Comparative analysis of clinicoradiological results in calcaneal fractures: Conservative versus operative management

INTRODUCTION

Calcaneal fractures constitute approximately 2% of all fractures, with 75% being displaced intra-articular fractures.^[1] These fractures can severely impair mobility and quality of life, presenting significant challenges for orthopedic surgeons in achieving proper anatomical reduction and improving patient outcomes. These injuries are commonly associated with high-energy traumas, such as falls or vehicle accidents, and often accompany spinal and lower limb fractures, complicating diagnosis. Patients generally present symptoms including heel pain, swelling, an inability to bear weight, and potential deformity.^[2]

Radiological assessment, using both lateral and axial views,^[3] is crucial for an accurate diagnosis. The Böhler and Gissane angles, analyzed through lateral radiographs, indicate subtalar joint alignment.^[4] The advent of computed tomography (CT) has dramatically enhanced the evaluation of calcaneal fractures, supplying detailed images that inform the Sanders classification system.

Management strategies have undergone significant evolution over time. Non-operative treatment is generally reserved for less severe or non-displaced fractures and includes methods such as rest, elevation, splinting, and systematic rehabilitation. While this approach avoids surgery, it carries risks of malunion and subtalar arthritis. For displaced fractures, operative management – particularly open reduction and internal fixation (ORIF) – is often the preferred method. The goal of surgery is to restore joint congruity, calcaneal height, and alignment, all of which are critical for proper foot biomechanics. However, this approach is not without risks, including potential complications such as wound healing issues, infections, and nerve injuries.

The optimal management of displaced intra-articular calcaneal fractures remains a subject of debate. While surgical intervention may offer better restoration of anatomy and function, conservative treatment may be favored due to patient comorbidities and concerns regarding soft tissue viability.

This study is vital due to the ongoing discussion regarding the optimal management of displaced intra-articular calcaneal fractures, as there remains no clear consensus on whether surgical or non-surgical management yields superior functional outcomes. Even with improvements in surgical methods and imaging technology, high complication rates and different fracture patterns continue to complicate decisions. Our study aims to compare the functional and radiological outcomes of calcaneal fractures treated operatively versus conservatively, with the goal of providing evidence-based guidance for the most effective treatment tailored to individual patient profiles.

MATERIALS AND METHODS

This comparative study was conducted prospectively at a tertiary care postgraduate teaching institute and involved 112 patient participants. A sample size was calculated using G*Power software, version 3.1.9.2, to achieve a 95% confidence level and 80% statistical power for two groups based on mean differences. With an effect size of 0.5 (Cohen’s d), the required sample size was 112 participants. Patients were divided into either Group A or Group B based on their consent. They received detailed explanations about both operative and conservative treatments, including their advantages and disadvantages. Patients’ treatment choices were grouped accordingly: Group A (n = 56) received conservative management, while Group B (n = 56) underwent surgery. Patients with intra-articular calcaneal fractures meeting the inclusion criteria underwent comprehensive assessments to determine surgical suitability. It included patients between the ages of 18 and 70 years with closed calcaneal fractures, Sanders Grade II-IV, fractures presenting within 3 weeks of injury. It excluded patients with open fractures, associated spinal injuries or peripheral vascular diseases, and patients refusing consent.

Furthermore, validated scoring systems were employed to assess functional recovery and compare radiological outcomes in this cohort in addition, evaluating postoperative complications and patient-reported outcomes. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and the Helsinki Declaration of 1975, revised in 2000.

Measures to mitigate edema included the application of a below-knee slab with cotton padding, limb elevation, and cryotherapy. Pre-operative radiographs (lateral and axial views) and CT scans of the calcaneum were procured to facilitate meticulous pre-operative planning. Bohler’s and Gissane’s angles were carefully measured using radiographs, and fractures were classified according to Sander’s classification system through CT imaging. After gaining informed consent and approval from the ethics committee, patients were scheduled for surgery once the swelling subsided, as indicated by a positive wrinkle sign.

During the operation, patients were placed in the lateral decubitus position on a radiolucent table, ensuring the operative side was accessible superiorly. The lower limbs were positioned in a scissor-like arrangement, with protective padding placed underneath the opposite limb to protect the peroneal nerve, and a pillow was placed between the legs. A pneumatic thigh tourniquet was applied, and the limb was exsanguinated using an Esmarch bandage to guarantee a clear operative field. The limb was aseptically prepared and draped up to the mid-calf region. A lateral extensile incision was executed, commencing 2 cm above the tip of the lateral malleolus and moving sideways to the Achilles tendon, then moving downward to the base of the fifth metatarsal in an L-shape fashion. The incision was made “straight to bone,” cautiously avoiding skin beveling. The flap was raised as a full-thickness subperiosteal flap and retracted utilizing the “no-touch” technique, with 1.5 mm K-wires inserted into the cuboid, talar neck, and fibula.

Fracture reduction involved correcting the calcaneum’s varus deformity, height, and width under direct visualization and fluoroscopic guidance. Initially, K-wires were used for the temporary stabilization of fracture fragments, after which a locking calcaneal compression plate and screws were applied. Intraoperative radiographic assessment utilized an image intensifier to include anteroposterior, axial, and lateral views [Figure 1]. The wound was irrigated entirely with normal saline and sutured using non-absorbable sutures (Ethilon) in accordance with the Allgower–Donati technique, followed by a thick cotton dressing. After surgery, patients were kept on below-knee slabs with their limbs elevated until their wounds healed and sutures were removed, typically by the 14^th day. Ankle range of motion exercises commenced in the 2^nd post-operative week. Regular outpatient follow-ups were conducted at 6 weeks, 12 weeks, 24 weeks, and 1 year, encompassing clinical and radiological imaging assessments. Weight-bearing was allowed after three months, depending on the fracture’s healing.

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Figure 1:

(a) Intraoperative fluoroscopic lateral view of foot showing the plate (red) and K-wires (yellow); (b) Intraoperative clinical image of the surgical exposure depicting thr plate (blue) and skin flap held with K-wires(red); (c) Immediate post-operative clinical image of the closure with monofilament polyamide sutures (red).

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For conservative management, we attempted a closed reduction by plantar-displacing both the forefoot and hindfoot to undo the injury mechanism, which facilitated elevation of the posterior facet. The standard treatment involved elevation, rest, ice application, and non-steroidal anti-inflammatory drugs. In cases of sudden foot swelling, we temporarily immobilized the foot with a short leg plaster of paris (POP) back slab and recommended limb elevation along with anti-inflammatory medication and pain relievers [Figure 2]. Once the swelling subsided, a short leg cast was applied. Limb elevation and toe movements were initiated.

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Figure 2:

A case of closed calcaneum fracture managed conservatively, showing (a) X-ray, (b) computed tomography scan, (c) last follow-up X-ray, and (d) range of movements.

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Patients were allowed to walk without weight-bearing using a walker or crutches. After 3 weeks, the cast was checked for looseness and recast if needed. Patients were encouraged to elevate the limb and actively move their toes whenever in bed. The cast was removed at 12 weeks.

Protected weight-bearing was allowed only after 12 weeks. Once patients began weight-bearing, they gradually transitioned into regular shoes based on their tolerance. Follow-ups involved clinical and radiological examinations. At the last follow-up, patients were finally assessed using the AOFAS scoring system and the Modified Rowe Score.

The radiological assessment involved accurate measurement of Gissane’s and Bohler’s angles, along with the union rate. Functional results were assessed using the Ankle Society (AOFAS) score,^[5] modified ROWE score,^[6] and American Orthopedic Foot and Ankle Scores, with 90 to 100 signifying an excellent result, 75 to 89 reflecting a good outcome, and 55 to 74 illustrating a fair score. At the same time, anything below 50 was deemed poor.

The data collected were carefully entered into a Microsoft Excel spreadsheet and subsequently analyzed using Statistical Package for the Social Sciences software version 25.0. Continuous data were reported as means with standard deviations (SD), while categorical data were presented as proportions and percentages. Chi-square and Fisher’s exact tests were employed for qualitative data analysis, and the t-test was used for quantitative data. To compare the mean angles before and after surgery, a student paired t-test was conducted, with a p-value of <0.05 deemed statistically significant.

RESULTS

This study focused on patients with intra-articular calcaneal fractures (Sanders type II, III, and IV), who were treated using both surgical and conservative methods [Table 1]. Results were assessed in terms of post-operative functional outcomes related to range of movement following union, the time taken for fracture union, and complications occurring early and late after surgery.

Sander’s type II fractures were the most frequent in our study, followed by type III. Type IV was the least frequently observed [Figure 3]. The average duration for radiological union was 14.06 ± 2.54 weeks for those treated conservatively, compared to 13.94 ± 2.30 weeks for the surgically treated group. It was noted that there was no significant difference in the time needed for union between the two groups. Nearly all operated patients showed an acceptable reduction on radiographs, whereas only 41% of patients treated conservatively exhibited an acceptable reduction on radiographs.

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Figure 3:

Types of distribution in Sander’s fracture classification within the study population.

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Approximately 70% of patients exhibited a Bohler’s angle ranging from 10° to 20°, while 29% had angles below 10° during the pre-cast phase, resulting in an average Bohler’s angle of 16.65 ± 6.23°. In the post-cast period, 23% of patients exhibited a Bohler’s angle <10°, while 65% had an angle ranging from 10° to 20°, resulting in a mean Bohler’s angle post-cast of 18.41 ± 6.79°. Whereas, approximately 35% of patients had a Bohler’s angle <10°, while 29% had an angle ranging from 10° to 20° during the pre-operative period, resulting in a mean Bohler’s angle of 15 ± 5.67°. In the post-operative phase, 47% of patients exhibited a Bohler’s angle ranging from 20° to 30°, while 53% ranged from 30° to 40°, resulting in a mean postoperative Bohler’s angle of 32.94 ± 5.65°.

About 59% of patients exhibited a Gissane angle ranging from 130° to 145° during the pre-cast period, with an average Gissane angle of 138.24° ± 7.93°. However, in the post-cast phase, 59% of patients exhibited a Gissane angle between 130° and 145°, resulting in an average post-cast Gissane angle of 134.71 ± 7.83°. Whereas approximately 65% of patients exhibited a Gissane angle ranging from 130° to 145° before surgery, with an average Gissane angle of 139.35° ± 6.48°. In the post-operative phase, 59% of patients exhibited a Gissane angle ranging from 110° to 120°, resulting in a mean postoperative angle of 117.06 ± 6.12°.

For Bohler’s angle, the mean values significantly increased from pre-operative (15°) to post-operative (32.94°), indicating a positive surgical outcome. The mean values for pre-cast and post-cast are 16.67° and 18.41°, respectively. For Gissane’s angle, the data show a decrease from pre-operative (139.35°) to post-operative (117.06°), with pre-cast and post-cast means of 138.24° and 134.71°, respectively. This change suggests improvements post-surgery [Figure 4].

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Figure 4:

Comparison of mean Bohler’s and Gissane’s angles before and after intervention.

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The AOFAS score was excellent at 35.29%, good at 35.29%, fair at 5.88%, and poor at 23.53% in patients treated operatively. In the patients treated by conservative method, the AOFAS score was excellent in none, fair at 52.94%, good at 11.76%, and poor at 35.29%. The AOFAS score (mean) was 81.65 ± 10.02 in the operative patients, much more than the conservatively treated patients, i.e., 68.53 ± 11.35. Overall, most studies indicate a significant advantage of surgical intervention [Figure 5].

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Figure 5:

AOFAS score distribution of functional outcomes within the study population. AOFAS: American orthopaedic foot and ankle society.

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The Modified Rowe Score was satisfactory in 23.5%, good in 58.8%, excellent in 17.6%, and poor in none of the patients treated operatively. Among the patients treated conservatively, the Modified Rowe Score was satisfactory in 35.3%, good in 41.2%, excellent in 11.8%, and poor in 11.8%. The modified Rowe score (mean) was 81.47 ± 13.67 in the operative patients, which was significantly higher than in the conservatively treated patients (72.65 ± 15.12) [Figure 6]. There is no statistically significant difference in AOFAS or Rowe scores between males and females [Figure 7]. In addition, the side of the fracture does not significantly impact these scores. However, Sanders’ fracture classification reveals a statistically significant difference in the outcome scores. The number of study subjects with complications was higher in the cast group [Figure 8], illustrating the distribution of complications among study participants in both groups. The heel pad pain was experienced in three subjects in the cast group as compared to the operative group. However, the complications, such as ankle and foot stiffness and malalignment, were observed only in the cast group. Similarly, the operation-related complications, such as implant prominence and peroneal tendon-related problems, were observed only in the operative group.

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Figure 6:

Outcome distribution analyzed through the modified Rowe Score in the study group.

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Figure 7:

Boxplots comparing American Orthopaedic Foot and ankle society (AOFAS) and Rowe scores across gender, side of fracture, and Sander’s fracture types.

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Figure 8:

Complications distribution among the study population.

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DISCUSSION

This study was a comprehensive, forward-looking, comparative analysis of displaced intra-articular fractures of the calcaneus, involving 56 patients treated operatively and 56 patients treated conservatively. The study was conducted in the Department of Orthopedics at a tertiary care postgraduate teaching institute, ensuring a high level of expertise and care. The mean follow-up period was 18 months, and functional outcomes were evaluated using the AOFAS score and Modified Rowe Score. Among the 112 cases, 82% were males and 18% were females. The mean age in the operative group was found to be 30 ± 6.98 years and 37.65 ± 9.75 years in the conservatively managed group, which matched the observations of Kamath et al.^[7] (operative 34.9 and cast 35) and Rushi et al.^[8] (operative 34.7 and cast 36.03). The most frequently involved patients were in the adolescent group, and a right-sided dominance was found in 56% of the subjects, compared to 44% for the left side. In 85% of cases, the mode of injury was due to falling from a height, which closely aligns with the findings of Kamath et al.^[7] (92.7%). The present study reports an average duration of 13.94 ± 2.30 weeks for radiological union following operative treatment and 14.06 ± 2.54 weeks for conservative treatment, indicating a slightly longer recovery time for the conservative method compared to the operative method [Figures 9 and 10].

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Figure 9:

Case 1: (a) Pre-operative X-ray, (b) pre-operative computed tomography scan, (c) intraoperative fluoroscopy, (d) intraoperative clinical presentation, (e) post-operative X-ray, (f) follow-up X-ray, and (g-h) assessment of range of motion at 18-month follow-up.

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Figure 10:

Case 2: (a) Pre-operative X-ray, (b) pre-operative computed tomography scan, (c) intraoperative fluoroscopy, (d) intraoperative clinical presentation, (e) post-operative X-ray, (f) follow-up X-ray, and (g-h) assessment of range of motion at 18-month follow-up.

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The present study reports slightly longer recovery times than those reported by Rushi et al. (2021),^[8] but it aligns closely with the findings of Chandrashekhar et al.^[9] and the recent systematic review by Selim et al.^[10] for operative treatment. In terms of the Bohler’s angle, conservatively managed patients had a mean of 16.65 ± 6.23°, which increased merely to 18.41 ± 6.79° post-cast. However, for operative treatment, the angle increased significantly from 15.00° ± 5.67° preoperatively to 32.94° ± 5.65° postoperatively. These results were similar in other studies like Aslan et al.^[11] (20.0 ± 10.9° for operative and 10.9 ± 11.1° for cast). The Gissane angle showed a similar pattern, with a significant decrease for both treatments. During the pre-cast period, patients had a Gissane angle with a mean of 138.24 ± 7.93°, which decreased to 134.71 ± 7.83° after casting. For operative treatment, the angle decreased from 139.35° ± 6.48° preoperatively to 117.06° ± 6.12° postoperatively. These results were similar in other studies like Kulkarni et al.^[12] ([PRE] 158.2°, [POST] 137.6° for operatives and [PRE] 160.3° [POST] 160° for cast). Most patients, 65%, had no associated injuries.

Specific injuries included contralateral side calcaneum, acetabulum, malleolar, metatarsal, and acromion process fractures. For fracture classification, the distribution was 47% Type II, 35% Type III, and 18% Type IV for operative treatments and 65% Type II, 23% Type III, and 12% Type IV for conservative treatments. Regarding functional scores, the AOFAS score was excellent in 35%, good in 35%, fair in 6%, and poor in 24% of patients treated operatively, with a mean score of 81.65 ± 10.02. In contrast, the conservative group achieved no excellent scores, with fair scores in 53%, good scores in 12%, and poor scores in 35%, resulting in a mean score of 68.53 ± 11.35. Similarly, Kamath et al.^[7] (78.783 ± 9.582 [operated] and 71.211 ± 8.121 [cast]) reported a significant difference with a P = 0.008, reinforcing the effectiveness of surgical intervention. Ahluwalia et al.^[13] provide further evidence that surgical intervention yields better functional outcomes compared to non-operative care for displaced intraarticular calcaneal fractures, with these improvements sustained over a 2-year follow-up period. The Modified Rowe Score was satisfactory in 23%, good in 59%, excellent in 18%, and poor in none of the patients treated operatively, with a mean score of 81.47 ± 13.67. The conservative group showed satisfactory results in 35%, good results in 41%, excellent results in 12%, and poor results in 12%, with a mean score of 72.65 ± 15.12. These findings align with those of Pflüger et al.,^[14] who observed markedly improved patient-reported outcomes for surgically treated calcaneal fractures in the short- to mid-term follow-up period. Kamath et al.^[7] (74.783 ± 11.229 [operated] and 57.368 ± 7.335 [cast]) observed a very significant difference, with a P = 0.001, suggesting strong evidence in favor of the surgical approach. The present study, with a P = 0.024, also supports this conclusion, although the difference is less pronounced [Table 2].

In terms of complications, both operated and non-operated groups experienced issues, but the types and frequencies varied. The operated group faced higher rates of surgical-related issues, such as infections and stiffness,^[15] may it be open technique which were linked to a higher risk of wound complications or percutaneous techniques led to less effective reductions^[16] while the non-operated group often encountered complications such as arthritis and malunion. Nonetheless, conservative treatment comes with its complications, including issues with the peroneal tendon impingement, heel varus, and subtalar joint pain.^[17]

Pendse et al.^[18] determined that ORIF is essential in intraarticular calcaneus fractures to restore anatomical articular congruency. This method also allows for early mobilization and serves as the primary option for subtalar arthrodesis if necessary. A lateral, medial, or combined approach can be used to treat calcaneal fractures.^[19-22]

Key factors for achieving success with this method involve meticulous flap elevation, employing a “no-touch” technique with K-wires, ensuring proper mobilization, and restoring the posterior facet anatomically further supported by the randomised controlled trial by Damian et al.^[23] Based on the current study’s findings, it can be stated categorically that using operative methods for displaced intraarticular fractures serves as a realistic alternative with a positive effect on functional outcomes. Nonetheless, additional research, ideally conducted at multiple centers with a larger sample size and extended follow-up, is necessary to establish and compare these findings conclusively. Our study had limitations due to the relatively small sample size and the short follow-up period. Strengths of our study include a prospective design with standardized follow-up and the use of validated functional outcome measures. Furthermore, this study provides insight for future long-term and randomized studies.

CONCLUSION

Surgical treatment of displaced intra-articular calcaneal fractures tends to yield better functional outcomes and more precise anatomical healing compared to conservative approaches. This is supported by higher AOFAS and Modified Rowe Scores and better restoration of Bohler’s and Gissane’s angles. Nonetheless, the higher likelihood of surgical complications necessitates careful patient selection and meticulous perioperative care. These results endorse surgery as the preferred approach for suitable patients, aiming to optimize both functional and radiological results.