Clinical Orthopaedics and Related Research®

, Volume 471, Issue 9, pp 2885–2898

Severity of Injury Predicts Subsequent Function in Surgically Treated Displaced Intraarticular Calcaneal Fractures

  • Stefan Rammelt
  • Hans Zwipp
  • Wolfgang Schneiders
  • Constanze Dürr
Symposium: Tscherne Festschrift

Abstract

Background

The treatment of displaced, intraarticular calcaneal fractures (DIACFs) remains challenging and the best treatment choices remain controversial. The majority of patients will have some lasting functional restrictions. However, it is unclear which patient- or surgeon-related factors predict long-term function.

Questions/purposes

We determined (1) the impact of patient- and surgeon-related factors on function of patients after internal fixation of DIACFs and (2) whether severity of injury correlated with subsequent function.

Methods

We retrospectively reviewed all 210 patients operatively treated for 242 DIACFs between 2000 and 2003; of these, 127 patients (60%) with 149 fractures were available for followup at a minimum of 69 months (average, 95 months; range, 69–122 months). Severity of injury was quantified by the classifications of Sanders and Zwipp Function was quantified using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, an adjusted Zwipp score, the Foot Function Index (FFI), and the SF-36 physical and mental component summary (PCS and MCS) scores.

Results

At latest followup, the median AOFAS score was 77, the median Zwipp score was 60, the median FFI was 27, and the median SF-36 PCS and MCS scores were 44 and 55, respectively. The foot-related scores and the SF-36 PCS negatively correlated with the severity of injury, work-related injuries, and bilateral fractures.

Conclusions

We found the severity of a DIACF related to subsequent foot function and quality of life. Both fracture severity classifications predicted function. Anatomic reconstruction of the shape and articular surfaces of the calcaneus leads to predictable function in the medium to long term.

Level of Evidence

Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

References

  1. 1.
    Abidi NA, Dhawan S, Gruen GS, Vogt MT, Conti SF. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int. 1998;19:856–861.PubMedCrossRefGoogle Scholar
  2. 2.
    Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot: surgical management of calcaneal fractures. Clin Orthop Relat Res. 1993;292:128–134.PubMedGoogle Scholar
  3. 3.
    Bèzes H, Massart P, Delvaux D, Fourquet JP, Tazi F. The operative treatment of intraarticular calcaneal fractures: indications, technique, and results in 257 cases. Clin Orthop Relat Res. 1993;290:55–59.PubMedGoogle Scholar
  4. 4.
    Bèzes H, Morilleau P. Ostéosynthèse des fractures du calcanéum avec enforcement thalamique par plaque viseé de “1/3 tube” (d’apres 75 observations). 4émes Journeés Militaires de Chirurgie Orthopedique. 1979:75ff.Google Scholar
  5. 5.
    Boack DH, Wichelhaus A, Mittlmeier T, Hoffmann R, Haas NP. [Therapy of dislocated calcaneus joint fracture with the AO calcaneus plate] [in German]. Chirurg. 1998;69:1214–1223.PubMedCrossRefGoogle Scholar
  6. 6.
    Borrelli JJ, Torzilli PA, Grigiene R, Helfet DL. Effect of impact load on articular cartilage: development of an intra-articular fracture model. J Orthop Trauma. 1997;11:319–326.PubMedCrossRefGoogle Scholar
  7. 7.
    Brattebø J, Molster AO, Wirsching J. Fractures of the calcaneus: a retrospective study of 115 fractures. Orthop Int. 1995;3:117–126.Google Scholar
  8. 8.
    Brenner P, Rammelt S, Gavlik JM, Zwipp H. Early soft tissue coverage after complex foot trauma. World J Surg. 2001;25:603–609.PubMedCrossRefGoogle Scholar
  9. 9.
    Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84:1733–1744.PubMedGoogle Scholar
  10. 10.
    Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol. 1991;44:561–570.PubMedCrossRefGoogle Scholar
  11. 11.
    Bullinger M. German translation and psychometric testing of the SF-36 Health Survey: preliminary results from the IQOLA Project. International Quality of Life Assessment. Soc Sci Med. 1995;41:1359–1366.PubMedCrossRefGoogle Scholar
  12. 12.
    Carr J, Hansen S, Benirschke S. Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle. 1988;9:81–86.PubMedCrossRefGoogle Scholar
  13. 13.
    Court-Brown CM, Schmied M, Schutte BG. Factors affecting infection after calcaneal fracture fixation. Injury. 2009;40:1313–1315.PubMedCrossRefGoogle Scholar
  14. 14.
    Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, Pate G, Petrie D, Galpin R. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003;17:106–112.PubMedCrossRefGoogle Scholar
  15. 15.
    Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma. 1999;13:369–372.PubMedCrossRefGoogle Scholar
  16. 16.
    Gaskill T, Schweitzer K, Nunley J. Comparison of surgical outcomes of intra-articular calcaneal fractures by age. J Bone Joint Surg Am. 2010;92:2884–2889.PubMedCrossRefGoogle Scholar
  17. 17.
    Geel CW, Flemister AS. Standardized treatment of intra-articular calcaneal fractures using an oblique lateral incision and no bone graft. J Trauma. 2001;50:1083–1089.PubMedCrossRefGoogle Scholar
  18. 18.
    Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–458.PubMedGoogle Scholar
  19. 19.
    Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: a meta-analysis. JAMA. 2005;293:1644–1652.PubMedCrossRefGoogle Scholar
  20. 20.
    Harvey EJ, Grujic L, Early JS, Benirschke SK, Sangeorzan BJ. Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int. 2001;22:868–873.PubMedGoogle Scholar
  21. 21.
    Heier KA, Infante AF, Walling AK, Sanders RW. Open fractures of the calcaneus: soft-tissue injury determines outcome. J Bone Joint Surg Am. 2003;85:2276–2282.PubMedGoogle Scholar
  22. 22.
    Herscovici DJ, Widmaier J, Scaduto JM, Sanders RW, Walling A. Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am. 2005;87:1260–1264.PubMedCrossRefGoogle Scholar
  23. 23.
    Hirschmüller A, Konstantinidis L, Baur H, Müller S, Mehlhorn A, Kontermann J, Grosse U, Südkamp NP, Helwig P. Do changes in dynamic plantar pressure distribution, strength capacity and postural control after intra-articular calcaneal fracture correlate with clinical and radiological outcome? Injury. 2011;42:1135–1143.PubMedCrossRefGoogle Scholar
  24. 24.
    James ET, Hunter GA. The dilemma of painful old os calcis fractures. Clin Orthop Relat Res. 1983;177:112–115.PubMedGoogle Scholar
  25. 25.
    Janzen DL, Connell DG, Munk PL, Buckley RE, Meek RN, Schechter MT. Intraarticular fractures of the calcaneus: value of CT findings in determining prognosis. AJR Am J Roentgenol. 1992;158:1271–1274.PubMedCrossRefGoogle Scholar
  26. 26.
    Jardé O, Havet E, Alovor G, Carpentier P, Meunier W. Intra-articular calcaneal fractures: clinical and radiological results of 54 cases with a minimum follow-up of 7 years. Med Chir Pied. 2005;21:107–117.CrossRefGoogle Scholar
  27. 27.
    Jiang N, Lin QR, Diao XC, Wu L, Yu B. Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. Int Orthop. 2012;36:1615–1622.PubMedCrossRefGoogle Scholar
  28. 28.
    Kitaoka H, Alexander I, Adelaar R, Nunley J, Myerson M, Sanders M. Clinical rating systems for the ankle, hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int. 1994;15:349–353.PubMedCrossRefGoogle Scholar
  29. 29.
    Kurozumi T, Jinno Y, Sato T, Inoue H, Aitani T, Okuda K. Open reduction for intra-articular calcaneal fractures: evaluation using computed tomography. Foot Ankle Int. 2003;24:942–948.PubMedGoogle Scholar
  30. 30.
    Lanzetta A, Meani E. Operative indications in fractures of the calcaneus: problems of reduction and fixation. Ital J Orthop Traumatol. 1978;4:31–35.PubMedGoogle Scholar
  31. 31.
    Lau JT, Mahomed NM, Schon LC. Results of an Internet survey determining the most frequently used ankle scores by AOFAS members. Foot Ankle Int. 2005;26:479–482.PubMedGoogle Scholar
  32. 32.
    Lenormant C, Wilmoth P, Lecoeur P. A propos du traitement sanglant des fractures du calcanéum. Bull Mem Soc Nat Chir. 1928;54:1353–1355.Google Scholar
  33. 33.
    Leriche MR. Ostéosynthèse primitive pour fracture par écrasement du calcanéum à sept fragments. Soc Chir de Lyon. 1922;Seànce du 2 de fevrier:559–560.Google Scholar
  34. 34.
    Letournel E. Open reduction and internal fixation of calcaneal fractures. In: Spiegel P, ed. Topics in Orthopaedic Surgery. Baltimore, MD: Aspen; 1984:173.Google Scholar
  35. 35.
    Letournel E. Open treatment of acute calcaneal fractures. Clin Orthop Relat Res. 1993;290:60–67.PubMedGoogle Scholar
  36. 36.
    Leung KS, Yuen KM, Chan WS. Operative treatment of displaced intra-articular fractures of the calcaneum: medium-term results. J Bone Joint Surg Br. 1993;75:196–201.PubMedGoogle Scholar
  37. 37.
    Makki D, Alnajjar HM, Walkay S, Ramkumar U, Watson AJ, Allen PW. Osteosynthesis of displaced intra-articular fractures of the calcaneum: a long-term review of 47 cases. J Bone Joint Surg Br. 2010;92:693–700.PubMedGoogle Scholar
  38. 38.
    Melcher G, Degonda F, Leutenegger A, Ruedi T. Ten-year follow-up after operative treatment for intra-articular fractures of the calcaneus. J Trauma. 1995;38:713–716.PubMedCrossRefGoogle Scholar
  39. 39.
    Mittlmeier T, Morlock MM, Hertlein H, Fassler M, Mutschler W, Bauer G, Lob G. Analysis of morphology and gait function after intraarticular calcaneal fracture. J Orthop Trauma. 1993;7:303–310.PubMedCrossRefGoogle Scholar
  40. 40.
    Mulcahy DM, McCormack DM, Stephens MM. Intra-articular calcaneal fractures: effect of open reduction and internal fixation on the contact characteristics of the subtalar joint. Foot Ankle Int. 1998;19:842–848.PubMedCrossRefGoogle Scholar
  41. 41.
    Naal FD, Impellizzeri FM, Huber M, Rippstein PF. Cross-cultural adaptation and validation of the Foot Function Index for use in German-speaking patients with foot complaints. Foot Ankle Int. 2008;29:1222–1228.PubMedCrossRefGoogle Scholar
  42. 42.
    Naovaratanophas P, Thepchatri A. The long term results of internal fixation of displaced intra-articular calcaneal fractures. J Med Assoc Thai. 2001;84:36–44.PubMedGoogle Scholar
  43. 43.
    Paley D, Hall H. Intra-articular fractures of the calcaneus: a critical analysis of results and prognostic factors. J Bone Joint Surg Am. 1993;75:342–354.PubMedGoogle Scholar
  44. 44.
    Palmer I. The mechanism and treatment of fractures of the calcaneus. J Bone Joint Surg Am. 1948;30:2–8.Google Scholar
  45. 45.
    Park IH, Song KW, Shin SI, Lee JY, Kim TG, Park RS. Displaced intra-articular calcaneal fracture treated surgically with limited posterior incision. Foot Ankle Int. 2000;21:195–205.PubMedGoogle Scholar
  46. 46.
    Pinsker E, Daniels TR. AOFAS position statement regarding the future of the AOFAS Clinical Rating Systems. Foot Ankle Int. 2011;32:841–842.PubMedCrossRefGoogle Scholar
  47. 47.
    Potter MQ, Nunley JA. Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2009;91:1854–1860.PubMedCrossRefGoogle Scholar
  48. 48.
    Radnay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? J Bone Joint Surg Am. 2009;91:541–546.PubMedCrossRefGoogle Scholar
  49. 49.
    Rammelt S, Amlang M, Barthel S, Gavlik JM, Zwipp H. Percutaneous treatment of less severe intraarticular calcaneal fractures. Clin Orthop Relat Res. 2010;468:983–990.PubMedCrossRefGoogle Scholar
  50. 50.
    Rammelt S, Barthel S, Biewener A, Gavlik JM, Zwipp H. [Calcaneus fractures: open reduction and internal fixation] [in German]. Zbl Chir. 2003;128:517–528.PubMedGoogle Scholar
  51. 51.
    Rammelt S, Gavlik JM, Barthel S, Zwipp H. The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures. Foot Ankle Int. 2002;23:906–916.PubMedGoogle Scholar
  52. 52.
    Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies and recent developments. Injury. 2004;35:443–461.PubMedCrossRefGoogle Scholar
  53. 53.
    Randle JA, Kreder HJ, Stephen D, Williams J, Jaglal S, Hu R. Should calcaneal fractures be treated surgically? A meta-analysis. Clin Orthop Relat Res. 2000;377:217–227.PubMedCrossRefGoogle Scholar
  54. 54.
    Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992;6:252–265.PubMedCrossRefGoogle Scholar
  55. 55.
    Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures: results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993;290:87–95.PubMedGoogle Scholar
  56. 56.
    Sangeorzan BJ, Ananthakrishnan D, Tencer AF. Contact characteristics of the subtalar joint after a simulated calcaneus fracture. J Orthop Trauma. 1995;9:251–258.PubMedCrossRefGoogle Scholar
  57. 57.
    Song KS, Kang CH, Min BW, Sohn GJ. Preoperative and postoperative evaluation of intra-articular fractures of the calcaneus based on computed tomography scanning. J Orthop Trauma. 1997;11:435–440.PubMedCrossRefGoogle Scholar
  58. 58.
    SooHoo NF, Farng E, Krenek L, Zingmond DS. Complication rates following operative treatment of calcaneus fractures. Foot Ankle Surg. 2011;17:233–238.PubMedCrossRefGoogle Scholar
  59. 59.
    Stephenson JR. Treatment of displaced intra-articular fractures of the calcaneus using medial and lateral approaches, internal fixation, and early motion. J Bone Joint Surg Am. 1987;69:115–130.PubMedGoogle Scholar
  60. 60.
    Tarlov AR, Ware JE Jr, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The Medical Outcomes Study: an application of methods for monitoring the results of medical care. JAMA. 1989;262:925–930.PubMedCrossRefGoogle Scholar
  61. 61.
    Tennent T, Calder P, Salisbury R, Allen P, Eastwood D. The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol. Injury. 2001;32:491–496.PubMedCrossRefGoogle Scholar
  62. 62.
    Tscherne H, Oestern HJ. [A new classification of soft-tissue damage in open and closed fractures] [in German]. Unfallheilkunde. 1982;85:111–115.PubMedGoogle Scholar
  63. 63.
    Westphal T, Halm JP, Piatek S, Schubert S, Winckler S. [Quality of life after calcaneal fractures: a matched-pairs trial with a standardised German control group] [in German]. Unfallchirurg. 2003;106:313–318.PubMedCrossRefGoogle Scholar
  64. 64.
    Willmott H, Stanton J, Southgate C. Böhler’s angle: what is normal in the uninjured British population? Foot Ankle Surg. 2012;18:187–189.PubMedCrossRefGoogle Scholar
  65. 65.
    Zwipp H. Chirurgie des Fußes. Vienna, Austria: Springer Verlag; 1994.CrossRefGoogle Scholar
  66. 66.
    Zwipp H, Rammelt S. [Subtalar arthrodesis with calcaneal osteotomy] [in German]. Orthopäde. 2006;35:387–404.PubMedCrossRefGoogle Scholar
  67. 67.
    Zwipp H, Rammelt S, Barthel S. Calcaneal fractures—open reduction and internal fixation (ORIF). Injury. 2004;35(suppl 2):SB46–SB54.Google Scholar
  68. 68.
    Zwipp H, Tscherne H, Thermann H, Weber T. Osteosynthesis of displaced intraarticular fractures of the calcaneus: results in 123 cases. Clin Orthop Relat Res. 1993;290:76–86.PubMedGoogle Scholar
  69. 69.
    Zwipp H, Tscherne H, Wülker N. [Osteosynthesis of dislocated intra-articular calcaneus fractures] [in German]. Unfallchirurg. 1988;91:507–515.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Stefan Rammelt
    • 1
  • Hans Zwipp
    • 1
  • Wolfgang Schneiders
    • 1
  • Constanze Dürr
    • 1
  1. 1.Clinic of Trauma and Reconstructive SurgeryUniversity Hospital “Carl Gustav Carus”DresdenGermany

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