title: Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification.
abstract: OBJECTIVE
  The primary purpose of this study was to determine whether the Sanders computed tomography (CT) scan classification was still prognostic for outcome when long-term (10-20 years) radiographic and functional data of patients after open reduction and internal fixation for Sanders type II versus type III displaced intra-articular calcaneal fractures (DIACFs) were compared. The secondary purpose was to assess whether a bone graft or a locked plate was needed to maintain a reduction over time.
  
  
  METHODS
  Prognostic case-control study.
  
  
  METHODS
  Level I trauma hospital.
  
  
  METHODS
  Patients with operatively treated Sanders type II/III DIACF managed between January 1, 1990, and December 31, 2000, by a single surgeon were identified from a prospectively gathered database. Skeletally mature patients with a closed isolated DIACF and a minimum of 10-year follow-up were included in this analysis. All fractures were classified according to Essex-Lopresti and Sanders. Of 638 fractures, 208 met the inclusion criteria.
  
  
  METHODS
  Surgery consisted of a lateral extensile approach, posterior facet reduction, and lag screw fixation, followed by reduction of the anterior process and tuberosity with the application of a nonlocked lateral plate. Neither bone graft nor locking plates were used.
  
  
  METHODS
  Articular congruity and overall reduction were assessed by CT scan and plain radiography (Böhler and Gissane angle) immediately postoperatively and at the final follow-up examination in all patients. Functional assessment and outcome scores were obtained [AOFAS-AHS, the Maryland Foot Score, Short Form-36 (SF-36), Ankle Osteoarthritis Score (AOS), and Visual Analog Scale (VAS)], and all complications and/or subsequent surgeries were noted. A subtalar (ST) arthrodesis was considered a treatment failure and was used as the determining outcome variable for comparing the 2 groups (II vs.
  One hundred eight fractures in 93 patients were available for follow-up at a minimum of 10 years (52%). Average follow-up was 15.22 years (range, 10.5-21.2 years). Eighty were joint depression (J) and 28 were tongue-type (T) fractures. There were 70 Sanders type II and 38 Sanders type III fractures. On immediate postoperative CT scan, posterior facet reduction was anatomic in 103 fractures (95%), near anatomic in 3 fractures (1-3 mm), and approximate in 2 fractures (3-5 mm step). There were no failed reductions (>5 mm step). Long-term results indicated that only 3 fractures settled, but no plates failed. There was 1 missed peroneal tendon dislocation. Seven patients had sural neuritis. Twelve fractures (11%) required local wound care for apical necrosis. One patient had a dehiscence resulting in osteomyelitis, requiring a ST fusion. Thirty-one fractures (29 patients) developed ST arthritis, requiring an arthrodesis (30 ST, 1 triple) for unrelenting pain (VAS, 8-10) during the follow-up period, resulting in an overall long-term failure rate of 29%. Further breakdown by fracture type revealed that an ST fusion was performed in 47% of type III fractures (18/38) versus only 19% of type II (13/70) fractures (P = 0.002). Type III fractures were 4 times more likely to need a fusion compared with type II fractures (relative risk = 3.94; 95% confidence interval, 1.64-9.48). The remaining 66 patients (77 fractures) who did not require a fusion were evaluated for long-term functional outcome. Of these, only 1 patient used a cane and had a limp. Seventy-seven percent of the nonfused group (51/66) were within the US norm for the SF-36 PCS, with 46% (30/66) above the norm. The average AOFAS-AHS was 75. The average VAS was 1.75, with scores of 0-1 (very little or no pain) seen in 56% of this subset of patients (37/66).
  
  
  CONCLUSIONS
  Based on the results of this comparative analysis, the Sanders classification remains prognostic; after a minimum of 10 years, type III fractures were 4 times more likely to need a fusion than type II fractures. Secondarily, it seems that neither a locked plate nor a bone graft is required to maintain a reduction over time, as virtually no loss of reduction was seen in this series (3/108, 0.9%). The "joint first" surgical treatment did not adversely affect calcaneocuboid joint outcome. Based on these results, if severe posttraumatic ST arthritis does not occur, long-term (10-20 years) functional results with mild pain, minimal alterations in activities of daily living or work, and essentially normal shoe wear can be expected from a properly performed open reduction and internal fixation. Patients must be counseled regarding difficulty with uneven ground and an inability to return to vigorous sports activities.
  
  
  METHODS
  Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; †Oakland Orthopaedic Surgeons, Royal Oak, MI; ‡Department of Orthopaedics and Trauma Surgery, Ondokuz Mayis University, Samsun, Turkey; and §Department of Family Science, University of Maryland, College Park, MD.
authors.forename: Roy
authors.initials: R
authors.lastname: Sanders
authors.forename: Zachary M
authors.initials: ZM
authors.lastname: Vaupel
authors.forename: Murat
authors.initials: M
authors.lastname: Erdogan
authors.forename: Katheryne
authors.initials: K
authors.lastname: Downes
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002111:Calcaneus / Q000000981:diagnostic imaging* / Q000293:injuries / Q000601:surgery; D016022:Case-Control Studies; D005260:Female; D005500:Follow-Up Studies; D050723:Fractures, Bone / Q000145:classification / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D057072:Intra-Articular Fractures / Q000145:classification / Q000000981:diagnostic imaging* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D014057:Tomography, X-Ray Computed