Session I - Foot & Ankle
Fri., 10/8/04 Foot & Ankle, Paper #2, 9:21 am
Long-term Outcome of Calcaneal Fractures as a Single Injury
Purpose: Operative treatment of calcaneal fractures has become common. Although it has been shown that the Boehler angle and the displacement of the posterior facet seem to be important for the outcome, other factors seem to influence the results as well. In a retrospective study, we evaluated the long-term results of patients who had operative treatment of a calcaneal fracture.
Methods: From 1990 to 1997, 289 patients underwent operative treatment for a calcaneal fracture. We included only patients with a fractured calcaneus without any other injury of the lower extremities and with a complete pre- and postoperative radiographic follow-up of both feet, including a computed tomographic scan. Open fractures or a soft tissue injury (Tscherne, G4) were excluded. Sixty-seven patients fulfilled these criteria. We evaluated subjective and objective clinical parameters after 7.1 years. For quantification of the injury and the reconstruction, the fractures were classified according to the system of Zwipp and Sanders (36 grade 2, 26 grade 3, and 3 grade 4). Preoperative and postoperative measurements were made of the displacement of the joints (gap, step) and varus formation of the hindfoot as well as of the angles of Boehler and Gissane, and the talocalcaneal and talometatarsal angle. The length and width of the calcaneus were measured and compared with the contralateral healthy side. On follow-up, any osteoarthritis of the subtalar and calcaneocuboid joints was noted. The results were scored with the Hannover Score, the AOFAS score, and the SF- 36. Statistical tests used included the Levene test and Pearson Correlation, with a 95% confidence interval.
Results: Prognostic factors were a preoperative low or negative Boehler angle, a significant shortening of the calcaneus and the displacement of the anterior and the posterior facet. Two patients (3%) sustained an infection, two (3%), a hematoma, and one patient (1.5%) developed a superficial skin necrosis. After revision surgery, the course was uneventful. Reconstruction of 94% (range, 91 to 103%) of the axes and angles in comparison with the contralateral healthy side was achieved. After reconstruction, an increased calcaneal width of more than 10% compared with the contralateral side was correlated with a painful peroneal tendinitis. Arthritis of the adjacent joints was seen in 65 (97%) patients, in most cases, grade 1.
Smoking did not influence the rate of complications and the outcome. Obesity (as measured by body mass index) was correlated with poor results; age did not show an influence. A good or excellent result was achieved in 86%, satisfactory or poor results in 14%. The Hannover score was 76.8% ± 18.5%, the AOFAS was 83% ± 15.6%; and the SF-36 score was 71.5 ± 13.8%. Analysis of the SF-36 score revealed that persistent pain and reduced function did not lead to a social disintegration.
Conclusion: The results of the study revealed that, in addition to the posterior facet and the Boehler angle, the primary displacement of the anterior facet also influences outcome. Although a reconstruction of the joints and the hind foot axes and angles was achieved in most cases, too wide a calcaneus resulted in peroneal tendinitis. Obesity seems to be a risk factor for a poor outcome, whereas smoking and age did not influence the results. Poor results regarding pain and function did not influence the social situation of the patients.