The calcaneus, also known as the heel bone, is the largest tarsal bone in the foot. It is the most commonly fractured tarsal bone, accounting for approximately 1-2% of all fractures in adults. Intra-articular fractures make up about 75% of calcaneal fractures, with around 70% of them being of the joint depression type. These fractures are frequently observed in younger males who have experienced high-energy trauma, often due to falls from heights or motor vehicle accidents. [1,2]

Calcaneal fractures are associated with blistering and significant swelling within the first 36 hours after injury. Compartment syndrome, complicates about 4-10% of all calcaneal fractures. Given that many affected individuals are industrial workers, these fractures carry a considerable economic burden in today's society. [3,4]

The evaluation of calcaneal fractures typically involves axial and lateral X-rays of the hind foot. Lateral radiographs are used to measure the Bohler's and Gissane's angles. Despite advancements in treatment technology, managing and achieving favorable outcomes for these fractures remains challenging. Treatment options include conservative approaches and operative methods. [5,6]

Conservative treatment may result in subtalar joint incongruity and malalignment between the ankle and foot, leading to subtalar joint arthritis and pain. Studies have shown that patients treated conservatively were 5.5 times more likely to require sub-talar arthrodesis for arthritis in the future. [7,8]

On the other hand, operative management, particularly with the conventional open reduction and internal fixation (ORIF) technique, can be associated with wound healing problems in up to 43% of patients. [7,8]

Recent advances in operative management, including the use of the lateral extensile approach and newer locking plates, have made surgical treatment more appealing. The lateral extensile approach involves raising a full-thickness flap that protects the peroneal tendons, sural nerve. The flap vascularity is also preserved thereby reducing the risk of wound complications. This has been theorized to improve the efficacy of operative treatment. [9,10,11]

Therefore, this study was conducted to assess the outcomes of calcaneal fractures treated with this newer operative approach, especially in a rural set up in India where the functional demands of the patients are different from the western world.  The study aimed to evaluate the overall outcomes, considering the functional, radiological, and clinical aspects of the cases

This study employed a prospective, interventional design and was conducted at a rural tertiary-level hospital in India.

Study Population:

The study included patients who presented to the outpatient and emergency departments of the Department of Orthopaedics from July 2019 till June 2023. The sample population consisted of individuals with joint depressed intra-articular calcaneal fractures.

Sample Size:

A total of 51 patients were included in the study.

Inclusive and Exclusive Criteria:

Inclusive criteria encompassed patients above 18 years of age with acute displaced calcaneal fractures falling under the joint depression category according to the Essex-Lopresti Classification. Exclusion criteria consisted of extra-articular calcaneal fractures, undisplaced calcaneal fractures, calcaneal fractures associated with other bone injuries, compound fractures of the calcaneus, calcaneal fractures with poor skin condition, patients unfit for surgery or with peripheral vascular disease, calcaneal fractures older than 3 weeks, patients with uncontrolled chronic diabetes and chronic smokers, patients exhibiting gross osteoporosis on X-ray, and patients with tongue-type calcaneal fractures according to the Essex-Lopresti classification.

Data Collection:

Patients suspected to have a calcaneal fracture underwent evaluation using lateral and axial X-rays of the heel. The fractures were classified according to the Essex Lopresti classification system based on the lateral radiographs. The Bohler's and Gissane's angles were calculated preoperatively. The functional score at presentation was measured using the AOFAS Ankle Hind foot scale.

Surgical Consideration:

Preliminary management involved splinting with limb elevation and administering appropriate analgesics and anti-inflammatory drugs. Surgery was performed once the "wrinkle sign" appeared. An extensile lateral approach, involving a full-thickness flap, was utilized. Flaps were retracted using the "no touch" technique, and in some cases lateral wall elevation was performed to facilitate reduction. Fixation was accomplished using a calcaneal locking plate and screws. Wound closure was conducted over a suction drain using interrupted Allgower Donati sutures, following strict aseptic precautions. The drain was removed on day 2, and physiotherapy commenced on the second day post-surgery. Strict limb elevation on two pillows was maintained till the sutures were removed. Sutures were removed on day 14 or as per wound conditions. Prophylactic antibiotics were administered. Patients were followed up at 1 month, 3 months, and 6 months.

Evaluation included X-rays and AOFAS scores at each follow-up visit. X-rays were used to assess the restoration of Bohler and Gissane’s angles and the time required for radiological union. The AOFAS scores categorized scores of 90 to 100 points as "excellent," 80 to 89 points as "good," 60 to 79 points as "fair," and less than 60 points as "poor." The collected data was coded and entered into a Microsoft Excel Worksheet. Data analysis was performed using SPSS Version 20.0 software.

Categorical data was expressed as rates, ratios, and proportions, and comparisons were made. A probability value (p-value) of ≤0.05 at a 95% confidence interval was considered statistically significant.

The age distribution of the study population revealed that the majority of patients (72%) belonged to the age group of 31-60 years, with a mean age of 41.4 ± 11.25 years. In terms of occupation, farmers accounted for the largest proportion (39.21%) of patients, followed by construction workers (23.53%). Regarding the mode of injury, out of the 51 patients, 27 (52.94%) had a history of road traffic injury (RTI), while 23 (45.09%) patients had a history of falls from height. The majority of patients (76.47%) underwent surgery within 7-10 days of the injury. The mean time for fracture union was 2.13 ± 0.35 months, and the mean duration of hospitalization was 10.07 ± 1.38 days.

Analysis of the Gissane’s Angle distribution showed that a majority of patients (79.22%) had Gissane’s angles greater than 145º preoperatively, while 37 (72.54%) had Gissane’s angles ranging from 130-145º postoperatively, which was statistically significant (P<0.05). The postoperative mean Gissane’s angle was 133.47 ± 5.23 compared to 154.33 ± 8.69 preoperatively, also demonstrating statistical significance (P<0.05). Examining the Bohler's Angle distribution at different intervals, it was found that preoperatively, 40 patients (78.43%) had Bohler's angles less than 10º, while postoperatively 37 patients (72.54%) had normal Bohler's angles. The postoperative mean Bohler's angle was 27.78 ± 6.90, whereas it was 12.26 ± 6.94 preoperatively, showing a significant difference (P<0.05).

Assessment of the Ankle-Hind foot Scale at different intervals revealed that the preoperative score was 40.76 ± 6.91, which significantly improved to 87.73 ± 5.45 at the final follow-up (P<0.05). The functional outcomes assessed by the

Ankle-Hind foot scale indicated that 33.33% of patients had an excellent outcome, 60.79% had a good outcome, and 5.88% had a fair outcome. Full weight bearing was initiated after 6-8 weeks in 33.33% of patients, after 8-10 weeks in 60.79% of patients, and only after more than 10 weeks in 0.588% of patients.

When reviewing complications, it was observed that the commonest complication in this study was widening of the heel which was observed in 6 patients (11.76%), followed by infection in 3 patients (5.88%), persistent heel pain in 3 patients (5.88%) and 2 patients (3.92 %) developed superficial wound dehiscence. All 3 patients who developed infection had superficial infection which responded to regular dressings and oral antibiotics. Most patients (60.79%) began full weight bearing at 8-10 weeks. Regarding the return to normal occupation, 90.20% of patients had no restrictions at the final follow-up, while only 9.8% of patients experienced some limitations in resuming their usual occupation.

Calcaneal fractures pose a challenging situation for orthopedic surgeons, with varying opinions on conservative versus surgical treatment. Our study's epidemiological findings regarding age, sex, and mode of injury were consistent with similar studies. All of the patients underwent surgery between 10 – 14 days following the injury when soft tissue swelling had significantly reduced and wrinkle sign appeared on foot as early surgery has been associated with increased infection rates and soft tissue healing complications. The mean time for fracture union was 2.13 ± 0.35 months, which supports the advantages of operative management in achieving faster union as in other studies in literature too by Rajesh V Chawda et al, Carlo Biz et al, Tennet TD et al and Benirscheke S K et al [12,13,14,15]

Analyzing the Gissane’s Angle distribution, most patients had angles greater than 145º preoperatively, while the majority had angles of 130-145º postoperatively. This significant difference indicates improved outcomes with operative treatment. This was consistent with studies by Rajesh V Chawda et al, A Islam and C McDonald [12,16]. Similarly, evaluating the Bohler's Angle at different intervals, the preoperative angles were mostly less than 12º, while postoperative angles showed improvement, emphasizing the importance of restoring Bohler's angle for prognosis. This was consistent with the studies by Rajesh V Chawda et al, Carlo Biz et al, A Islam et al and Paley and Hall [12,13,16,17]

Comparing the Ankle-Hind foot Scale at different intervals, the preoperative scores significantly improved at the final follow-up, aligning with existing literature advocating for surgical treatment to achieve better functional outcomes. Traditional non-operative treatment often resulted in complications such as incomplete restoration of calcaneal anatomy, short and wide heels, and impingement of peroneal tendons, leading to unfavorable outcomes. [21,22,23]

In terms of complications, our study observed heel widening, operative site infections, persistent heel pain. Superficial infections were successfully treated with antibiotics, and superficial wound dehiscence healed with dressing and antibiotics, thanks to preoperative antibiotic administration and proper surgical practices. Post-traumatic arthritis was rare, likely due to the short follow-up period. Most patients were able to resume their pre-injury duties without significant restrictions, supporting the improved outcomes and low complication rates associated with operative procedures as in the studies by Voclav Rak D et al, Gusic N et al and Mohamad Mostafa F et al . [18,19,20]

Our study favored the use of an extensile lateral approach, providing good visualization of the joint depressed fractures of calcaneum as in studies by Jain V et al and Freeman B et al. [24,25]. However, recent advancements have suggested a sinus tarsi minimally invasive approach to minimize soft tissue complications by Weber M et al and Schepers T et al etc. Both approaches yielded comparable results in terms of restoring calcaneal anatomy, with the sinus tarsi approach offering fewer complications and reduced operative time. [26,27]

Limitations of our study

Included a small sample size, limited follow-up period, and reliance on plain radiographic findings without CT scans.

Operative treatment using an extensile lateral approach for these types of fractures resulted in improved functional outcomes and minimal complications. Both functional and radiological outcomes were favorable. Specifically, displaced, comminuted and joint depressed fractures showed better functional outcomes with plating, particularly when the Bohler's and Gissane’s angles were restored.

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