Effect of Surgeon Training, Fracture, and Patient Variables on Calcaneal Fracture Management

FOOT & ANKLE INTERNATIONAL

Copyright 2011 by the American Orthopaedic Foot & Ankle SocietyDOI: 10.3113/FAI.2011.0262

Effect of Surgeon Training, Fracture, and Patient Variables on CalcanealFracture Management

John Y. Kwon, MD1; Amna Diwan, MD1; Seenu Susarla, DMD, MPH2; Aron T. Chacko, BS3; Edward K. Rodriguez, MD, PhD3

Boston, MA

ABSTRACT

Background: There appears to be a general lack of consensusin treating calcaneus fractures. Many different patient-basedvariables such as smoking, diabetes, or occupation, may influ-ence treatment decisions possibly more so than the natureof the injury itself. Indications for operative versus nonop-erative treatment are often unclear. The goals of this studywere to determine if lack of consensus exists, determine whichfactors most influence orthopaedic surgeons in choosing oper-ative versus nonoperative treatment and determine if thereare differences in treatment based on fellowship training andexposure to these injuries. Materials and Methods: Practicingorthopaedic surgeons of various backgrounds and training wereadministered an electronic survey. The survey consisted ofclinical vignettes and questions regarding fellowship training,demographics and exposure to calcaneus fractures. Orthopaedicsurgeons were asked to weigh the importance of patient-basedvariables in determining operative versus nonoperative treat-ment. Results: For patients with an uncomplicated medicalhistory, there was a general consensus on treatment as guidedby the Sanders classification. For those with a complex medicalhistory, there was less consensus on management despite frac-ture pattern. Foot & ankle fellowship-trained surgeons (F&AT)ranked calcaneal deformity as more important than traumafellowship-trained surgeons (NFT), and ranked peripheralvascular disease (PVD)/diabetes mellitus (DM) more important

1Harvard Combined Orthopaedic Residency Program, Boston, MA.2Harvard Medical School, Boston, MA.3Dept of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, HarvardCombined Orthopedic Surgery Program, Boston, MA.

No benefits in any form have been received or will be received from a commercialparty related directly or indirectly to the subject of this article.

Corresponding Author:John Y. Kwon, MDDept. of Orthopaedic SurgeryMassachusetts General HospitalClinical Instructor, Harvard Medical SchoolMassachusetts General Hospital55 Fruit St.Boston, MA 02114E-mail: [email protected] information on pricings and availability of reprints, call 410-494-4994, x232.

than did both trauma fellowship-trained surgeons (TFT) andNFT surgeons. There was no significant difference in choosingoperative versus nonoperative treatment for surgeons treatingmore calcaneus fractures (more than four per month) versusthose who treated fewer (less than one a month). Conclu-sion: There was general agreement among surgeons regardingthe most important variables for determining management ofcalcaneus fractures. How this information is utilized variesaccording to practitioner and leads to varying consensus.There was generalized consensus regarding management incases of anatomic deformity at either end of the spectrumof severity and non-complex medical histories. When addi-tional confounders were added, the agreement between surgeonsdeclined.

Key Words: Calcaneus Fracture; Operative Calcaneus; Nonop-erative Calcaneus

INTRODUCTION

The treatment of calcaneus fractures is controversial inthe literature. Historically, the pendulum has swung betweenconservative and surgical treatment. As early as 1916, Cottonand Henderson recognized poor outcomes from calcaneusfractures stating, “The man who breaks his heel bone isdone.”5 However in the early 1930’s Bohler advocatedopen reduction internal fixation but recognized technicalproblems and associated poor outcomes secondary to pooranesthetics, limited radiography/fluoroscopy, as well as apoor understanding of principles of internal fixation.1 Theadvent of better anesthetics, widespread use of antibi-otics, and advancement in imaging and fixation princi-ples/instrumentation has advanced our ability to achieveimproved outcomes from surgery. Despite these advancesthe controversy regarding treatment of calcaneus fracturesremains. With operative treatment the risk of complications isincreased, especially in high risk patients. Generally nonop-erative treatment has been advocated for these patients

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Foot & Ankle International/Vol. 32, No. 3/March 2011 CALCANEAL FRACTURES AND SURGEONS’ TRAINING 263

but results have been poor. Several authors have lookedto address risk factors for treatment of calcaneus frac-tures and many patient-based variables such as smoking,diabetes, occupation, and worker’s compensation3,4 havebeen shown to affect outcomes. For example, in a large,prospective, randomized multicenter trial comparing oper-ative with nonoperative treatment of displaced intra-articularcalcaneus fractures, findings were statistically different forsuch patient-based variables. However, to our knowledgethere is no agreed-upon algorithm to effectively weighthese multiple patient-based variables and help orthopaedicsurgeons determine the best course of treatment. It is unclearhow surgeons decide who to treat operatively versus nonop-eratively and what are the factors that influence this decision.It was our hypothesis that treatment of calcaneus fracturesmay be highly influenced by surgeon training, practice char-acteristics and exposure to patients with calcaneus fractures.To our knowledge there has been no study that has analyzedwhat variables surgeons actually assign more importance toand how this influences their management of patients withcalcaneus fractures. The purpose of the current study wasto illustrate how various patient, surgeon, and fracture vari-ables influence the management of calcaneus fractures andhow differences in training may account for this.

MATERIALS AND METHODS

An extensive internet search was performed to identifywhich surgeons would receive the survey. This was basedon the availability of email addresses on publically availableor freely obtainable sources such as departmental listings,society listings and personal contact listings. No emailaddress lists were commercially purchased.

Non-responders were sent a second request for participa-tion. Orthopaedic surgeons were sent an electronic surveythrough www.surveymonkey.com which consisted of 22questions including five clinical vignettes. The surveywas sent electronically to 2,471 orthopedic surgeons andresponses were received from 375 surgeons, resulting ina 15% response rate. The study sample was composed of183 foot & ankle fellowship-trained (F&AT) orthopaedicsurgeons, 61 trauma fellowship-trained (TFT) orthopaedicsurgeons, and 117 neither fellowship-trained (NFT) ortho-paedic surgeons. Fourteen participants reported fellowshiptraining in both trauma and foot & ankle surgery.

Surgeons were asked various questions including fellow-ship training, practice demographics, patient population,number of acute calcaneus fractures (as defined by injuryless than 2 weeks old) treated per month, as well as theimportance of different patient-based variables that mayinfluence treatment. Figure 1 demonstrates question #7 fromthe survey. Surgeons were asked to weigh the impor-tance of the following variables in determining operativeversus nonoperative treatment: age, gender, smoking history,ETOH/substance abuse, occupation, worker’s compensa-tion, articular involvement, calcaneal deformity, periph-eral vascular disease/diabetes, compliance issues and othermedical comorbidities. Surgeons were also shown five clin-ical vignettes each of which included a short medical history,a lateral X-ray of the foot and a single coronal CT scan ofthe hindfoot. The lateral radiograph was included in eachvignette so that surgeons could assess Bohler’s angle, angleof Gissane, and heel shortening/loss of height. The singlecoronal CT image was included so surgeons could measurethe amount of articular displacement and classify each frac-ture per the Sanders classification. The vignettes demon-strated patients of different gender, varying age, medical

Fig. 1: Question #7 asking surgeons to indicate the importance of patient-based variables.

Copyright 2011 by the American Orthopaedic Foot & Ankle Society



264 KWON ET AL. Foot & Ankle International/Vol. 32, No. 3/March 2011

comorbidities, social histories, and calcaneus fractures withvarying articular involvement/deformity. For each clinicalvignette surgeons were asked various questions regardingtheir decision for operative versus nonoperative management,

need for referral and factors influencing their decisions.Figure 2 demonstrates clinical vignette #4 and associatedquestions. Surgeons were given the option to opt out ofparticipation. Results were tabulated by Surveymonkey.com.

A

B

Fig. 2: Clinical vignette #4 with associated questions.





The clinical vignettes, with images, are described below:

Clinical vignette #1 (Figure 3)

HPI: 27-year-old female s/p fall off ladder while paintingher room

PMHx: noneSH: no toxic habits, works as accountantFx: Sanders 1 calcaneus fx


HPI: 55-year-old male s/p fall down stairs while inebri-ated

PMHx: un-treated diabetes mellitusSH: + tobacco (1 PPD × 30 years), + ETOH (2–4

beers/night), hx of recent incarceration forassault

Fx: Sanders 3 calcaneus fx


HPI: 50-year-old male s/p MVAPMHx: none

SH: no toxic habits, works in constructionFx: Sanders 4 calcaneus fx

A B

Fig. 3: Coronal CT image (A) and plain film (B) of clinical vignette #1.

A B


A B






A B


Table 1: Summary Statistics for Study Population

Fellowship Trained

SampleNon-F&A/trauma

Fellowship TrainedFoot and

Ankle Trauma Both

n = 375 n = 117 n = 183 n = 61 n = 14 p value

Practice Characteristics1

Solo 27 (7.2) 13 (11.1) 11 (6.0) 2 (3.3) 1 (7.1) 0.22Group<5 43 (11.5) 17 (14.5) 21 (11.5) 2 (3.3) 3 (21.4) 0.09≥5 167 (44.5) 39 (33.3) 110 (60.1) 14 (23.0) 4 (28.6) <0.001Academic 138 (36.8) 41 (35.0) 47 (25.7) 43 (70.5) 7 (50.0) <0.001Rural 18 (4.8) 8 (6.8) 8 (4.4) 2 (3.3) 0 (0.0) 0.54Suburban 40 (10.7) 12 (10.3) 24 (13.1) 1 (1.6) 3 (21.4) 0.05Urban 45 (12.0) 16 (13.7) 23 (12.6) 5 (8.2) 1 (7.1) 0.68Non-Trauma Center 45 (12.0) 17 (14.5) 25 (13.7) 1 (1.6) 2 (14.3) 0.06Level II or Level III 60 (16.0) 18 (15.4) 34 (18.6) 6 (9.8) 2 (14.3) 0.44Trauma CenterLevel I Trauma Center 29 (7.7) 4 (3.4) 15 (8.2) 8 (13.1) 2 (14.3) 0.09

Patient Population <0.001General Orthopedics 91 (24.3) 55 (47.1) 27 (14.8) 8 (13.1) 1 (7.1)Foot and Ankle 180 (48.0) 14 (12.0) 152 (83.1) 4 (6.6) 10 (71.4)Orthopedic Trauma 64 (17.1) 11 (9.4) 3 (1.6) 48 (78.7) 2 (14.3)Other Orthopedic Subspecialty 40 (10.6) 37 (31.6) 1 (0.5) 1 (1.6) 1 (7.1)

Fracture Exposure <0.001<1 149 (39.7) 74 (63.2) 63 (34.4) 10 (16.4) 2 (14.3)1–4 211 (56.3) 39 (33.3) 114 (62.3) 46 (75.4) 12 (85.7)>4 15 (4.0) 4 (3.4) 6 (3.3) 5 (8.2) 0 (0.0)

Difficulty accessing a specialist? (Yes) 13 (3.5) 11 (9.4) 1 (0.5) 1 (1.6) 0 (0.0) <0.001Does availability of specialists 5 (1.3) 4 (3.4) 0 (0.0) 1 (1.6) 0 (0.0) 0.45influence your treatment decisions? (Yes)

1, For practice characteristics, the numbers listed may not add, in any given category, to the total number of respondents, since each respondent could listmultiple choices for practice characteristics. For these variables, the number of respondents selecting that option and the percent of total respondents islisted.






HPI: 29 yo male s/p fall off scaffolding at workPMHx: none

SH: social smoking (4 cigarettes/week), social ETOH(4–6 beers Friday night), works in construction

Fx: Sanders 2 calcaneus fx


HPI: 56-year-old male s/p fall off ladderPMHx: CAD s/p CABG 5 years ago, hx of mild stroke

SH: no toxic habits, works as lawyerFx: Sanders 2 calcaneus fx

STATISTICAL METHODS

Survey data were entered into a statistical database (SPSSv.11.0, SPSS Inc., Chicago, IL) for analysis. Descriptivestatistics were computed to provide a general description ofthe sample and for the various subgroups, which includedF&AT surgeons, TFT surgeons, and NFT surgeons. Surveyresponses with scaled categorical data regarding the impor-tance of various factors in determining treatment algorithmwere converted to importance scores by assigning ascendingnumerical values to each graded response category (0, no

importance; 1, little importance; 2, some importance; 3,moderate importance; 4, very important; 5, extremely impor-tant). The numerical scores for each respondent were subse-quently averaged and the means for various parameterswere compared using bivariate statistics. Given the lackof confirmed normality within the dataset, non-parametricmethods were used to compare the different study groups. Formultiple comparisons, the Bonferroni procedure was used.For all analyses, a p value <0.05 was considered statisticallysignificant.

RESULTS

In regards to practice demographics the majority ofsurgeons reported participation in a group practice (92.8%).Approximately 37% of respondents stated that at least partof their practice was in an academic center. Even thougha minority of respondents reported affiliation with level 1(7.7%), level 2, or level 3 (16.0%) trauma centers, 56.3%reported seeing between one and four calcaneus fractures permonth. Descriptive statistics for the population are summa-rized in Table 1. While F&AT surgeons were significantlymore likely to work in groups with more than five surgeons(p < 0.01), TFT surgeons were more likely to be found inacademic centers (p < 0.01). As expected practice patternsdiffered significantly between surgeons with the practice

Table 2: Comparison of Relative Importance Rankings1 Which Characteristics are the Most Important When TreatingCalcaneus Fractures? (0 = No Importance; 5 = Extremely Important)

Fellowship Trained

SampleNon-F&A/trauma

Fellowship TrainedFoot and

Ankle Trauma Both

n = 375 n = 117 n = 183 n = 61 n = 14 p value

Age 2.7 ± 1.1 3.0 ± 1.2 2.6 + 1.1 2.5 + 1.2 2.5 + 1.3 0.07Gender 0.6 ± 0.9 0.65 ± 0.9 0.5 + 0.9 0.8 + 1.0 0.6 + 1.0 0.11Smoking History 3.3 ± 1.4 3.1 ± 1.4 3.5 + 1.2 3.0 + 1.5 2.8 + 1.5 0.01Alcohol or Substance Abuse History 2.8 ± 1.3 2.8 ± 1.4 2.9 + 1.2 2.7 + 1.4 2.8 + 1.0 0.55Occupation 2.4 ± 1.3 2.6 ± 1.3 2.4 + 1.2 2.4 + 1.3 2.3 + 0.9 0.56Work vs. Non-Work Related Injury 1.3 ± 1.3 1.2 ± 1.2 1.4 + 1.3 1.6 + 1.3 1 + 1.0 0.16Articular Involvement 4.2 ± 0.9 4.2 ± 0.9 4.2 + 0.9 4 + 1.0 4.1 + 0.8 0.41Calcaneal Deformity 4.3 ± 0.8 4.1 ± 0.8 4.4 + 0.7 4.3 + 0.9 4.1 + 0.9 0.01Peripheral Vascular Disease or Diabetes 4.0 ± 1.0 3.8 ± 1.1 4.2 + 0.9 3.9 + 1.2 3.9 + 0.8 <0.001Compliance Issues 3.5 ± 1.1 3.5 ± 1.1 3.6 + 1.0 3.3 + 1.3 3.5 + 0.5 0.29Other Medical Comorbidities 3.2 ± 1.1 3.2 ± 1.1 3.2 + 1.0 3.1 + 1.1 2.8 + 1.1 0.39

1, The numerical scores in each category listed above are reported as mean ± SD. These values were computed by averaging the assessments of therespondents according to the following scale: 0, No importance; 1, Little Importance; 2, Some Importance; 3, Moderate Importance; 4, Very Important; 5,Extremely Important.





patterns noted to be consistent with the corresponding fellow-ship training (i.e. F&AT surgeons had significantly higherproportions of their practice dedicated to foot and ankleproblems). TFT surgeons were significantly more likely tosee acute calcaneus fractures than F&AT surgeons, who, inturn, were more likely to see calcaneus fractures than NFTsurgeons (p < 0.02).

Table 2 provides a summary of the relative importance ofvarious contributing factors in determining operative versusnonoperative management of calcaneal fractures. Factorsassociated with anatomic deformity (calcaneal deformity orarticular involvement) were rated the most important in termsof determining treatment for the group as a whole and withineach training subgroup. Gender and injury setting (work-related versus non-work related) were consistently reportedas the least important factors for determining treatmentcourse. The relative rankings of factors are shown graphicallyin Figure 7.

Table 3 summarizes the treatment decisions of the variousgroups by clinical vignette, along with the pertinent casecharacteristics. For clinical vignette #1, the vast majority ofrespondents (96%) stated that they would manage this injurynonoperatively, with no significant differences noted basedon level of training (p = 0.37). For clinical vignette #2, 59%of the sample stated that they would manage the fractureoperatively, with F&AT surgeons statistically significantlymore likely to suggest nonoperative management than NFTsurgeons (68% versus 47%, respectively, p = 0.01). Themajority of respondents (greater than 90%) recommendedoperative management in clinical vignettes #3 and 4. Seventypercent of respondents recommended nonoperative manage-ment for clinical vignette #5.

DISCUSSION

The results of this study suggest there is general agree-ment in terms of which factors orthopaedic surgeons believeare the most important for determining management ofcalcaneal fractures. In general, surgeons consider thosefactors which cause anatomic disruption (calacaneus defor-mity and articular disruption) or impaired wound healing tothe fractured area (diabetes mellitus or peripheral vasculardisease, smoking) to be of extreme importance. These factorswere generally followed by social factors (substance abuse,compliance issues) and other medical comorbidities (notincluding PVD/DM) which were deemed to be of moderateimportance. Finally, the least important factors were demo-graphic factors (age, gender, occupation and work versusnon-work related injury).

While these findings suggest a clinical paradigm forthe management of calcaneus fractures, there were notice-able differences in how the information related to thesefactors was utilized across specialists with different levels oftraining. In general for patients with uncomplicated medicalhistory there is general consensus on treatment as guided bythe Sanders classification. In cases where there was artic-ular involvement with displacement at either end of thespectrum of severity (Sanders 1 or 4) there was gener-alized agreement between surgeons regarding management(greater than 90% recommending the same treatment). Whenadditional confounding variables were added, the agreementon management of the various fracture patterns betweensurgeons decreased. This was found to be the case onlyin the presence of factors considered to be of moderateor greater importance. For example clinical vignette #4

Fig. 7: Relative importance rankings by training level.





Tab

le3:

Dec

isio

nPr

opor

tion

byC

linic

alV

igne

tteC

hara

cter

istic

s

Tre

atm

ent

Rec

omm

enda

tion

Sam

ple

Non

-Fel

low

ship

Tra

ined

Foo

tan

dA

nkle

Tra

uma

Bot

hF

eatu

res

Cas

en

=37

5n

=11

7n

=18

3n

=61

n=

14A

geG

ende

rD

MP

MH

Smok

eE

TO

HSa

nder

sC

ompl

yW

ork

Cas

e1

27F

No

No

No

No

1N

oN

oO

pera

tive

3.2%

5.1%

2.2%

1.6%

7.1%

Non

oper

ativ

e96

.8%

94.9

%97

.8%

98.4

%92

.9%

Cas

e2

55M

Yes

No

Yes

Yes

3Y

esN

oO

pera

tive

40.8

%47

.0%

32.2

%42

.6%

42.9

%N

onop

erat

ive

59.2

%53

.0%

67.8

%57

.4%

57.1

%C

ase

350

MN

oN

oN

oN

o4

No

No

Ope

rativ

e92

.5%

88.0

%94

.0%

95.1

%10

0.0%

Non

oper

ativ

e7.

5%12

.0%

6.0%

4.9%

0.0%

Cas

e4

29M

No

No

Yes

Yes

2N

oY

esO

pera

tive

96.8

%94

.0%

99.5

%93

.4%

100.

0%N

onop

erat

ive

3.2%

6.0%

0.5%

6.6%

0.0%

Cas

e5

56M

No

Yes

No

No

2N

oN

oO

pera

tive

30.7

%32

.4%

27.9

%37

.7%

21.4

%N

onop

erat

ive

69.3

%67

.6%

72.1

%62

.3%

78.6

%

DM

,di

abet

edm

ellit

us;

PMH

,pa

stm

edic

alhi

stor

y;E

TO

H,

etha

nol.





describes a patient with a Sanders 2 fracture but withconfounding factors including smoking, alcohol use andworkman’s compensation. In this case, the confoundingfactors were those that were classified as having minimal tomoderate importance, and there was still significant agree-ment between surgeons, with 97% suggesting operativemanagement. This is in contrast to clinical vignette #5which described a patient with a similar Sanders 2 calca-neus fracture but with a significant medical co-morbidityincluded (CAD). In this case, there was a majority opinion tooffer nonoperative management, but less agreement (70%).Finally, in clinical vignette #2, the presence of multipleconfounding factors of varying importance (diabetes mellitus,smoking, alcohol use, and possible compliance issues) inthe setting of a Sanders 3 calcaneus fracture led to signif-icant discordance among practitioners. These data suggestthat practitioners may initially evaluate characteristics ofthe fracture (articular involvement/calcaneal deformity) andthe corresponding Sanders classification as a primary factorin determining operative versus nonoperative managementas consistency was noted across practitioners with thesebeing the most important variables. However, as confoundingfactors were added, there was less agreement between prac-titioners about the importance of the added variables and,consequently, less consensus in terms of management.

While there was no statistically significant differencebetween the group rankings for the importance of articularinvolvement in determining operative management, F&ATsurgeons felt that calcaneal deformity was more importantthan did NFT surgeons. There may be several possibleexplanations for this difference. NFT surgeons who evaluateand treat these patients likely do so when taking trauma calland less so on a referral or elective basis. This accounts forour results which demonstrate that NFT surgeons see fewersuch patients per month than F&AT surgeons. With no formalfellowship training in foot & ankle, and less exposure topatients with calcaneal fractures, NFT surgeons likely haveless experience with the long-term complications associatedwith residual calcaneal deformity. These long-term secondarycomplications from unresolved calcaneal deformity, such asdifficulty with shoe wear, gait problems, posterior tibial nerveimpingement, subtalar arthritis and anterior tibial/sub-fibularimpingement, are treated more frequently by F&AT surgeonswho receive specialized training in this domain and thus mayexplain why this group indicated calcaneal deformity as themost important factor over articular involvement relative toNFT surgeons.

All groups ranked peripheral vascular disease and diabetesmellitus overall as the third most important variable, andsmoking history as either fourth or fifth most importantvariable. However, there were statistical differences amongthe groups on the level of importance assigned on the scaleutilized (i.e., no importance to extremely important). F&ATsurgeons ranked PVD/DM statistically more important thandid both TFT and NFT surgeons. These results can be

explained by the degree of exposure that F&AT surgeonshave to the complications associated with these comorbidconditions as they affect the lower extremity in general.Calcaneus fractures aside, F&AT surgeons manage a myriadof diabetic complications including ulcerations, infectionsand Charcot joints more frequently than a general practitioneror other subspecialty trained orthopedic surgeon.

Overall, there was no significant difference in choosingoperative versus nonoperative treatment for surgeons seeingmore patients with calcaneus fractures (more than fourpatients per month) versus those who see less (less thanone patient per month). There was no statistically significantdifference between the groups with regard to treatment forclinical vignettes #1, 2, 4 and 5 although for clinical vignette#3 surgeons who saw less than one fracture per month wereless likely to choose operative management when comparedto those who saw one to four fractures per month (p = 0.03).This lack of overall significance may be due to a significantsample size asymmetry as only 15 respondents reportedseeing more than four calcaneus fractures per month. A largersample size in this group may result in differential results asthere was a trend toward significance in our study.

We recognize several weaknesses in our study. The inter-pretation of our results is limited by Level V evidenceand participation bias. Although we only achieved a 15%participation rate our distribution of NFT, F&AT and TFTsurgeons was acceptable for statistical analysis. Our conclu-sions were based on the opinions of 375 participatingsurgeons, which may be non-representative of a larger popu-lation and increased participation may have resulted indifferent results. In regards to worker’s compensation, ourrationale for inclusion of this variable in Question #7 was toinvestigate surgeon’s attitudes given published data demon-strating that worker’s compensation claims have generallyworse outcomes following calcaneus fractures than casesinvolving non-compensations issues.2–4 However, we recog-nize that this question may have been interpreted differentlybased on financial issues given differential reimbursementfor worker’s compensation claims versus non-work injuries,and misinterpretation may have affected how this variablewas weighed by our participants. Our survey was not formu-lated to assess the possible financial bias towards surgicaltreatment in a worker’s compensation case. There is somedegree of selection bias present in this study, as 40% ofthe respondents reported seeing less than one fracture permonth. In addition, the survey question and response struc-ture used would not be able to distinguish those practitionerswho saw one fracture per month and subsequently referredit to another provider versus those who saw one fractureper month and treated it themselves. Though these clini-cians may not be the end-providers for patients with frac-tures, they are the “first-responders” and triage the patient.Factors considered relevant by this group of practitioners andtheir algorithm for triage and management is thus important.In regards to clinical vignette #4 (Sanders 4 calcaneus





fracture) there may have been ambiguity regarding operativetreatment. Operative treatment for the purposes of our studywas implied, but not explicitly stated, to be open reductioninternal fixation. However there is data advocating primarysubtalar fusion for Sanders 4 type calcaneus fractures.6

Respondents who chose operative treatment for this vignettemay have done so considering fusion over ORIF and thisdistinction could not be elicited from our question format.

Despite these shortcomings our study demonstrates thatthere are statistically significant differences in how patient-based variables are weighed and how these variables areinterpreted in determining treatment of patients with calca-neus fractures based on fellowship training and exposure. Webelieve that surgeons treating patients with calcaneus frac-tures can simplify decision processes by stratifying multiplepatient-based variables into three categories:

(1) Extremity specific factors: ie anatomic disruption(calcaneal deformity and articular disruption), softtissue problems (swelling, blisters and open wounds),concerns for impaired wound healing to the frac-tured area (diabetes mellitus or peripheral vasculardisease, smoking).

(2) Social factors (substance abuse, compliance issues)and those medical factors not directly associated withimpairment of local wound healing.

(3) Demographic factors (age, gender, occupation andwork versus non-work related injury).

REFERENCES

1. Bohler, L: Diagnosis, pathology, and treatment of fractures of thecalcaneus. J Bone Joint Surg. 13:75– 89, 1931.

2. Buckley, RE; Meek, RN: Comparison of open versus closed reductionof intra-articular calcaneal fractures: a matched cohort in workmen. JOrthop Trauma. 6(2):216– 22, 1992. http://dx.doi.org/10.1097/00005131-199206000-00014

3. Buckley, R; Tough, S: Displaced intra-articular calcaneal fractures. JAm Acad Orthop Surg. 12(3):172– 8, 2004.

4. Buckley R, Tough S, et al.: Operative compared with non-operativetreatment of displaced intra-articular calcaneal fractures: a prospective,randomized, controlled multicenter trial. J Bone Joint Surg Am. 84-A(10): 1733– 44, 2002.

5. Cotton, FS; Henderson, FF: Results of Fractures of the Os Calcis. Am.J. Orthop. Surg. 14:290, 1916.

6. Csizy, M; Buckley, R; Tough, S; et al.: Displaced intra-articularcalcaneal fractures: variables predicting late subtalar fusion. J OrthopTrauma. 17(2):106– 112, 2003. http://dx.doi.org/10.1097/00005131-200302000-00005

7. Howard, JL; Buckley, R; McCormack, R; et al.: Complicationsfollowing management of displaced intra-articular calcaneal fractures; aprospective randomized trial comparing open reduction internal fixationwith non-operative management. J Orthop Trauma. 17(4):241– 9, 2003.http://dx.doi.org/10.1097/00005131-200304000-00001




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Effect of Surgeon Training, Fracture, and Patient Variables on Calcaneal Fracture Management