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TraumaFurther Opinion

Osteosynthesis of displaced intra-articular fractures of the calcaneum

D Makki, HM Alnajjar, S Walkay, U Ramkumar, AJ Watson, PW Allen

J Bone Joint Surg [Br] 2010;92-B:693-700.


We find this paper timely due to the controversy regarding the appropriate treatment of intra-articular calcaneal fractures:  Is operative intervention better than non-operative intervention?

This particular study is truly impressive for the 92% response rate, the utilisation of four clinical rating scales, and ten year follow-up all performed by a single surgeon.  Overall, 75% of patients had an excellent or a good result and 25% had a fair or poor result, which is comparable with existing published results.

Complications included five patients (10.6%) with superficial wound infections, one of who required grafting.  The extensile “L” incision continues to be worrisome for many, and we believe that a less extensile approach, while maintaining appropriate reduction of fracture fragments, needs to be perfected.  The current trend seems to be heading this way.  Standard lateral calcaneal wall plates have been introduced through a less extensile subtalar incision, and new “Z shaped” plates have recently been developed with the less extensile approach in mind.  Hopefully this will decrease soft tissue complications.

The authors have noted that restoration of Bohler’s angle was associated with a better outcome, and that the majority of patients with poor outcomes had a suboptimal post-operative Bohler’s angle.  This is consistent with other previous studies.1,2 When calcaneal height is restored, the talar declination angle is restored, and this prevents anterior tibio-talar impingement.  When the talus is allowed to flatten and collapse upon the calcaneum, patients do worse.  Interestingly, Hetsroni et al,3 examined foot and ankle kinematics following operative reduction of comminuted calcaneal fractures and found that they were closer to normal in those who underwent internal fixation than in those patients who were treated conservateively.

Not surprisingly, degenerative changes in the subtalar joint were present in all patients, but this was unrelated to the initial degree of comminution and it did not correlate with the outcome scores. Kinematic studies performed by Hetsroni et al noted a reduced velocity and range of movement consistent with subtalar arthrosis after osteosynthesis. 

Without a doubt, the greatest limitation of this study is its weakness in the grand scheme of evidence-based medicine.  This is a level IV case series without a control group.  We regret the absence a non-operative control group which might have provided contrast to the findings of Buckley et al.4 This paper left some questions unanswered.  It failed to examine patients who smoked and confused us with the workers compensation issue.  While this paper attempts to argue for operative intervention, we cannot reach a definitive conclusion due to the study design.   Instead, we are left to ponder what if?  We are still waiting for that proper randomised trial with controls and with validated outcomes that can challenge the shortcomings of Buckley’s article.


1. 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-A:342-54.
2. Paul M, Peter R, Hoffmeyer P. Fractures of the calcaneum: a review of 70 patients. J Bone Joint Surg [Br] 2004;86:1142-5.
3. Hetsroni et al. Paper presented at AAOS Annual meeting in New Orleans 2010.
4. Buckley R, Tough S, McCormack, et al. Operative compared with nonoperative treatment of displaced intraarticular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg [Am]  2002;84-A:1733-44.


Hirose C, MD

The Coughlin Clinic, Idaho, USA