heel-unloader with early full weight-bearing. Böhler angle (BA) loss, evaluating macroscopic fracture displacement and heel height, was the primary endpoint; secondary outcomes were pain, ankle/subtalar motion, complications, and radiologically subtalar degeneration. Equivalence in BA loss was tested by 2 one-sided tests (TOST). Results Overall, 16.8% of the fractures were managed non-operatively and 83.2% operatively, with similar distributions between the groups (P = .397). After 4 weeks of non-weight-bearing, 59 (58.4%) fractures continued in a heel-unloader and 42 (41.6%) with a cast. Baseline and fracture characteristics were comparable. Mean BA loss at 12 weeks was -4.7° ± 5.3° (heel-unloader group) vs -3.8° ± 5.5° (cast group) (P = .44), confirming equivalence (TOST P < .001). Other outcomes showed no significant differences. Conclusion Early full weight-bearing with a heel-unloader yields radiologically and clinically equivalent macroscopic results to traditional casting and is a safe alternative for early mobilization. Level Of Evidence Level III, retrospective comparative study.