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The Journal of Foot & Ankle Surgery 51 (2012) 182–186

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The Journal of Foot & Ankle Surgery

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Subjective Results after Surgical Treatment for Displaced Intra-articularCalcaneal Fractures

Attilio Basile, MDFoot and Ankle Trauma Surgeon, Department of Orthopaedics and Traumatology, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy

a r t i c l e i n f o

Level of Clinical Evidence: 3Keywords:calcaneusheelinjuryfractureoutcomesurgerytrauma

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Attilio Basile, MD, F

Department of Orthopaedics and Traumatology, AzForlanini, Via Nicola Pellati 45, Rome 00149 Italy.

E-mail address: attbasile@tiscali.it

1067-2516/$ - see front matter � 2012 by the Americdoi:10.1053/j.jfas.2011.10.042

a b s t r a c t

We present a retrospective study investigating the results of the subjective assessment of displaced intra-articular calcaneal fractures in a selected cohort of 42 patients treated operatively, with a follow-up dura-tion of at least 3 years. The adjusted American Orthopaedic Foot and Ankle Society questionnaire, FootFunction Index, and visual analog scale were used to quantify the subjective evaluations. Our hypothesis wasthat good subjective results could be predicted and obtained in patients with specific characteristics ifanatomic reduction of the fracture was achieved. The results of the study confirmed our hypothesis. A numberof specific subgroup analyses were undertaken. The study confirmed that B€ohler angle restoration and thequality of reduction of the subtalar joint facet are important prognostic factors related to the outcome. Incontrast, gender and Sanders type had less influence at the intermediate-term follow-up results. The mainweaknesses of the present study included its retrospective nature, the lack of a control group managednonoperatively for comparison, and the small sample size. Moreover, the operating surgeon performed theradiographic measurement and categorized the quality of the surgical reconstruction.

� 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.

The calcaneus is the most commonly fractured bone in the foot, Because subjective issues can influence the outcome, patients and their

representing approximately 75% of fractures affecting the foot and 1%to 2% of all fractures. Roughly three quarters of calcaneal fractures areintra-articular (1).

Historically, most surgeons have favored nonoperative treatmentbecause the surgical outcomes were unpredictable (2,3). A betterunderstanding of the debilitating nature of these injuries, combinedwith improvements in implants and the routine use of intraoperativeimaging, has renewed the interest in operative fixation during thepast decade (4–7). Surgical reduction and fixation is now routinelyrecommended for displaced intra-articular calcaneal fractures, andstudies have demonstrated a decrease in the late consequences andsocioeconomic burden of these injuries (4–8).

Surgery is still strongly discouraged for patients affected byspecific pathologic disease such as vascular disease or diabetes, or ifthey are heavy smokers, immunocompromised, or noncompliant.

Recent evidence has emerged suggesting that the factors influ-encing the outcome are fracture type, individual patient characteris-tics, and the quality of the reduction (4–7,9,10).

These injuries can be associated with prolonged and substantialphysical and psychological distress, especially in active individuals.

oot and Ankle Trauma Surgeon,ienda Ospedaliera San Camillo-

an College of Foot and Ankle Surgeon

doctors candiffer in their perceptionandevaluationof the results. Thus,patient self-assessment of fracture-related health status provides, webelieve, more definite answers regarding the effectiveness of thetreatment (11). We believe that the effort to find methods of rigorousdocumentation of the results from the patients’ perspective has been 1of themajor progressions inorthopedic surgeryduring thepast decade.

We retrospectively analyzed the subjective results of operativetreatment of displaced intra-articular calcaneal fractures (DIACFs) ina selected cohort of patients with a follow-up duration of at least 3years.

Our hypothesis was that the fracture type, specific patient char-acteristics, and anatomic or nearly anatomic reduction of the fracturewould be predictors of subjective positive results if infection and/ormajor wound complications were avoided. To the best of ourknowledge, this is the first study in which such an investigation hasbeen undertaken.

Patients and Methods

We performed a multicenter (2 urban level 1 trauma centers) retrospective reviewof patients affected by DIACFs treated operatively from January 2004 to December 2007(mean follow-up 4.8 � 2.5 years). The fractures were categorized according to theSanders classification (12). The entry criteria for all patients enrolled in the trial were asfollows:

1. Patients aged 18 to 65 years whowere affected by isolated intra-articular fracturesdisplaced more than 2 mm from the anatomic position as demonstrated by axial

s. All rights reserved.

A. Basile / The Journal of Foot & Ankle Surgery 51 (2012) 182–186 183

coronal and sagittal computed tomography scans (excluding Sanders type IVfractures [12] and all open fractures)

2. No previous involvement of the ipsilateral foot and/or ankle by surgery, fracture,osteoarthritis, or inflammatory arthritis

3. No major underlying medical co-morbidities (i.e., uncontrolled hypertension,previousmyocardial infarction, cancer, stroke or transient ischemic attack, chronicobstructive lung disease, cardiac arrhythmia, morbid obesity, diabetes mellitus,peripheral vascular disease, or peripheral neuropathy)

4. Nonsmokers and those who quit smoking at the operation and remainednonsmokers for the next 12 weeks, and who, at the time of the injury, either hada full-time occupation (working at least 38 hours weekly) and/or participated inmoderate to strenuous recreational activities (e.g., walking, jogging, golfing,tennis, bowling, weight lifting, cycling, and other active sports)

5. Patients in which anatomic or nearly anatomic (joint surface step-off <2 mm)reduction of the posterior subtalar joint facet had been obtained

6. Patients who had not developed any septic complication after surgery7. A minimal follow-up of 3 years

All pre- and postoperative clinical data were obtained by reviewing the charts. Forthe purposes of our study, the patients were contacted by telephone, letter, and/orelectronic mail. The responders were given the opportunity to answer the question-naires by conventional mail, electronic mail, or presenting directly to the investigator’soffice. All the patients provided informed consent to participate in the study.

A total of 42 patients were willing to participate. The other 19 patients who fulfilledthe inclusion criteria either did not want to participate in the study or did not respondto our invitation to participate. The mean patient age was 39.85 � 13.70 years; 27 weremale and 15 female. The injury mechanisms were falling or jumping from a height in26 patients and motor vehicle accidents in 16 patients.

An average of 16.2 days (range 5 to 25) after the initial injury, the soft tissueenvelope was determined to be stable, and the patients underwent open reduction andinternal fixation (ORIF) with a nonlocking plate and screws.

An extensile lateral approachwas used; the reduction and fixation techniques werethose popularized by Benirshcke and Sangeorzan (13). The use of bone grafting and/orbone substitutes (autograft or calcium phosphate) was left to the discretion of thesurgeon. Physical therapy began on postoperative day 2 and included: swelling control,active and passive range of motion exercises of the foot and ankle joints, andprogressive partial weight bearing. Gait training began at 10weeks postoperatively, andfull weight bearing was authorized at 12 weeks.

Follow-up radiographic assessment consisted of serial radiographs and computedtomography scans. The specific radiographic views included lateral, 30� Broden andHarris projections, which were taken immediately postoperatively and 6 and 12 weeksand 1 and 2 years postoperatively. The B€ohler angle was measured using a hand-heldgoniometer placed over the lateral plain film and compared with the same anglemeasured in the uninjured foot. This method of angle measurement has previouslybeen shown to provide reliable results (4,9). Computed tomography scans (1-mm cutsin 3 planes) were obtained in the immediate postoperative period and 1 and 2 yearsafter surgery. The evaluation of the reduction was performed at 2 years of follow-upusing the radiographs and computed tomography scans. Posterior facet joint congru-ency was used to categorized the quality of the fracture reduction, in accordance withthe method described by Janzen et al (14). The quality of reduction was classified asanatomic (no joint surface step-off) or nearly anatomic (joint surface step-off <2 mm).

Table 1Results for patients with Sanders II fractures (n ¼ 19 patients)

Patient No. Gender Age (yr) Sanders Fracture Type Postoperative B€o

1 Female 43 II 23� (23�)2 Female 25 II 45� (45�)3 Female 36 II 40� (40�)4 Female 53 II 30� (22�)5 Female 48 II 30� (30�)6 Female 32 II 45� (45�)7 Female 21 II 25� (20�)8 Female 63 II 35� (35�)9 Male 19 II 40� (40�)

10 Male 59 II 25� (25�)11 Male 38 II 38� (33�)12 Male 32 II 44� (44�)13 Male 27 II 27� (21�)14 Male 44 II 39� (39�)15 Male 49 II 36� (36�)16 Male 30 II 47� (42�)17 Male 51 II 36� (30�)18 Male 42 II 28� (28�)19 Male 19 II 33� (33�)

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; FFI, Foot Function In* B€ohler angle for uninjured foot, with that for injured foot in parentheses.

Hindfoot alignment was categorized as varus, valgus, or neutral according to theorientation of the long axis of the calcaneus relative to the long axis of the leg.

The patients were evaluated using region-specific functional questionnaires toassess the severity of disability. The adjusted American Orthopaedic Foot and AnkleSociety (AOFAS) ankle–hindfoot score (15), Foot Function Index (FFI) (16), and 10-cmvisual analog scale (VAS) (17) were used to quantify the subjective evaluations.

The AOFAS ankle-hindfoot score has 2 sections: a subjective division completed bythe patient and an objective division completed by the surgeon. For our study, only thesubjective component was used. The score was calculated according to the methodpreviously reportedddividing the patient’s score by the maximum score that could beobtained on the subjective component and multiplying by 100 (adjusted AOFAS ankle-hindfoot score) (18).

The FFI was developed to measure the effect of foot pathology on function in termsof pain, disability, and activity restriction. The FFI is a self-administered index consistingof 23 items divided into 3 subscales. The possible score range for the FFI is 0 to 100, withlower scores denoting better outcomes.

Operationally, the VAS is a horizontal line, 100 mm long, anchored by descriptors ateach end (0 mm, no pain to 100 mm, very severe pain). The score was determined bymeasuring from the left end (no pain) of the line to the point marked by the patient.

Both the subjective portion of the AOFAS scale and the FFI were recently validatedby Ibrahim et al (18). The VAS scoring system has been validated in several trials todetermine the functional results in patients with DIACFs (17,19,20).

We also enquired whether patients had undergone any additional foot and anklesurgery because of complications after ORIF of the calcaneus (including soft tissueprocedures, hardware removal, hindfoot fusions, and/or other procedures for align-ment, nonunion, ormalunion correction), or if they required a custom-made orthosis orshoe modification for painless ambulation.

The Student t test was used to compare the results between the patient groups,with statistical significance defined at the 5% level (p � .05).

Results

Using our inclusion criteria, 42 patients were available for theanalyses used in the present retrospective cohort study; 19 patientshad sustained Sanders II fractures and 23 Sanders III fractures. Of the42 patients, 7 (16.6%) had a negative (<0) preoperative B€ohler angle,31 (73.8%) a B€ohler angle of 0� to 5�, and 4 (9.5%) a B€ohler angle >5�.

The results for the treatment groups are summarized in Tables 1and 2. The mean age of the 19 patients in the Sanders II group was38.47 � 13.32 years and was 41 � 14.20 years for the 23 patients inthe Sanders III group. The difference was not statistically significant(p ¼ .55). In the Sanders II group, 11 (57.9%) were male and 8 (42.1%)were female, and in the Sanders III group, 16 (69.6%) were male and7 (30.4%) were female. This difference was also not statisticallysignificant. The surgeon could not achieve anatomic reduction in6 patients in the Sanders II cohort and in 5 patients in the Sanders III

hler Angle* Reduction Quality FFI Score AOFAS Score VAS Score

Anatomic 15 80 25Anatomic 22 90 10Anatomic 12 90 10Nearly anatomic 30 70 32Anatomic 0 95 0Anatomic 10 90 12Nearly anatomic 43 69 35Anatomic 12 86 25Anatomic 25 70 45Anatomic 0 100 0Nearly anatomic 37 67 38Anatomic 12 90 20Nearly anatomic 32 69 45Anatomic 15 86 20Anatomic 10 90 15Nearly anatomic 39 70 40Nearly anatomic 38 65 40Anatomic 10 93 11Anatomic 35 72 45

dex; VAS, visual analog scale.

Table 2Results for patients with Sanders III fractures (n ¼ 23 patients)

Patient No. Gender Age (yr) Sanders Fracture Type Postoperative B€ohler Angle* Reduction Quality FFI Score AOFAS Score VAS Score

1 Female 22 III 25� (25�) Anatomic 37 70 372 Female 48 III 38� (38�) Anatomic 15 80 183 Female 53 III 40� (40�) Anatomic 0 100 04 Female 27 III 36� (30�) Nearly anatomic 37 67 375 Female 32 III 28� (28�) Anatomic 18 89 106 Female 59 III 33� (33�) Anatomic 10 92 107 Female 18 III 45� (45�) Anatomic 32 75 398 Male 62 III 28� (28�) Anatomic 8 95 59 Male 39 III 41� (36�) Nearly anatomic 32 67 38

10 Male 56 III 25� (25�) Anatomic 10 87 1511 Male 49 III 39� (39�) Anatomic 11 85 2012 Male 30 III 43� (43�) Anatomic 10 90 713 Male 41 III 26� (26�) Anatomic 8 90 1214 Male 49 III 47� (47�) Anatomic 16 85 1015 Male 27 III 38� (30�) Nearly anatomic 39 65 4016 Male 33 III 27� (27�) Anatomic 24 88 1917 Male 46 III 35� (30�) Nearly anatomic 38 62 3518 Male 65 III 39� (30�) Nearly anatomic 36 68 3519 Male 60 III 30� (30�) Anatomic 15 80 2020 Male 39 III 35� (35�) Anatomic 9 91 1821 Male 19 III 42� (42�) Anatomic 37 70 4022 Male 30 III 38� (38�) Anatomic 29 70 4023 Male 39 III 29� (29�) Anatomic 10 87 7

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; FFI, Foot Function Index; VAS, visual analog scale.* B€ohler angle for uninjured foot, with that for injured foot in parentheses.

Table 4

A. Basile / The Journal of Foot & Ankle Surgery 51 (2012) 182–186184

group (minor posterior facet step defect and depressed B€ohler’s anglecompared with the uninjured foot).

The adjusted AOFAS ankle-hindfoot score (15), FFI score (16), and10-cm VAS (17) were used to quantify the subjective evaluations;their mean values are summarized in Table 3. No statistically signifi-cant differences were observed for any of the outcome scores (FFI,AOFAS, VAS) between the Sanders II and III fracture types (Table 3),indicating similar function and patient satisfaction between the2 groups. Although the Sanders classification was found to beprognostic of long-term outcomes, with type II fractures havingthe best results, our mid-term follow-up study (mean follow-up4.8�2.5 years) did not confirm this.

A number of specific subgroup analyses were undertaken. Nostatistically significant difference was found in any of the outcomescales in either treatment group (Table 4) analyzed by gender. Addi-tional results showed that the mean preoperative B€ohler angle andthe mechanism of injury (fall/jump from a height or motor vehicleaccident) were not significantly different statistically between thegenders in both groups (Sanders II and III).

Our findings highlight the importance of an anatomic reduction ofthe subtalar joint facet and the restoration of the original B€ohlerangle. Statistically significant improvements were observed in theAOFAS, FFI, and VAS scores when those patients with radiographicevidence of an anatomic reduction of the subtalar joint werecompared with those with a nearly anatomic reduction (Tables 5and 6). The outcomes for patients who had merely a small residualstep defect (nearly anatomic reduction) were significantly worse thanthose for the patients with anatomic restoration of the posterior facet.Analysis of the data also revealed that anatomic restoration of the

Table 3Comparison of adjusted AOFAS, FFI, and VAS scores between fracture groups

Fracture Group Patients (n) Mean AOFAS Score Mean VAS Score Mean FFI Score

II 19 81.15 � 11.40 24.63 � 15.23 20.89 � 13.59III 23 80.56 � 11.14 22.26 � 13.74 20.91 � 12.67

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; FFI, Foot Func-tion Index; VAS, visual analog scale.Differences were not statistically significant (p < .05).

B€ohler angle resulted in improved scores compared with those inwhich the angle remained depressed.

We found worse subjective scores in younger patients (age 18 to35 years) than in the other age groups (age 36 to 50 and 51 to65 years). These younger patients complained of a limitation in theirrecreational activities in the sense that they could not reach theirpreinjury performance. The numbers available in the present study,however, were too small to perform any statistical analysis. No otherdifferences were found, comparing the results of the other age groups(age 36 to 50 and 51 to 65 years).

One patient developed a partial wound breakdownwith bone andhardware exposition that was successfully treated with a local fas-ciocutaneous flap. No other patient had undergone any additional footand ankle surgeries because of complications after ORIF of thecalcaneus such as hardware removal, hindfoot fusions, and/or otherprocedures for alignment, nonunion, or malunion correction. None ofthe patients required a custom-made orthosis or shoe modificationfor painless ambulation.

Discussion

The results of the present retrospective study confirmed ourhypothesis that good subjective results can be predicted and obtainedwith operative treatment of Sanders type II and III DIACFs in a care-fully selected patient population, if anatomic reduction of the fractureis achieved and septic complications are avoided.

Comparison of adjusted AOFAS, VAS, and FFI scores between genders

Group Patients (n) Mean AOFAS Score Mean VAS Score Mean FFI Score

Sanders IIFemale 8 83.75 � 9.77 18.62 � 12.35 18 � 13.38Male 11 79.27 � 12.56 29 � 16.16 23 � 13.99

Sanders IIIFemale 7 81.85 � 12.21 21.57 � 15.94 21.28 � 14.37Male 16 80 � 11.01 22.56 � 13.23 20.75 � 12.36

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; FFI, Foot Func-tion Index; VAS, visual analog scale.Differences were not statistically significant (p < .05).

Table 5Comparison of AOFAS, VAS, and FFI scores between Sanders II subgroups

Group Patients (n) Mean AOFAS Score Mean VAS Score Mean FFI Score

Anatomic reduction 13 87.07 � 8.55 18.30 � 14.23 13.69 � 9.48Nearly anatomic

reduction6 68.33 � 1.96 38.33 � 4.50 36.5 � 4.76

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; FFI, Foot Func-tion Index; VAS, visual analog scale.Differences were not statistically significant (p < .05).

A. Basile / The Journal of Foot & Ankle Surgery 51 (2012) 182–186 185

The adjusted AOFAS ankle-hindfoot (subjective section), FFI, andVAS were chosen as the outcome measures because they had beenvalidated in several trials to determine reliable subjective functionalresults in patients with DIACFs (1,15–17,21–23); they generate stan-dardized scores that can be compared effectively across studies; andboth the AOFAS hindfoot score and FFI score are more responsive tocalcaneal injuries than general measures such as the MedicalOutcomes Study 36-item short-form health survey (1,16).

We focused on patient self-assessment of fracture-related healthto provide a response regarding the outcome of the operative treat-ment from the patient’s perspective. There is a trend amongresearchers to promote a patient-orientated approach in clinicaloutcome investigations. A review of the orthopedic literature from1991 to 2001 displayed an increased use of patient-based measures inclinical outcome studies (24,25).

It is somewhat common in clinical practice for objective findings tonot correlate with the subjective findings. It is apparent that onlypatients can judge the extent to which they have healed. This isaccurate especially in lower extremity injuries (26). Subjects withhigh-energy, lower extremity fractures have a disease process thatoften requires prolonged treatment and could have significantmorbidity that endures for years (26). Studies that investigated thedifferences between patient and surgeon evaluation of outcomes aftera “major” fracture indicated that the most important parametersinfluencing surgeon satisfactionwere the “objective” parameters suchas fracture healing and alignment, but patient satisfactionwas mainlydriven by “subjective” variables such as pain, walking speed, andcosmesis (26). That the patient and surgeon perspectives regardingoutcomes differ has been explored in multiple clinical settings, andthis research has reinforced the potential importance of efforts tobetter understand the determinants of patient satisfaction (24–28).

Evidence in published studies has demonstrated that in thetreatment of calcaneal fractures, it is not just the fracture type but alsothe patient characteristics and quality of the reduction that influencethe outcome (4,5,9,10). We concur and strongly re-enforce this notionthat underlines the importance of a careful selection of candidates forsurgical repair according to the fracture type and individual patientcharacteristics.

The other factors of success include anatomic reconstruction andstable fixation of the fracture (4,9,10,29–31). Published data supportthe concept that restoration of the B€ohler angle and the quality of thesubtalar joint reduction predict the outcome in the treatment ofDIACFs. From our results, we have confirmed this statement. In ourcohort, patients with restoration of the B€ohler angle to its original

Table 6Comparison of AOFAS, VAS, and FFI scores between Sanders III subgroups

Group Patients (n) Mean AOFAS Score Mean VAS Score Mean FFI Score

Anatomic reduction 18 84.66 � 8.79 18.16 � 12.71 16.61 � 10.77Nearly anatomic

reduction5 65.8 � 2.38 37.0 � 2.12 36.4 � 2.70

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; FFI, Foot Func-tion Index; VAS, visual analog scale.Differences were not statistically significant (p < .05).

value and with anatomic reconstruction of the subtalar joint surfaceexperienced better outcome scores (AOFAS, FFI, and VAS) than thosein whom these surgical parameters were not restored to theiranatomic alignment, and this difference was statistically significant.

The 3-year follow-up period was chosen because, regardless ofwhether a fracture heals, patients can experience pain anda decreased quality of life for up to 3 years after the injury (26–28).

Controversy concerning which is the better care for DIACFspersists today, with some investigators advocating ORIF and othersrecommending closed treatment. Many retrospective and a few smallprospective studies have reported better results from operativetreatment than from conservative management of DIACFs (32–34).The meta-analysis of Randle et al (34) reported an insignificant trendfor a better outcome from surgical treatment of calcaneal fractures,but the investigators underlined the weakness of the evidence fordeciding on the optimal management for this fracture type. Otherrandomized controlled trials comparing operative and nonoperativetreatment were unable to identify statistically significant differencesin functional results between the 2 groups, noting that patientstreated surgically were more likely to develop severe complications(5,35).

Theweakness of those older studies was the lack of stratification ofcases on the basis of patient characteristics. After careful stratificationof the patient population in a large prospective randomizedcontrolled multicenter trial, Buckley et al (4) found that adult females,patients who were not receiving Workers’ Compensation, youngermales, patients with a greater B€ohler angle, those with a lighterworkload, and those with a single, simple, displaced intra-articularfracture had better results after operative treatment than afternonoperative treatment.

They also stated that anatomic reductions enhance the positiveoutcome and communition and/or a poor reduction produced long-term outcomes that were less satisfactory. Also, the arthrodesisrates were significantly reduced with operative treatment. Patientswho benefit from nonoperative treatment included those receivingWorkers’ Compensation, patients with highly comminuted articularfractures (Sanders IV), and those aged 50 years or older.

Recent investigations by Herscovici et al (10), Basile (9), and Gaskillet al (36) have challenged this last statement; sustaining that openreduction and internal fixation appears to be an acceptable method oftreatment for DIACFs even in elderly patients. However, all thesestudies highlighted the importance of the careful selection of surgicalcandidates according to specific patient characteristics and fracturetype (9,10,36).

In critically analyzing our data, some considerations should bemade. First, our low rate of complications (compared with olderstudies) was similar to that reported in recent studies (4,13,37) andreflect better patient selection, a greater understanding of theprocedure, and improvements in the surgical technique.

Previous reports (4,5,32) revealed better outcomes in females thanin males, regardless of the treatment type. In these particular studies,the differences were reported to result because in the female patients,the degree of traumawas less severe and caused by lower energy. Ourresults did not confirm this trend because we included a selectedpopulation that was affected by a homogenous fracture pattern(Sanders II and III), with similar injury mechanisms.

The Sanders classification was determined to be prognostic oflong-term outcomes, with type II fractures having the best results(12). We did not detect any difference. Again, this can be explainedby our patient cohort selection and the relatively short follow-up(<5 years).

Published data have also indicated that the initial B€ohler angle isprognostic of the long-term outcomes (38). Our results only partiallyconfirmed this finding. The difficulty was that the operating surgeon

A. Basile / The Journal of Foot & Ankle Surgery 51 (2012) 182–186186

could not achieve an anatomic reduction in 5 of the 7 fractures witha negative preoperative B€ohler angle. This point is valid in thatsimpler fractures (Sanders II and III) with less initial displacement(greater B€ohler angle) have better mid-term outcomes.

Younger patients (age 18 to 30 years) experienced worse resultsthan older patients (age 31 to 65 years) in our study. However, thenumbers available were too small for any statistical analysis. Thisoutcome can be explained by the greater functional requirements ofthe younger cohort of patients, because a number of them stated thatthey experienced limitations in their recreational activities. Otherstudies of long-term subjective outcomes after operative treatmentfor DIACFs have confirmed this finding (1).

The main weaknesses of the present study were its retrospectivenature, the lack of a control group managed nonoperatively forcomparison, and the small sample size. The reason for the small sizecould be explained by the strict criteria for patient selection. Othershortcomings included the lack of an explanatory analysis involvingunivariate and multivariate methods and the lack of a sensitivityanalysis that could have determined the resistance of our results tothe potential influence of unmeasured confounding variables. More-over, the operating surgeon performed the radiographic measure-ments and categorized the quality of the surgical reconstruction. Also,an inherent limitation exists in measuring patient satisfaction withsubjective outcomes tools. Although the scales we used have beenvalidated, additional research is needed to determine how otheraspects of patient satisfaction (e.g., financial, interpersonal, andconvenience of care) relate to our questions in this population (26,39).

Despite the limitations, the strengths of the present study includedthe relatively large number of patients with the same characteristicsand fractures type, the length of follow-up, and the development ofa protocol for the appropriate measurement of multiple subjectiveoutcome parameters with the use of validated injury-specific scales.Although we could not draw definitive conclusions because of themethodologic shortcomings, our results indicate that patient satis-faction after isolated closed Sanders II and III DIACFs is associatedwithspecific patient characteristics, anatomic fracture reduction, and theavoidance of major wound and/or septic complications. The infor-mation obtained offers a contribution regarding the mid-termsubjective outcomes that can be expected after operative treatmentof DIACFs in a carefully selected patient population treated bysurgeons experienced with this sort of injury.

References

1. Potter MQ, Nunley JA. Long term functional outcome after operative treatment ofintra-articular fractures of the calcaneus. J Bone Joint Surg Am 91-A:1854–1860,2009.

2. Vestad E. Fractures of the calcaneum: open reduction and bone grafting. Acta ChirScand 134:617–625, 1968.

3. Linsday WR, Dewar FP. Fractures of the os calcis. Am J Surg 95:555–576, 1958.4. Buckley RE, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galfin R. Operative

compared with nonoperative treatment of displaced intra-articular calcanealfractures: a prospective, randomized controlled multicenter trial. J Bone Joint SurgAm 84:1733–1744, 2002.

5. Barla J, Buckley R, McCormac R, Pate G, Leighton R, Petrie D, Galpin R; CanadianOrthopaedic Trauma Society. Displaced intra articular calcaneal fractures: longterm outcomes in women. Foot Ankle Int 25:853–856, 2004.

6. Clare MP, Lee WE, Sanders RW. Intermediate to long term results of a treatmentprotocol for calcaneal fracture malunions. J Bone Joint Surg Am 87:963–973, 2005.

7. Randay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intra-articularcalcaneal fractures: does initial operative treatment matter? J Bone Joint SurgAm 91:541–546, 2009.

8. Brauer CA, Manns BC, Ko M, Donaldson C, Bucley R. An economic evaluation ofoperative compared to nonoperative management of displaced intra-articularcalcaneal fractures. J Bone Joint Surg Am 87:2741–2749, 2005.

9. Basile A. Operative versus nonoperative treatment of displaced intra articularcalcaneal fractures in elderly patients. J Foot Ankle Surg 49:25–32, 2010.

10. Herscovici D, Widmaier J, Scaduto J. Operative treatment of calcaneal fractures inelderly patients. J Bone Joint Surg Am 87:1260–1263, 2005.

11. Kooistra BW, Sprague S, Bhandari M, Schemitsch EH. Outcomes assessmentin fracture healing trials: a primer. J Orthop Trauma 24(3 Suppl):S71–S75,2010.

12. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment of 120 displacedintra articular calcaneal fractures: results using a prognostic computer tomog-raphy scan classification. Clin Orthop Rel Res 290:87–95, 1993.

13. Benirshcke SK, Sangeorzan BJ. Extensive intra articular fractures of the foot:surgical management of calcaneal fractures. Clin Orthop Rel Res 292:128–134,1993.

14. Janzen D, Connel DG, Munk PL. Intra-articular fractures of the calcaneus: valueof the CT scan findings in determining prognosis. AJR Am J Roentgenol158:1271–1274, 1992.

15. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinicalrating system for the ankle hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int15:128–134, 1994.

16. SooHoo NF, Samimi D, Vyas RM. Evaluation of the validity of the Foot FunctionIndex in measuring outcomes in patients with foot and ankle disorders. Foot AnkleInt 27:38–42, 2006.

17. Hildebrand KA, Buckley RE, Mohtadi NG, Faris P. Functional outcome measuresafter displaced intra articular calcaneal fractures. J Bone Joint Surg Br78-B:119–123, 1996.

18. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validityof the subjective component of the American Orthopaedic Foot and Ankle Societyclinical rating scales. J Foot Ankle Surg 46:665–674, 2007.

19. O’Brien J, Buckley RE, McCormack R, Pate G, Leighton R, Petrie D, Galpin R.Personal gait satisfaction after displaced intra-articular calcaneal fractures: a 2–8years’ follow-up. Foot Ankle Int 25:657–665, 2004.

20. Morin P, Buckley RE, Stewart R, Vande Gutche R. Oral analogue scale as anoutcome measure after displaced intra-articular calcaneal fractures. Foot Ankle Int19:694–697, 1998.

21. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I.Conceptual framework and item selection. Med Care 30:473–483, 1992.

22. Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of footpain and disability. J Clin Epidemiol 44:561–570, 1991.

23. Agel J, Beskin JL, Brage M, Guyton GP, Kadel NJ, Saltzman CL, Sands AK,Sangeorzan B, SooHoo NF, Stroud CC, Thordarson DB. Reliability of the FootFunction Index: a report of the AOFAS Outcomes Committee. Foot Ankle Int26:962–967, 2005.

24. Beaton DE, Schemitsch E. Measures of health related quality of life and physicalfunction. Clin Orthop Rel Res 413:90–105, 2003.

25. Agel J, Swiontkowsky MF. Guide to outcomes instruments for musculoskeletaltrauma research. J Orthop Trauma 20:S65–S146, 2006.

26. O’Tool RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ; LEAP Study Group.Surgeons and their patients disagree regarding cosmetic and overalloutcomes after surgery for high-energy lower extremity trauma. J Orthop Trauma23:716–723, 2009.

27. Butcher JL, MacKenzie E, Cushing B. Long term outcome after lower extremitytrauma. J Trauma 41:4–9, 1996.

28. Dogra AS, Ruiz A, Marsh DR. Late outcome of isolated tibial fractures treated byintramedullary nailing: the correlation between disease specific and genericoutcome measures. J Orthop Trauma 16:245–249, 2002.

29. Buckley RE, Meek RN. Comparison of open versus closed reduction of intra-articular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma6:216–222, 1992.

30. Paul M, Peter R, Hoffmeyer P. Fractures of the calcaneum: a review of 70 patients.J Bone Joint Surg Br 86-B:1142–1145, 2004.

31. Catani F, Benedetti MG, Simoncini L, Leardini A, Giannini S. Analysis of func-tion after intra-articular fractures of the os calcis. Foot Ankle Int 20:417–421,1999.

32. Parmar HV, Triffit PD, Gregg PJ. Intra-articular fractures of the calcaneum treatedoperatively or conservatively: a prospective study. J Bone Joint Surg Br75-B:932–937, 1993.

33. Thordarson DB, Krieger LE. Operative versus non operative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot AnkleInt 17:2–9, 1996.

34. Randle JA, Kreder HJ, Stephen D, Williams J, Jagal S, Hu R. Should calcaneal frac-tures be treated surgically? A meta analysis. Clin Orthop Rel Res 377:217–227,2000.

35. Howard JL, Buckley R, McCormack R. Complications following management ofdisplaced intra articular calcaneal fractures: a prospective randomized trialcomparing open reduction internal fixation with nonoperative management.J Orthop Trauma 17:241–249, 2003.

36. Gaskill T, Schweitzer K, Nunley J. Comparison of surgical outcomes ofintra-articular calcaneal fractures by age. J Bone Joint Surg Am 92:2884–2889,2010.

37. Zwipp H, Tscherne H, Thermann H, Weber T. Osteosynthesis of displaced intra-articular calcaneal fractures. Clin Orthop Rel Res 290:76–86, 1993.

38. Loucks C, Buckley R. B€ohler angle correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma 13:554–558, 1999.

39. O’Tool RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ; LEAP Study Group.Determinants of patient satisfaction after severe lower extremities injuries. J BoneJoint Surg Am 90-A:1206–1211, 2008.