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Displaced intra-articular calcaneal fractures: is there a consensus on treatment in Germany?

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Open reduction in displaced intra-articular calcaneal fractures entails a high rate of wound healing deficits and infections as well as an uncertain outcome, which leads to remaining ambiguity in treatment preferences.


Between January and July 2011, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 31–question web-based survey regarding three broad domains: fracture classification, surgical treatment algorithms and risk factors for wound healing deficits.


The response rate was 47 %. With an incidence of 77 %, open reduction via an extended lateral approach and plate fixation was the main treatment option for displaced intra-articular fractures of the joint-depression-type (Sanders II or III). Percutaneous techniques were only preferred in individual cases, with mainly precarious wound situations (59 %) as well as in patients with a reduced general health condition (ASA 3 and 4; 41 %). The re-operation rate due to infections and wound healing deficits after an extended lateral approach was reported with a percentage of 0-5 % by 88 % of the respondents. Participants stated that especially a poor microcirculation of the foot, disregard of soft tissue conserving techniques, overall condition of the patient, smoking, long time-to-surgery and operation time are the main reasons for wound healing deficits.


Given the extended lateral approach as the preferred treatment option, we found minimally invasive techniques and primary arthrodesis of the lower ankle joint play a minor role in treating intra-articular calcaneal fractures in Germany. Ninety percent of our respondents stated less than 5 % of patients required re-operations due to infections and wound healing deficits.

Level of Evidence Level V, expert opinion.

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  1. Bohler L (1931) Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joit Surg 75–89

  2. Essex-Lopresti P (1993) The mechanism, reduction technique, and results in fractures of the os calcis, 1951–52. Clin Orthop Relat Res 290:3–16

    PubMed  Google Scholar 

  3. Sanders R, Fortin P, DiPasquale T, Walling A (1993) Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 290:87–95

    PubMed  Google Scholar 

  4. Zwipp H, Rammelt S, Barthel S (2004) Calcaneal fractures--open reduction and internal fixation (ORIF). Injury 35(Suppl 2):SB46–SB54

    Article  PubMed  Google Scholar 

  5. Rammelt S, Zwipp H (2004) Calcaneus fractures: facts, controversies and recent developments. Injury 35(5):443–461

    Article  PubMed  Google Scholar 

  6. Stulik J, Stehlik J, Rysavy M, Wozniak A (2006) Minimally-invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg (Br) 88(12):1634–1641

    Article  CAS  Google Scholar 

  7. Tornetta P 3rd (2000) Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res 375:91–96

    Article  PubMed  Google Scholar 

  8. Giachino AA, Uhthoff HK (1989) Intra-articular fractures of the calcaneus. J Bone Joint Surg Am 71(5):784–787

    CAS  PubMed  Google Scholar 

  9. Jarvholm U, Korner L, Thoren O, Wiklund LM (1984) Fractures of the calcaneus. A comparison of open and closed treatment. Acta Orthop Scand 55(6):652–656

    Article  CAS  PubMed  Google Scholar 

  10. Bruce J, Sutherland A (2013) Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database Syst Rev 1:CD008628

    PubMed  Google Scholar 

  11. Chen L, Zhang G, Hong J, Lu X, Yuan W (2011) Comparison of percutaneous screw fixation and calcium sulfate cement grafting versus open treatment of displaced intra-articular calcaneal fractures. Foot Ankle Int 32(10):979–985

    Article  PubMed  Google Scholar 

  12. Schepers T, Vogels LM, Schipper IB, Patka P (2008) Percutaneous reduction and fixation of intraarticular calcaneal fractures. Oper Orthop Traumatol 20(2):168–175

    Article  PubMed  Google Scholar 

  13. Femino JE, Vaseenon T, Levin DA, Yian EH (2010) Modification of the sinus tarsi approach for open reduction and plate fixation of intra-articular calcaneus fractures: the limits of proximal extension based upon the vascular anatomy of the lateral calcaneal artery. Iowa Orthop J 30:161–167

    PubMed  PubMed Central  Google Scholar 

  14. Abdelazeem A, Khedr A, Abousayed M, Seifeldin A, Khaled S (2014) Management of displaced intra-articular calcaneal fractures using the limited open sinus tarsi approach and fixation by screws only technique. Int Orthop 38(3):601–606

    Article  PubMed  Google Scholar 

  15. Folk JW, Starr AJ, Early JS (1999) Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma 13(5):369–372

    Article  CAS  PubMed  Google Scholar 

  16. Court-Brown CM, Schmied M, Schmidt M, Schutte BG (2009) Factors affecting infection after calcaneal fracture fixation. Injury 40(12):1313–1315

    Article  PubMed  Google Scholar 

  17. Surgeons CoTotACo (2000) Resource for Optimal Care of the Injured Patient 1999. American College of Surgeons, Chicago

    Google Scholar 

  18. Knobe M, Gradl G, Ladenburger A, Tarkin IS, Pape H-C (2013) Unstable intertrochanteric femur fractures: is there a consensus on definition and treatment in Germany? Clin Orthop Relat Res 471:2831–2840

    Article  PubMed  PubMed Central  Google Scholar 

  19. Feinstein A (1987) The theory of evaluation of sensibility in clinimetrics. Yale University Press, pp 141–166

  20. Lawshe C (1975) A quantitative approach to content validity. Pers Psychol 563–575

  21. Jiang N, Lin Q-R, Diao X-C, Wu L, Yu B (2012) Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. Int Orthop 36(8):1615–1622

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gougoulias N, Khanna A, McBride DJ, Maffulli N (2009) Management of calcaneal fractures: systematic review of randomized trials. Br Med Bull 92:153–167

    Article  PubMed  Google Scholar 

  23. Randle JA, Kreder HJ, Stephen D, Williams J, Jaglal S, Hu R (2000) Should calcaneal fractures be treated surgically? a meta-analysis. Clin Orthop Relat Res 377:217–227

    Article  PubMed  Google Scholar 

  24. Rubino R, Valderrabano V, Sutter PM, Regazzoni P (2009) Prognostic value of four classifications of calcaneal fractures. Foot Ankle Int 30(3):229–238

    Article  PubMed  Google Scholar 

  25. Schepers T, van Lieshout MM, Ginai AZ, Mulder PGH, Heetveld MJ, Patka P (2009) Calcaneal fracture classification: a comparative study. J Foot Ankle Surg 48(2):156–162

    Article  PubMed  Google Scholar 

  26. Kinner BJ, Best R, Falk K, Thon K-P (2002) Is there a reliable outcome measurement for displaced intra-articular calcaneal fractures? J Trauma 53(6):1094–1101, discussion 1102

    Article  PubMed  Google Scholar 

  27. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R (2002) Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 84-A(10):1733–1744

    PubMed  Google Scholar 

  28. Thordarson DB, Krieger LE (1996) Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int 17(1):2–9

    Article  CAS  PubMed  Google Scholar 

  29. Bakker B, Halm JA, Van Lieshout MM, Schepers T (2012) The fate of Bohler’s angle in conservatively-treated displaced intra-articular calcaneal fractures. Int Orthop 36(12):2495–2499

    Article  PubMed  PubMed Central  Google Scholar 

  30. Jain V, Kumar R, Mandal DK (2007) Osteosynthesis for intra-articular calcaneal fractures. J Orthop Surg (Hong Kong) 15(2):144–148

    CAS  Google Scholar 

  31. Rak V, Bucek P, Ira D, Masek M (2006) Surgical treatment method of calcaneal intraarticular fractures. Rozhl Chir 85(6):311–317

    CAS  PubMed  Google Scholar 

  32. DeWall M, Henderson CE, McKinley TO, Phelps T, Dolan L, Marsh JL (2010) Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma 24(8):466–472

    Article  PubMed  Google Scholar 

  33. Rammelt S, Amlang M, Barthel S, Zwipp H (2004) Minimally-invasive treatment of calcaneal fractures. Injury 35(Suppl 2):SB55–SB63

    Article  PubMed  Google Scholar 

  34. Koski A, Kuokkanen H, Tukiainen E (2005) Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scand J Surg 94(3):243–245

    CAS  PubMed  Google Scholar 

  35. Backes M, Schepers T, Beerekamp MSH, Luitse JSK, Goslings JC, Schep NWL (2014) Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach. Int Orthop 38(4):767–773

    Article  PubMed  Google Scholar 

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We would like to thank Michael Pastor for his creative and constructive ideas and especially Torsten Mueller for his support. The authors would also like to thank all the participants of this study. Without all of them this work would not have been possible.

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Correspondence to Matthias Knobe.

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Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

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Pastor, T., Gradl, G., Klos, K. et al. Displaced intra-articular calcaneal fractures: is there a consensus on treatment in Germany?. International Orthopaedics (SICOT) 40, 2181–2190 (2016).

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