Effect of surgeon training, fracture, and patient variables on calcaneal fracture management

There appears to be a general lack of consensus in treating calcaneus fractures. Many different patient-based variables such as smoking, diabetes, or occupation, may influence treatment decisions possibly more so than the nature of the injury itself. Indications for operative versus nonoperative treatment are often unclear. The goals of this study were to determine if lack of consensus exists, determine which factors most influence orthopaedic surgeons in choosing operative versus nonoperative treatment and determine if there are differences in treatment based on fellowship training and exposure to these injuries.

Practicing orthopaedic surgeons of various backgrounds and training were administered an electronic survey. The survey consisted of clinical vignettes and questions regarding fellowship training, demographics and exposure to calcaneus fractures. Orthopaedic surgeons were asked to weigh the importance of patient-based variables in determining operative versus nonoperative treatment.

For patients with an uncomplicated medical history, there was a general consensus on treatment as guided by the Sanders classification. For those with a complex medical history, there was less consensus on management despite fracture pattern. Foot & ankle fellowship-trained surgeons (F&AT) ranked calcaneal deformity as more important than trauma fellowship-trained surgeons (NFT), and ranked peripheral vascular disease (PVD)/diabetes mellitus (DM) more important than did both trauma fellowship-trained surgeons (TFT) and NFT surgeons. There was no significant difference in choosing operative versus nonoperative treatment for surgeons treating more calcaneus fractures (more than four per month) versus those who treated fewer (less than one a month).

There was general agreement among surgeons regarding the most important variables for determining management of calcaneus fractures. How this information is utilized varies according to practitioner and leads to varying consensus. There was generalized consensus regarding management in cases of anatomic deformity at either end of the spectrum of severity and non-complex medical histories. When additional confounders were added, the agreement between surgeons declined.