Operative versus Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures in Elderly Patients

doi:10.1053/j.jfas.2009.08.001

The Journal of Foot and Ankle Surgery

Volume 49, Issue 1, January–February 2010, Pages 25-32

https://doi.org/10.1053/j.jfas.2009.08.001 Get rights and content

Abstract

We compared the outcomes of displaced intra-articular calcaneal fractures in 33 patients aged 65 to 75 years, who were treated either operatively (n = 18) or nonsurgically (n = 15), between December 2001 and December 2005. The operative treatment group scored higher on the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and had less pain as measured with the 10-cm visual analog scale than did the nonsurgically treated group, with the differences being statistically significant (P ≤ .05), suggesting that results can be improved by operative treatment. Böhler's angle, the quality of operative reduction, subtalar joint motion, gender, and the Sanders type of fracture were also analyzed and compared between the treatment groups. The results confirmed that Böhler's angle, the quality of the reduction, and subtalar joint motion were important prognostic factors related to outcome, regardless of treatment; whereas gender and Sanders type had less influence on the results at the 2-year follow-up evaluation. The prevalence of complications observed in the surgically treated group was similar to that reported in prior publications, except for subtalar arthritis (38.9%), which may have been higher because of the age of our patients and the duration of follow-up.

Section snippets

Patients and Methods

We performed a multicenter retrospective investigation of patients aged 65 to 75 years who had sustained a displaced intra-articular calcaneal fracture that was treated either by means of ORIF or nonoperative care between December 2001 and December 2005. Protocols were different between the 2 hospitals involved in the study in the sense that in one center all the displaced intra-articular calcaneal fractures in patients older than 65 years were treated without surgery, whereas in the other

Results

Based on our inclusion criteria, 33 patients were available for the analyses used in this retrospective cohort study, and 18 (54.6%) of these underwent surgical repair of their calcaneal fracture, whereas 15 (45.5%) were treated nonsurgically. Results for the treatment groups at the 2-year follow-up evaluation are summarized in Table 1, Table 2, and Table 3 depicts statistical comparisons for the demographic and outcome variables between the treatment groups. The mean age for the patients in

Discussion

Controversy exists as to which is the best treatment for displaced intra-articular calcaneal fractures. A number of retrospective and few small prospective studies reported better results with operative treatment than with nonsurgical management 20, 21, 22, 23. The meta-analysis of Randle et al. (21) reported a trend for a better outcome from surgical treatment of calcaneal fractures, but the authors stressed their concerns for the weakness of their evidence for deciding on the optimal

References (40)

G.H. Duncan et al.
Comparison of verbal and visual analogue scales for measuring the intensity and unpleasantness of experimental pain
Pain
(1989)
D.A. O'Farrell et al.
Fracture of the os calcis: improved results with internal fixation
Injury
(1993)
A. Fortina et al.
Reconstruction of calcaneal skeletal defects caused by trauma
J Foot Ankle Surg
(1998)
R. Lindsay et al.
Fracture of the os calcis
Am J Surg
(1958)
C.R. Rowe et al.
Fractures of the calcaneus
JAMA
(1963)
U. Järvholm et al.
Fractures of the calcaneus. A comparison of open and closed treatment
Acta Orthop Scand
(1984)
R. Buckley et al.
Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures
J Bone Joint Surg Am
(2002)
H. Zwipp et al.
Osteosynthesis of displaced intra-articular calcaneal fractures of the calcaneus
Clin Orthop
(1993)
D. Paley et al.
Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors
J Bone Joint Surg Am
(1993)
J.L. Howard et al.
Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management
J Orthop Trauma
(2003)

D. Herscovici et al.

Operative treatment of calcaneal fractures in elderly patients

J Bone Joint Surg Am

(2005)

R. Sanders et al.

Operative treatment of 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification

Clin Orthop Relat Res

(1993)

S.K. Benirschke et al.

Extensive extra-articular fractures of the foot

Clin Orthop

(1993)

E.J. Harvey et al.

Morbidity associated with ORIF of intra-articular calcaneal fractures using a lateral approach

Foot Ankle Int

(2001)

H.B. Kitaoka et al.

Clinical rating systems for the ankle-hindfoot, midfoot, hallux and lesser toes

Foot Ankle Int

(1994)

K.A. Hildebrand et al.

Functional outcome measures after displaced intra-articular calcaneal fractures

J Bone Joint Surg Br

(1996)

J. O'Brien et al.

Personal gait satisfaction after displaced intraarticular calcaneal fractures: a 2–8 year follow-up

Foot Ankle Int

(2004)

P. Morin et al.

Oral analogue scale as an outcome measure after displaced intra-articular calcaneal fractures

Foot Ankle Int

(1998)

B.F. Morrey et al.

Complications and long term results of ankle arthrodesis following trauma

J Bone Joint Surg Am

(1980)

C. Loucks et al.

Böhler's angle: correlation with outcome in displaced intra-articular calcaneal fractures

J Orthop Trauma

(1999)

Cited by (71)

Effect of sequential burr passes on osteotomy magnitude and calcaneal morphology in minimally invasive Zadek osteotomy
2024, Foot and Ankle Surgery
This study aimed to evaluate the impact of each burr pass on degree of correction, gap size and calcaneal morphology in MIS Zadek osteotomy.
MIS Zadek osteotomy was performed on ten cadaveric specimens using a 3.1 mm Shannon burr. After each burr pass, the osteotomy gap was manually closed, and the subsequent burr passes were carried out with the foot held in dorsiflexion, which was repeated five times. Lateral X-rays were taken before and after each burr pass. Two independent reviewers measured the dorsal calcaneal length after each burr passage, as well as changes in several calcaneal parameters including X/Y ratio, Fowler Philip angle, and Böhler angle.
The average decrease in dorsal calcaneal cortical length with each burr pass was as follows: 2.6 ± 0.9 mm at the 1st pass, 2.4 ± 1 mm at the 2nd pass, 2 ± 1 mm at the 3rd pass, 1.6 ± 1 mm at the 4th pass, and 1.4 ± 0.7 mm at the 5th pass. The Fowler Philip and Böhler angles consistently decreased while the X/Y ratio consistently increased following each consecutive burr pass. Interobserver reliability analysis demonstrated good agreement for all parameters.
The results revealed the trends of length and anatomical changes in the calcaneus with each burr pass. On average, a dorsal wedge resection of 10 mm was achieved after 5 burr passes. This data can aid surgeons in determining the optimal number of burr passes required for a particular amount of resection, ensuring the attainment of the desired patient-specific surgical outcome.
Approach to Displaced Intra-Articular Calcaneus Fractures After Attempted Suicide Among Patients With Psychiatric Disorders: Nonsurgical or Surgical?
2022, Journal of Foot and Ankle Surgery
Displaced intra-articular calcaneus fracture is one of the injurious events in psychiatric patients after high-jump suicide attempts. These patients are reported to have poorer compliance and worse postoperative outcomes compared to those with no psychiatric condition. We aimed to compare nonsurgical and surgical treatment with respect to functional and radiological outcomes and complications in this patient. We evaluated medical records of 42 psychiatric patients who had displaced intra-articular calcaneal fractures after high-jump suicide attempt. 20 (54%) of these were treated nonsurgically and further 17 patients (46%) received surgical intervention. We compared to nonsurgical and surgical approaches statistically. The mean follow-up period were 30.4 ± 8.02 months and 31.8 ± 7.5 months in the nonsurgical and surgical groups, respectively. Böhler's angle was significantly higher in the surgical group (30.4 ± 6.4) than that in the nonsurgical group (16.1 ± 3.7) (p = .001). AOFAS scores and supination levels were significantly higher in the surgical group than that in the nonsurgical group (p ≤ .05). During the follow-up period, one patient from the surgical group re-attempted high-jump suicide and died, and another one caused the subtalar joint to re-collapse after full weightbearing on the first postoperative day. Surgical treatment of displaced intra-articular calcaneal fractures following a high-jump suicide attempt in psychiatric patients may not cause increased complication rates. However, behavioral manifestations of the psychiatric disorder might be associated with several complications. Should any surgical intervention be decided, minimal invasive approach would be the appropriate choice.
The Association of Bohler's Angle With Postoperative Pain and Gender for Displaced Intra-Articular Calcaneal Fracture, Multicenter Retrospective Study—TRON Study
2022, Journal of Foot and Ankle Surgery
A relationship between Böhler angle (BA) before or after surgery and clinical outcomes remains unclear. This retrospective multicenter cohort study aimed to compare pain and functional outcomes between a group in which the reduction angle was preserved and a group in which the reduction angle was lost during follow-up, and to clarify the risk factors leading to loss of last follow-up BA. From 2014 to 2018, 271 cases of calcaneal fractures were surgically treated at ten facilities. We divided patients into Group L (lost reduction of fracture) and Group P (preserved reduction of fracture). We matched subjects between the 2 groups according to age, sex and BA before surgery and compared American Orthopedic Foot and Ankle Society (AOFAS) score between the groups. We investigated the correlation between the amount of BA loss and postoperative pain. The factors leading to loss of last follow-up BA were examined by logistic regression analysis. Ultimately, 112 patients were eligible. After matching, each group included 38 patients. There was no difference between the 2 groups in total AOFAS score. However, the pain component of AOFAS score at 6 months and 12 months were worse in group L than in group P (p = .011, p = .031, respectively). We also showed a weak correlation between the amount of BA loss and postoperative pain. Logistic regression analysis revealed that female and BA before surgery independently predicted loss of reduction (odds ratios: 4.66, 95% CI: 1.15-18.9 and odds ratios: 0.90, 95% CI: 0.82-0.99, respectively). We clarified that reduction and preservation of BA within its normal range should lead to decrease postoperative pain. Female and lower pre-BA were risk factors leading to loss of reduction of BA in operative treatment of calcaneal fractures.
A Novel Prediction Model for Determining Coronal Length of Calcaneus Using CT: A Guide for Surgery of Calcaneal Fracture
2021, Journal of Foot and Ankle Surgery
The objective of this study was to determine the anatomical relationship between the calcaneus and its neighboring bones. Furthermore we tested a prediction model that enables to estimate safe screw length during the surgery of calcaneus fractures.
A total of 169 feet were used for the study based on CT scans. We measured two horizontal and two parallel lines. The coronal length of the cuboid bone (CL) was a horizontal line anterior to the calcaneocuboidal joint, and W1 of calcaneus was a horizontal line posterior to the articular surface of the calcaneocuboidal joint. The subtalar articular length (STA) was a parallel line above the talocalcaneal joint, and W2 of calcaneus was a parallel line below to the talocalcaneal joint. Relationship of each measurement was determined through correlation analysis. A prediction model was developed based on observed correlations and the quality analyzed and validated.
The CL and W1 had a significant positive correlation (r = 0.899, p < .001). The STA and W2 also had a significant positive correlation (r = 0.939, p < .001). Based on these correlations, the prediction model was made. In the quality analysis, the values of concordance correlation coefficient (CCC) for W1 and W2 were 0.894, and 0.937 respectively. In the validation analysis, the values of CCC for W1, W2 were 0.79, and 0.8, respectively.
This study made it possible to predict the anatomical reference point using preoperative coronal length of the calcaneus to guide safety margin of screw length, and thereby to prevent the iatrogenic injuries on medial neurovascular structures of the calcaneus.
Displaced intra-articular fractures of the calcaneus: ORIF through an extended lateral approach
2019, Injury
Introduction: Displaced intra-articular calcaneal fractures (DIACF) represent a challenging and controversial issue in traumatology. Conservative treatment has been recommended to avoid surgical problems and complications. The final result, however, is often a painful malunioun of the calcaneus with peroneal impingement. Surgical treatment is gaining acceptance since it offers a chance to restore bone anatomy improving function as long as complications are avoided.
Material and method: We reviewed a series of 59 DIACF treated by a single surgeon during a 9 years period. A clinical and radiological follow-up was obtained in 44 cases (74,6%) (average of 5,5 years; range 2–9). There were 29 males and 15 females with an average age of 54 years (range 25–74). Patients were operated through an extended l-shaped lateral approach and fixation was achieved with lag screws and plate. Outcome measures method included the AOFAS score, the Maryland Foot Score, the Foot Function Index and the SF-36.
Results: The average AOFAS score was 80,5 points. The result was excellent in 18 cases (40,9%), good in 14 cases (31,8%), fair in 10 cases (22,7%) and poor in 2 (4,6%). The mean score for pain was 33,5/40 points, for function 40/50 and for alignment 7/10. Pain was absent in 17 cases (38%), 19 patients (43%) had no functional limitations and 11 (25%) could walk on uneven ground without difficulties. The average FFI score was 25/100 points. The average MFS score was 89/100 points. Subtalar motion was reduced. Reconstruction of the calcaneus was anatomic in 20 cases (45,5%) with an improved clinical outcome. Eight patients (17%) had minor wound healing complications. Three patients (6,8%) required a subtalar arthrodesis after the procedure.
Conclusions: Ostheosytesis through an extended lateral approach restored bone morphology with a reasonable complications rate. The clinical results were good but a normal function and complete subtalar motion were rarely achieved.
Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most?
2019, Clinics in Podiatric Medicine and Surgery

View all citing articles on Scopus

: Financial Disclosure: None reported.

: Conflict of Interest: None reported.

View full text

Original ResearchOperative versus Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures in Elderly Patients

Abstract

Section snippets

Patients and Methods

Results

Discussion

Pain

Injury

J Foot Ankle Surg

Fracture of the os calcis

Am J Surg

Fractures of the calcaneus

JAMA

Fractures of the calcaneus. A comparison of open and closed treatment

Acta Orthop Scand

Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures

J Bone Joint Surg Am

Osteosynthesis of displaced intra-articular calcaneal fractures of the calcaneus

Clin Orthop

Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors

J Bone Joint Surg Am

Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management

J Orthop Trauma

Operative treatment of calcaneal fractures in elderly patients

J Bone Joint Surg Am

Operative treatment of 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification

Clin Orthop Relat Res

Extensive extra-articular fractures of the foot

Clin Orthop

Morbidity associated with ORIF of intra-articular calcaneal fractures using a lateral approach

Foot Ankle Int

Clinical rating systems for the ankle-hindfoot, midfoot, hallux and lesser toes

Foot Ankle Int

Functional outcome measures after displaced intra-articular calcaneal fractures

J Bone Joint Surg Br

Personal gait satisfaction after displaced intraarticular calcaneal fractures: a 2–8 year follow-up

Foot Ankle Int

Oral analogue scale as an outcome measure after displaced intra-articular calcaneal fractures

Foot Ankle Int

Complications and long term results of ankle arthrodesis following trauma

J Bone Joint Surg Am

Böhler's angle: correlation with outcome in displaced intra-articular calcaneal fractures

J Orthop Trauma

Original Research
Operative versus Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures in Elderly Patients