Schindler et al.

BMC Musculoskeletal Disorders (2021) 22:234

https://doi.org/10.1186/s12891-021-04088-w

RESEARCH ARTICLE Open Access

Outcomes of intra-articular calcaneal

fractures: surgical treatment of 114
consecutive cases at a maximum care
trauma center
Christin Schindler1* , Andreas Schirm2, Vilijam Zdravkovic1, Primoz Potocnik1, Bernhard Jost1 and Andreas Toepfer1

Abstract
Background: The aim of this retrospective monocentric study was to investigate the outcomes of surgically treated
intra-articular calcaneus fractures in a maximum care trauma center.
Methods: One hundred forty patients who had undergone surgery for intra-articular calcaneal fractures between
2002 and 2013 were included. One hundred fourteen cases with 129 fractures were eligible to participate in the
study of which 80 were available for a clinical and radiological follow-up. 34 patients were followed up by
telephone interview only. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS)
hindfoot score, Short Form 36 Health Status Survey (SF-36), complications, and subsequent surgeries.
Results: Mean follow-up was 91 months (range 12–183). The overall complication rate was 29% (37/129 ft).
Disturbed wound healing (11%) and infection (5%) occurred most commonly. Non-union (4%) only occurred in
smokers (p = 0.02). A high rate of posttraumatic subtalar arthritis (77%) and need for subsequent subtalar fusion
(18%) without independent risk factors for subsequent subtalar fusion was found. The revision rate was high (60%)
after primary fusion. Mean AOFAS-hindfoot score was 74 (Sanders I: 99, Sanders II: 74, Sanders III: 77, Sanders IV: 70).
The postoperative Boehler angle improved significantly in all subgroups (p < 0.01). Patients with a decreased
Boehler angle between postoperative images and the follow-up had significantly lower AOFAS hindfoot scores
(p < 0.01).
Conclusions: Our data can aid decision-making in the treatment of calcaneal fractures. We advocate to use primary
subtalar fusion with caution due to the high revision rate. Smoking status should always be considered.
Level of evidence: Level III, retrospective cohort study.
Keywords: Calcaneal fracture, Operative treatment, Outcome, Subtalar fusion

* Correspondence: [email protected]
1
Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen,
Rorschacher Strasse 95, 9007 St. Gallen, Switzerland
Full list of author information is available at the end of the article

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Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 2 of 12

Background of more than 2–3 mm, flattening of Bohlers angle,

The calcaneus is the most commonly fractured tarsal coronal plane malalignment of the tuberosity, and
bone accounting for 1–2% of all fractures [1, 2]. large laterally displaced fragments that would lead to
Seventy-five percent of all calcaneal fractures involve subfibular impingement. Exclusion criteria were extra-
the subtalar joint [3]. The injury is most often articular fractures, conservative treatment, and known
caused by falling from a height [4, 5]. Young male pre-existing osteoarthritis of the subtalar joint. Ethics
workers are frequently affected, which explains the committee approval and informed consent were ob-
high socio-economic burden of this injury [1, 5]. tained. All eligible patients were invited to be exam-
Intra-articular calcaneal fractures are known to have ined clinically and radiologically. This involved gait
an unfavourable outcome [6]. The impact of this in- assessment, hindfoot alignment, tenderness to palpa-
jury on personal well-being has been shown to be tion, swelling, heel width, and subtalar range of mo-
higher than that of myocardial infarction [6]. The tion (ROM).
optimal treatment has been subject to debate for Patient history was documented including: injury
many decades and until today no commonly ac- mechanism, age at the time of injury, gender, injured
cepted consensus found [7]. Even the existing ran- side, work-related accident, occupation, return to
domized controlled trials on operative vs. work, concomitant injuries, delay until surgery, surgi-
nonoperative treatment of the last 25 years failed to cal technique, subsequent operations, complications,
establish clarity. Parmar et al. 1993, Ibrahim et al. symptoms of arthritic changes (weather-dependent
2007 and Sharma et al. 2011 found no significant discomfort, morning stiffness, night pain), swelling,
differences between their operative and nonoperative pre-existing conditions (smoking, diabetes, osteopor-
groups [8–10]. Thordarson and Krieger 1996, osis, steroids), use of medical aids (insoles, orthopedic
Rodriguez-Merchan et al. 1999, Howard et al. 2003 shoes) and difference in shoe size. The American
and Bahari et al. 2013 had better functional results Orthopaedic Foot and Ankle Society (AOFAS) hind-
in their operative group [11–14]. Some studies did foot score was completed and all patients were asked
show better outcomes in a subgroup of their oper- to answer the Short Form 36 Health Status Survey
ated patients: Buckley et al. 2002 in the group with- (SF-36). Quality Metric Health Outcomes scoring
out workers´ compensation; Nouraei and Moosa software 5.0 was used to collect, evaluate, and score
2011 in operatively treated patients without open SF-36 data. X-rays were taken of the feet involved
fractures, osteoporosis, poor general health, or severe and assessed for signs of subtalar osteoarthritis. Frac-
comminution [15, 16]. Griffin et al., on the other ture severity was classified according to Sanders with
hand, found higher complication rates in the opera- the initial CT scan. Boehler angles were measured at
tive group and did not recommend operative treat- the time of injury, postoperatively, and at the latest
ment at all [2]. Agren et al. showed a higher follow-up. Patients unable or unwilling to attend the
complication rate as well but a lower incidence of clinical and radiological examination were asked to
posttraumatic arthritis [17]. participate in a telephone interview.
Sanders et al. found a correlation between the need for All statistical analyses were performed with R (R Foun-
subsequent subtalar arthrodesis and Sanders classifica- dation for Statistical Computing, Vienna, Austria. URL
tion in their long-term study, where patients with a San- http://www.R-project.org/). Descriptive statistics in-
ders III fracture were 4 times more likely to need a cluded means, standard deviations, ranges, and propor-
subtalar fusion than patients with a Sanders II fracture tions. Comparative statistics included t-tests and the
[18]. The long-term study by Rammelt et al. also showed Chi-square test (where appropriate the Fisher exact test
worse functional outcomes in patients with higher frac- was applied). The level of significance was set at p <
ture severity [19]. This study was conducted to investi- 0.05.
gate the relationship between fracture severity, method
of operative treatment, and outcome. We were searching Results
for independent risk factors for the need for subtalar Figure 1 shows patient flow: 114 patients with 129 oper-
arthrodesis. ated feet (62 right, 67 left feet). The mean follow-up was
91 months (range 12–183 months). Table 1 shows pa-
Methods tient demographics.
As part of a monocentric retrospective study, we Fracture severity according to the Sanders classifica-
identified all patients who had sustained intra- tion was distributed as shown in Table 2.
articular calcaneal fractures between February 2002 The three Sanders Type I fractures that were
and August 2013 and were treated operatively. Cri- treated operatively were tongue type fractures with an
teria for surgical fixation were: posterior facet step-off undisplaced intraarticular extension. Twenty-four
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 3 of 12

Fig. 1 Patient selection flow chart

fractures could not be classified retrospectively be- disease in the other patient. Forty-seven patients (41%)
cause the preoperative CT scans were not available. stated that they were smokers at the time of the accident
Four fractures were open (2 Sanders IV, 1 IIIBC, 1 and perioperatively. The detailed number of pack-years
unknown). Two of the open fractures occurred in pa- (py) was only obtainable in 26 patients (mean 22 py,
tients with bilateral calcaneal fractures. Fifty-one pa- range 4–40 py).
tients sustained concomitant injuries (Table 3). The mean time between the accident and the de-
Patients with Sanders IV fractures suffered from con- finitive surgery was 8.3 days (range 0–38 days). Rea-
comitant injuries significantly more often (p < 0.01). The sons for delay in surgery included waiting for
AOFAS hindfoot score was significantly worse (p = 0.02) subsidence of swelling and fracture blisters, delayed
in the presence of concomitant injuries. surgery of non-life-threatening injuries in polytrauma
Preexisting medical conditions were uncommon patients, definite surgery after repatriation from
among our patients. Two patients had diabetes, two abroad. One hundred two fractures were treated with
were on oral steroids and two had previously diagnosed open reduction and internal plate fixation (ORIF)
osteoporosis. Steroid medication was used due to through an extended lateral approach. The implant
rheumatoid arthritis in one and chronic obstructive lung used for osteosynthesis was either the Synthes Lock-
ing Calcaneal Plate (DePuy Synthes Medical Devices,
Table 1 Patient demographics
Oberdorf, Switzerland) or the Mondeal Calcaneus
Plate (Mondeal Medical Systems GmbH, Muehlheim,
all male female
Germany). Other methods (K-wires, Ex-fix, screw fix-
Patients 114 83 31
ation) were used in 22 fractures. One patient with bi-
Mean age (range) 41.5 (11–83) 41.2 (11–75) 45.6 (15–83) lateral Sanders IV fractures developed compartment
Cause of injury syndrome in both feet prior to surgical fixation and
Fall from height 90 67 23
Sport injury 17 15 2
MVA 15 10 5 Table 2 Sanders classification
Sanders I II III IV
other 7 3 4
IIA IIB IIC IIIAB IIIAC IIIBC
Work-related 34 29 5
6 11 1 18 9 5
Not work-related 80 54 26
total 3 18 32 52
MVA: motor vehicle accident.
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 4 of 12

Table 3 Concomitant injuries

Concomitant Injuries Sanders I Sanders II Sanders III Sanders IV Not classified Total
None 0 12 23 19 13 67
Spine 1 1 4 11 3 20
Ipsilateral foot/lower extremity 1 3 1 8 5 18
Contralateral calcaneus operative 0 0 2 11 2 15
Contralateral calcaneus nonoperative 0 2 2 4 1 9
Others 1 1 6 15 4 27
Multiple concomitant injuries 0 1 3 12 3 19

was treated with foot compartment release. In total, The mean preoperative Boehler angle was one degree
ten different board-certified trauma surgeons per- (range − 70°- 45°) and improved by a mean of 23 degrees
formed the surgeries over a period of 11 years. Fig- (range − 17-95°). There was a clear difference in mean
ures 2, 3, 4 and 5 show a case of a Sanders II preoperative Boehler angle depending on the Sanders
fracture treated with ORIF. type: Sanders II: 11.6° (range − 11° - 44° max), Sanders
Five fractures (all Sanders IV and closed) were III: 1.9° (range - 44°- 30°), Sanders IV: −5° (range - 70 -
treated with primary subtalar fusion. The decision 45°).
was made by the attending surgeon according to The postoperative Boehler angle improved signifi-
fracture severity and patient profile. Four of the five cantly in all subgroups (p < 0.01). The subgroup of
patients had concomitant injuries in the involved Sanders IV fractures showed a tendency of a de-
foot or lower leg. Primary fusion was associated crease in the Boehler angle between the postopera-
with a high revision rate of 60% (3/5). Two patients tive and the follow-up X-rays without statistical
needed subsequent revision-arthrodesis due to non- significance (p = 0.09). Patients with a decrease in
union (both smokers) and one patient a wound Boehler angle had significantly lower AOFAS hind-
revision and partial implant removal of one of two foot scores (p < 0.01).
subtalar arthrodesis screws due to deep infection Complications occurred in 37 out of 129 ft (29%).
(non-smoker). One arthrodesis (in a smoker) had to Postoperative complications included infection, dis-
be revised twice due to non-union. Only one pri- turbed wound healing, hardware failure, and non-
mary fusion healed without adverse events within 4 union. At 11%, disturbed wound healing was the most
months (in a healthy non-smoker). The fifth patient commonly reported complication (14/129) followed by
(smoker) developed chronic pain without signs of deep infection 5% (6/129). Disturbed wound healing
non-union in the CT scan 6 months after the pri- was defined as wound dehiscence or secretion (de-
mary arthrodesis. Figures 6, 7, 8, 9 and 10 show one fined as persistent production of fluid from the
of the cases that was treated with a primary subtalar wound) 21 days postoperatively or wound necrosis
arthrodesis. Table 4 shows the mode of fixation and [20]. Seven patients needed secondary surgery for in-
outcome in correlation to fracture severity. fections and/or disturbed wound healing. Five of

Fig. 2 Case 1 Preoperative radiographs. Radiographs left calcaneus lateral (A) and axial (B) view, 62 year old male patient, non-smoker
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 5 of 12

Fig. 3 Case 1 Preoperative CT. Coronal (A), sagittal (B) and axial (C) views representing a Sanders IIb fracture type pattern

those patients required a plastic-surgical procedure to and IV fractures (20 months, range 4–51 months), who
cover the soft tissue defect. Seven of the fifteen pa- worked in physically demanding professions. The num-
tients (7/15, 47%) with infection/disturbed wound bers in each subgroup were too small to reach statistical
healing had Sanders IV fractures. Non-union 4% (5/ significance.
129) occurred in three patients after ORIF and in two Seventy-six percent (87/114) of our patients required
after primary fusion. All non-unions occurred in subsequent surgical interventions. Implant removal, per-
smokers (p = 0.02). formed on 86 ft (67%), made up the majority of those.
The mean time to return to work was nine months Twenty-two subtalar arthrodeses (18%) were performed
(range 1–100). Twenty-seven patients were not able to 6–80 months (mean 29 months) after the primary oper-
return to their former occupation. Table 5 shows the ation. Subtalar arthrodesis rates in correlation to fracture
time to return to work depending on the pre-accident severity are shown in Table 6.
degree of manual labour. Three secondary arthrodesis (14%, all smokers) had to
The mean time to return to work was highest for pa- be revised due to symptomatic non-union after a mean
tients with Sanders III (30 months, range 5–100 months) of 9 months (range 6.5–12 months). Logistic regression

Fig. 4 Case 1 Postoperative radiographs. Lateral (A) and axial (B) radiographs after ORIF via an extended lateral approach
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 6 of 12

Fig. 5 Case 1 Radiographs at follow-up Weightbearing left foot lateral (A) and calcaneus axial (B) 40 months post-surgery, AOFAS score 95

did not show independent risk factors for subsequent telephone ten reported no clinical signs of osteoarthritis,
arthrodesis. nine had one and 12 reported two or more symptoms of
Of the feet that had not undergone subtalar arthrod- subtalar osteoarthritis. Two patients did not answer the
esis at the time of follow up and were followed up clinic- question.
ally and radiologically, 52 (57%) showed clinical and
radiological signs (sclerosis, joint line narrowing, sub- Functional outcome scores
chondral cysts, and osteophytes) of subtalar osteoarth- The functional outcome measures were taken postopera-
ritis. Criteria for having clinical signs was to show two tively at the time of the latest follow-up (Table 7).
or more typical symptoms (weather dependent worsen- In the three primarily fused patients that were ex-
ing of symptoms, start-up pain in the morning or after amined, the mean AOFAS score was 50 (range 30–
rest, pain at night) or one in addition to a severe reduc- 66). The six Sanders IV fractures with a completed
tion of subtalar ROM and/or swelling and pain with ac- score that were subsequently fused had a slightly
tivity. Ten patients had radiologic signs without being higher mean AOFAS score of 64 (range 33–82). The
symptomatic. Of the 33 patients interviewed via numbers were too small to reach statistical
significance.
The postoperative Boehler angle was a strong inde-
pendent predictor for the AOFAS hindfoot scores at
the time of follow-up (p < 0.01). There was a ten-
dency to lower AOFAS scores with increasing age
(p > 0.05).

Clinical examination
Clinical follow-up was obtained in 80 patients with 90
fractures. Restricted hindfoot motion was a common
finding. Table 8 shows the subtalar range of motion
dependent on Sanders classification. Only subtalar joints
that had not undergone arthrodesis previous to the
examination were considered (n = 74).
Hindfoot alignment was clinically assessed in the
standing patient. A neutral hindfoot up to 10° valgus
was considered normal. Most feet (87%, 77/89) were
within the normal range. Five feet had valgus mala-
lignment (15–30°), seven varus (5–10°). We could not
assess hindfoot alignment in one patient as he was
not able to fully weight bear at the time of examin-
ation due to an unrelated injury of the contralateral
ankle.
Fig. 6 Case 2 Preoperative radiographs. Radiograph right calcaneus
Heel width difference was assessed by letting the pa-
lateral, 35 year old female patient, smoker
tient stand on a piece of paper and tracing the outline of
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 7 of 12

Fig. 7 Case 2 Preoperative CT Coronal (A) sagittal (B) and axial (C) views representing a Sanders IV fracture type pattern

both heels with a pen. The widest part was measured Thirty-one patients (30%) answered the question with
and compared to the contralateral side. The measure- yes (0 Sanders I, 5 Sanders II, 7 Sanders III, and 16 San-
ment was done in all but two patients. We only consid- ders IV), seventy-three with no.
ered patients with unilateral injuries that had an Orthopaedic insoles were used by 21% (23 out of 112)
uninjured side to compare to. Thirty out of 68 patients of all patients. Seventeen percent of all patients stated
(44%) showed a heel width difference between 0.5-1 cm; the need for orthopaedic shoes (19 out of 112). Two pa-
three patients (4%) had a difference > 1 cm. tients did not answer the question.
All feet were examined for tenderness to palpation. 58
of 90 (64%) felt no pain. Lateral pain was most common SF-36
among our patient collective (n = 26, 29%). The SF-36 questionnaire was completed by 71 pa-
The question if their shoe size has changed after the tients. Overall the two domains with scores furthest
injury was answered by 104 out of the 114 patients. from the normative data were physical functioning

Fig. 8 Case 2 Postoperative radiographs Lateral (A) and axial (B) radiographs after primary subtalar arthrodesis
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 8 of 12

Fig. 9 Case 2 Complications. CT scan sagittal (A) and coronal (B) view 6 months after primary subtalar fusion showing a subtalar non-union

and bodily pain. Social functioning is the domain The occurrence of posttraumatic subtalar arthritis var-
least influenced by surgically treated calcaneal frac- ies greatly in literature from 2.5% in Poeze’s systematic
tures. In all domains patients with Sanders IV frac- review to 100% in the long term (10y) follow up of
tures reached the lowest scores, except for social Makki et al. [22, 23]. We assume the great range is partly
functioning where patients with Sanders II fractures due to dissimilar follow-up times as well as the variety of
scored slightly worse, but still close to the norm. Fig- criteria applied by the different authors (radiological
ures 11 and 12 show the scores of the eight SF-36 signs, symptoms, or need for fusion). Seventy percent of
domains in all calcaneal fractures and scores our patients had clinical and radiological signs of subta-
dependent on Sanders classification in comparison lar arthritis. The subsequent subtalar fusion rate after
with the normative data. ORIF was 18% in our patients which is higher than the
In addition to the eight scale scores the physical com- previously reported ranges of 0% [2, 24] to 12% [17].
ponent summary (PCS) scores and mental component The higher fusion rate in our patients might be due to
summary (MCS) scores were calculated and compared the high percentage of Sanders IV fractures (40%). We
[21]. Patients who were treated for a calcaneus fracture were not able to identify independent risk factors for the
classified Sanders II-IV showed below-average PCS need for subtalar fusion after operative treatment of
scores. Only patients with Sanders IV fractures showed intra-articular calcaneal fractures.
below-average MCS scores (Table 9). Primary arthrodesis which was performed in five pa-
tients with Sanders IV fractures was associated with high
Discussion revision rates of 60% and non-union rates of 40%. Buck-
Intra-articular calcaneal fractures are serious injuries ley et al. found no statistically significant difference in
that are associated with prolonged functional limitations his randomized controlled trial comparing 14 patients
in many patients. that received primary subtalar fusions and 17 that

Fig. 10 Case 2 Radiographs at follow-up Weightbearing right foot lateral (A) and calcaneus axial (B) 27 months post-surgery, AOFAS: 53
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 9 of 12

Table 4 Mode of fixation and outcome in correlation to Table 6 Rate of subtalar arthrodesis
fracture severity Sanders Rate of subtalar arthrodesis
Sanders Method of Number of AOFAS Secondary n
fixation feet mean if arthrodesis (n)
n >1
I (n = 3) 0 (0%)
(range) II (n = 18) 6 (33%)
I (n = 3) ORIF plate 1 97 0
III (n = 32) 3 (9%)
ORIF screws 2 100 0
IV (n = 52)* 14 (27%)
II (n = ORIF plate 15 76.8 (52– 6
18) 100) unknown (n = 24) 4 (17%)
ORIF screws 1 72 0 * Including 5 primary subtalar arthrodesis

K-wires 1 72 0
ExFix 1 50 0 received ORIF for Sanders IV fractures [25]. The authors
III (n = ORIF plate 27 75.5 (46– 3 excluded patients that continued to smoke and those
32) 97) with concomitant injuries. Since 3 out of 5 patients in
ORIF screws 2 69.0 (40– 0 our analysis that were primarily fused were smokers and
98)
4 had additional injuries to the foot or lower leg, patient
K-wires 2 84.5 (84– 0
85) selection might be the cause for different outcomes. Po-
ExFix 1 98 0
tenza et al. published a mean AOFAS of 70, 12 months
after primary subtalar fusion, and of 85 after 53 months
IV (n = ORIF plate 38 74.9 (52– 8
52) 97) in 6 patients (7 ft) with Sanders IV fractures. The aver-
ExFix 9 60.0 (33– 1 age time to fusion was 3 months and return to work
70) 100% (no patient doing heavy work) [26]. Compared to
Primary fusion 5 49.7 (30– na the patients who received subtalar fusion after ORIF of a
66)
Sanders IV fracture in our collective, mean AOFAS (64
na: not applicable.
vs. 50) was lower after primary fusion. There was no
statistical significance though, because of the small num-
ber of patients.
Complication rates are known to be high ranging from
17.3 to 29% in the literature [24, 27]. Recent studies
show lower complication rates with minimally invasive
Table 5 Return to work depending on pre-injury degree of techniques compared to open reduction and internal fix-
manual labor and Sanders classification. ation over an extensile lateral approach (4.8% vs. 20.8%)
Degree of Sanders n return to mean time return to mean time [28]. In our study, we found an overall complication rate
physical old job (months) any job (months)
work of 29%. Disturbed wound healing (11%) and infection
Light I 0 0 0 0 0 (5%) occurred most commonly. Non-union (4%) devel-
II 1 1 1 1 1 oped significantly more often in smokers. Part of our
III 11 9 4 (1–14) 9 4 (1–14)
high complication rate might be explained through the
IV 8 8 6 (3–12) 8 6 (3–12)
fact that we had a high percentage of Sanders IV frac-
tures (40%) and smokers (41%) in our collective.
unknown 4 4 3 (2–4) 4 3 (2–4)
The Boehler angle as an outcome predictor has been
total 24 22 4 22 4
described in numerous studies [23, 27, 29–31]. Rammelt
Moderate I 2 2 8 (4–12) 2 8 (4–12)
et al. stated that a reduction of the Boehler angle to less
II 8 5 8 (2–18) 8 7 (2–18) than 30% of the healthy side is associated with worse
III 8 5 6 (2–18) 7 5 (2–18) outcomes [27]. Basile et al. found a positive correlation
IV 15 8 14 (3–48) 10 13 (3–48)
Table 7 AOFAS hindfoot scores
unknown 13 9 7 (1–18) 9 7 (1–18)
AOFAS Mean (range)
total 46 29 9 36 8
Total (n = 90) 73.5 (30–100)
Heavy I 1 1 4 1 4
Sanders I (n = 2) 98.5 (97–100)
II 5 3 7 (3–14) 4 7 (3–14)
III 7 4 30 (5–100) 6 21 (3–100) Sanders II (n = 13) 74.0 (50–100)
IV 7 3 20 (4–51) 5 21 (4–51) Sanders III (n = 26) 76.6 (40–98)
unknown 4 1 7 2 16 Sanders IV (n = 32) 70.2 (30–97)
total 24 12 17 18 16 unknown (n = 17) 71.9 (37–100)
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 10 of 12

Table 8 Subtalar range of motion depending on Sanders postoperative and follow-up X-rays, indicating a loss of
classification reduction, is associated with a significantly worse
Sanders Subtalar range of motion outcome.
none < 15° > 15° Limitations of our study are the retrospective study
I (n = 2) 0 0 2 design, different methods of treatment, and the small
II (n = 10) 3 4 3
population number in certain subgroups. The use of the
AOFAS score as a primary outcome measure is another
III (n = 24) 9 8 7
limitation, because although it is widely used the AOFAS
IV (n = 23) 7 14 2 score has not been adequately validated. The relatively
uc (n = 15) 4 10 1 large number of surgeons performing a technically de-
total (n = 74) 23 36 15 manding procedure (1.2 fractures/surgeon/year) could
uc = unclassified. be another limitation as previous studies have shown a
correlation between institutional fracture load and out-
between the restoration of the Boehler angle and postop- come [22].
erative AOFAS and VAS scores in elderly patients [31]. Residual step-offs in the articular surface where not in-
Su et al. investigated the role of the Boehler angle in cluded in the analysis of prognostic factors as we did not
assessing fracture severity and functional outcome and conduct postoperative CT scans or intraoperative subta-
found a correlation of fracture severity with the pre- lar arthroscopy to accurately measure that factor. The
operative Boehler angle and a correlation of the postop- restoration of Boehler angle is only an indirect measure
erative Boehler angle with the AOFAS score [30]. We of the quality of joint reduction. Moreover, the Boehler
also noticed that the postoperative Boehler angle is a angle has a great individual variability of 20–40°. With-
strong independent predictor for the AOFAS hindfoot out measuring the unfractured side’s Boehler angle no
score at the time of follow up. Additionally, we could statement can be made as to whether we managed to re-
show that a decrease in the Boehler angle between the store the patient’s individual Boehler angle.

Fig. 11 SF-36 normative data compared to all patients with surgically treated calcaneal fractures. PF: Physical functioning. RP: Role physical. BP:
Bodily pain. GH: General health. VT: Vitality. SF: Social functioning. RE: Role Emotional. MH: Mental health
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 11 of 12

Fig. 12 SF-36 normative data compared to patients with surgically treated calcaneal fractures depending on Sanders classification. PF: Physical
functioning. RP: Role physical. BP: Bodily pain. GH: General health. VT: Vitality. SF: Social functioning. RE: Role emotional. MH: Mental health

Strengths are the long follow-up of ø 91 months with a contraindications for surgical treatment. This and other
relatively high overall patient number for a monocentric studies led to changes in our surgical approach. At our
study. We were able to conduct follow-up on 114 out of institution most fractures are currently treated with less-
140 patients (81%) which is superior to previously pub- and minimally- invasive techniques. The lateral extensile
lished long term follow-up studies. approach is avoided whenever possible. We routinely
use intraoperative 3D-imaging to ensure adequate reduc-
Conclusions tion is achieved. Smoking status should be considered
Due to the unfavorable outcome in our patient collective and cessation strongly recommended.
and to the fact that we could not make out clear risk fac-
Abbreviations
tors for subsequent fusion, we indicate primary subtalar AOFAS hindfoot score: American Orthopaedic Foot and Ankle Society
fusion with great caution. We believe the restoration of hindfoot score; SF-36: Short Form 36 Health Status Survey; ROM: range of
the anatomy is paramount in the treatment of displaced motion; py: pack-years; ORIF: open reduction and internal plate fixation; PCS
score: physical component summary scores; MCS score: mental component
intraarticular calcaneus fractures in all patients without summary scores; MVA: motor vehicle accident

Table 9 SF- 36 Physical component summary (PCS) score and Acknowledgements

The authors thank Daniela Tanner for her enormous administrative support.
mental component summary (MCS) score.
Sanders PCS MCS Authors’ contributions
I (n = 1) 55.7 57.7 CS and AS contributed to the conception of the work and acquisition of the
data, CS drafted the manuscript, VZ provided statistical expertise, BJ, AT and
II (n = 10) 43.3 51.2 PP substantively revised the manuscript. All authors were involved in data
analysis and/or interpretation. All authors read and approved the submitted
III (n = 22) 45.6 52.3
version.
IV (n = 23) 40.9 48.1
Funding
uc (n = 14) 40.5 51.9
This work was supported by the clinical trials unit of the Cantonal Hospital,
Average norm: 50, uc: unclassified. St. Gallen. The funding source was not involved in the study design,
Schindler et al. BMC Musculoskeletal Disorders (2021) 22:234 Page 12 of 12

collection, Interpretation, or analysis of data, the writing of the report nor the 14. Bahari Kashani M, Reza Kachooei A, Ebrahimi H, Taghi Peivandi M,
decision to submit for publication. Amelfarzad S, Bekhradianpoor N, et al. Comparative study of peroneal
tenosynovitis as the complication of intraarticular calcaneal fracture in
Availability of data and materials surgically and non-surgically treated patients. Iran Red Crescent Med J.
The datasets used and analysed during the current study are available from 2013;15(10).
the corresponding author on reasonable request. 15. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al.
Operative compared with nonoperative treatment of displaced intra-
Ethics approval and consent to participate articular calcaneal fractures: a prospective, randomized, controlled
Ethics approval was granted by the ethical review committee of the multicenter trial. J Bone Joint Surg Am. 2002;84-A(10):1733–44.
Kantonsspital St. Gallen. Written informed consent to participate was 16. Author C, Hadi Nouraei M, Mostafa Moosa F. A r c h i v e o f S I D Operative
obtained. compared to non-operative treatment of displaced intra-articular calcaneal
fractures * [Internet]. Vol. 16, J Res Med Sci. 2011. Available from: www.SID.ir
Consent for publication 17. Agren P-H, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative
Not applicable. treatment of displaced intra-articular calcaneal fractures: a prospective, randomized,
controlled multicenter trial. J Bone Joint Surg Am. 2013;95(15):1351–7.
18. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of
Competing interests
displaced intraarticular calcaneal fractures: long-term (10-20 years) results in
The authors declare that they have no competing interests.
108 fractures using a prognostic CT classification. J Orthop Trauma. 2014;
28(10):551–63.
Author details
1 19. Rammelt S, Zwipp H, Schneiders W, Dürr C. Severity of injury predicts
Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen,
subsequent function in surgically treated displaced intraarticular calcaneal
Rorschacher Strasse 95, 9007 St. Gallen, Switzerland. 2Hand und Fuss
fractures. In: Clinical Orthopaedics and Related Research. Springer New York
Facharztpraxis, Pestalozzistr.2, Zentrum St. Leonhard, 9000 St. Gallen,
LLC; 2013. p. 2885–98.
Switzerland.
20. Müller AM, Toepfer A, Harrasser N, Haller B, Walther M, von Eisenhart-
Rothe R, et al. Significant prevalence of peripheral artery disease in
Received: 7 July 2020 Accepted: 17 February 2021
patients with disturbed wound healing following elective foot and
ankle surgery: Results from the ABI-PRIORY (ABI as a PRedictor of
Impaired wound healing after ORthopedic surgerY) trial. Vasc Med
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