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CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2019; 54(02): 156-164
DOI: 10.1016/j.rbo.2017.12.005
Original Article | Artigo Original
Sociedade Brasileira de Ortopedia e Traumatologia. Published by Thieme Revnter Publicações Ltda Rio de Janeiro, Brazil

Böhler's Angle—Comparison Between the pre- and Postoperative in Displaced Intra-Articular Calcaneal Fractures[*]

Article in several languages: português | English
Pedro José Labronici
1   Serviço de Ortopedia e Traumatologia, Hospital Santa Teresa, Petrópolis, RJ, Brasil
2   Universidade Federal Fluminense, Niterói, RJ, Brasil
,
Guilherme Guerra Pinheiro de Faria
1   Serviço de Ortopedia e Traumatologia, Hospital Santa Teresa, Petrópolis, RJ, Brasil
,
Bruno Miranda Pedro
1   Serviço de Ortopedia e Traumatologia, Hospital Santa Teresa, Petrópolis, RJ, Brasil
,
Marcos Donato Franco de Araújo Serra
1   Serviço de Ortopedia e Traumatologia, Hospital Santa Teresa, Petrópolis, RJ, Brasil
,
Robinson Esteves Santos Pires
3   Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
,
Jorge Luiz Tamontini
4   Instituto de Ortopedia e Traumatologia, Hospital Dr. Bartolomeu Tacchini, Bento Gonçalves, RS, Brasil
› Author Affiliations
Further Information

Publication History

16 August 2017

07 December 2017

Publication Date:
22 April 2019 (online)

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Abstract

Objective To compare pre- and postoperative variation of radiographic measurements of the Böhler angle (BA) in fractures with two types of deviations: severe and moderate.

Methods Pre- and postoperative BAs in 31 calcaneal fracture radiographs were retrospectively analyzed. A total of 4 patients were female (6.5%) and 26 were male (83.9%), with age ranging from 23 to 72 years old, and a mean age of 44.5 years old.

Results The results show that the postoperative BA was significantly larger than the preoperative BA (p = 0.000). At the intraevaluator and overall assessments, the postoperative BA was, on average, 10.6° higher than the preoperative measure. The postoperative angle was, on average, 108% higher than the preoperative angle. In the global assessment, the agreement between evaluators was excellent, both regarding the estimated point value (0.98) and the intraclass correlation (ICC) confidence interval (CI).

Conclusion In the global analysis, the postoperative BAs were, on average, significantly higher than the preoperative measurements. The farther from the normal range (20° to 40°) the preoperative angle is, the greater the difference after the surgery. When the preoperative angle was normal, the postoperative angle was, on average, 1.28 times the preoperative measurement. If the preoperative BA was abnormal, the postoperative angle was, on average, 17.3 times the preoperative measurement. It was demonstrated that more severe fractures present better anatomic results when compared with moderate fractures. The present study also confirms a good interobserver correlation for the BA.

Keywords

calcaneus - fractures bone - intra-articular fractures - radiography

* Work developed at the Serviço de Ortopedia e Traumatologia, Hospital Santa Teresa, Petrópolis, RJ, Brazil.


 

  • References

  • 1 Tomesen T, Biert J, Frölke JPM. Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am 2011; 93 (10) 920-928
    CrossrefPubMedGoogle Scholar
  • 2 Eastwood DM, Langkamer VG, Atkins RM. Intra-articular fractures of the calcaneum. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. J Bone Joint Surg Br 1993; 75 (02) 189-195
    PubMedGoogle Scholar
  • 3 Johnson EE, Gebhardt JS. Surgical management of calcaneal fractures using bilateral incisions and minimal internal fixation. Clin Orthop Relat Res 1993; (290) 117-124
    PubMedGoogle Scholar
  • 4 Leung KS, Chan WS, Shen WY, Pak PP, So WS, Leung PC. Operative treatment of intraarticular fractures of the os calcis--the role of rigid internal fixation and primary bone grafting: preliminary results. J Orthop Trauma 1989; 3 (03) 232-240
    CrossrefPubMedGoogle Scholar
  • 5 O'Farrell DA, O'Byrne JM, McCabe JP, Stephens MM. Fractures of the os calcis: improved results with internal fixation. Injury 1993; 24 (04) 263-265
    CrossrefPubMedGoogle Scholar
  • 6 Parkes 2nd JC. The nonreductive treatment for fractures of the Os calcis. Orthop Clin North Am 1973; 4 (01) 193-195
    CrossrefPubMedGoogle Scholar
  • 7 Böhler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg Am 1931; 13 (01) 75-89
    Google Scholar
  • 8 Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D. , et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002; 84-A (10) 1733-1744
    Google Scholar
  • 9 Dooley P, Buckley R, Tough S, McCormack B, Pate G, Leighton R. , et al. Bilateral calcaneal fractures: operative versus nonoperative treatment. Foot Ankle Int/Am Orthop Foot Ankle Soc/Swiss Foot Ankle Soc 2004; 25 (02) 47-52
    Google Scholar
  • 10 Loucks C, Buckley R. Bohler's angle: correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma 1999; 13 (08) 554-558
    CrossrefPubMedGoogle Scholar
  • 11 Basile A. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures in elderly patients. J Foot Ankle Surg 2010; 49 (01) 25-32
    CrossrefPubMedGoogle Scholar
  • 12 Maskill JD, Bohay DR, Anderson JG. Calcaneus fractures: a review article. Foot Ankle Clin 2005; 10 (03) 463-489 , vi
    CrossrefPubMedGoogle Scholar
  • 13 Hyer CF, Atway S, Berlet GC, Lee TH. Early weight bearing of calcaneal fractures fixated with locked plates: a radiographic review. Foot Ankle Spec 2010; 3 (06) 320-323
    CrossrefPubMedGoogle Scholar
  • 14 Knight JR, Gross EA, Bradley GH, Bay C, LoVecchio F. Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. Am J Emerg Med 2006; 24 (04) 423-427
    CrossrefPubMedGoogle Scholar
  • 15 Di Schino M, Bensaïda M, Vandenbussche E, Augereau B, Nich C. [Results of open reduction and cortico-cancellous autograft of intra-articular calcaneal fractures according to Palmer]. Rev Chir Orthop Repar Appar Mot 2008; 94 (02) 135-144
    Google Scholar
  • 16 Cave EF. Fracture of the os calcis--the problem in general. Clin Orthop Relat Res 1963; 30 (30) 64-66
    PubMedGoogle Scholar
  • 17 Hildebrand KA, Buckley RE, Mohtadi NG, Faris P. Functional outcome measures after displaced intra-articular calcaneal fractures. J Bone Joint Surg Br 1996; 78 (01) 119-123
    PubMedGoogle Scholar
  • 18 Kitaoka HB, Schaap EJ, Chao EY, An KN. Displaced intra-articular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground-reaction and temporal forces. J Bone Joint Surg Am 1994; 76 (10) 1531-1540
    CrossrefPubMedGoogle Scholar
  • 19 Lindsay WR, Dewar FP. Fractures of the os calcis. Am J Surg 1958; 95 (04) 555-576
    CrossrefPubMedGoogle Scholar
  • 20 Paley D, Hall H. Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors. J Bone Joint Surg Am 1993; 75 (03) 342-354
    CrossrefPubMedGoogle Scholar
  • 21 Pillai A, Basappa P, Ehrendorfer S. Modified Essex-Lopresti / Westheus reduction for displaced intra-articular fractures of the calcaneus. Description of surgical technique and early outcomes. Acta Orthop Belg 2007; 73 (01) 83-87
    PubMedGoogle Scholar
  • 22 Hutchinson III F, Huebner MK. Treatment of os calcis fractures by open reduction and internal fixation. Foot Ankle Int 1994; 15 (05) 225-232
    CrossrefPubMedGoogle Scholar
  • 23 O'Brien J, Buckley R, McCormack R, Pate G, Leighton R, Petrie D. , et al. Personal gait satisfaction after displaced intraarticular calcaneal fractures: a 2-8 year followup. Foot Ankle Int 2004; 25 (09) 657-665
    CrossrefPubMedGoogle Scholar
  • 24 Jiang SD, Jiang LS, Dai LY. Surgical treatment of calcaneal fractures with use of beta-tricalcium phosphate ceramic grafting. Foot Ankle Int 2008; 29 (10) 1015-1019
    CrossrefPubMedGoogle Scholar
  • 25 Shuler FD, Conti SF, Gruen GS, Abidi NA. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes?. Orthop Clin North Am 2001; 32 (01) 187-192 , x
    CrossrefPubMedGoogle Scholar
  • 26 Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R. , et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma 2003; 17 (02) 106-112
    CrossrefPubMedGoogle Scholar
  • 27 Isaacs JD, Baba M, Huang P, Symes M, Guzman M, Nandapalan H. , et al. The diagnostic accuracy of Böhler's angle in fractures of the calcaneus. J Emerg Med 2013; 45 (06) 879-884
    CrossrefPubMedGoogle Scholar
  • 28 Neyt JG, Weinstein SL, Spratt KF, Dolan L, Morcuende J, Dietz FR. , et al. Stulberg classification system for evaluation of Legg-Calvé-Perthes disease: intra-rater and inter-rater reliability. J Bone Joint Surg Am 1999; 81 (09) 1209-1216
    CrossrefPubMedGoogle Scholar
  • 29 Andersen DJ, Blair WF, Steyers Jr CM, Adams BD, el-Khouri GY, Brandser EA. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg Am 1996; 21 (04) 574-582
    CrossrefPubMedGoogle Scholar
  • 30 Carman DL, Browne RH, Birch JG. Measurement of scoliosis and kyphosis radiographs. Intraobserver and interobserver variation. J Bone Joint Surg Am 1990; 72 (03) 328-333
    CrossrefPubMedGoogle Scholar
  • 31 Bernstein J, Adler LM, Blank JE, Dalsey RM, Williams GR, Iannotti JP. Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg Am 1996; 78 (09) 1371-1375
    CrossrefPubMedGoogle Scholar
  • 32 Otero JE, Westerlind BO, Tantavisut S, Karam MD, Phisitkul P, Akoh CC. , et al. There is poor reliability of Böhler's angle and the crucial angle of Gissane in assessing displaced intra-articular calcaneal fractures. Foot Ankle Surg 2015; 21 (04) 277-281
    CrossrefPubMedGoogle Scholar
  • 33 Gonzalez TA, Ehrlichman LK, Macaulay AA, Gitajn IL, Toussaint RJ, Zurakowski D. , et al. Determining measurement error for Bohler's angle and the effect of X-ray obliquity on accuracy. Foot Ankle Spec 2016; 9 (05) 409-416
    CrossrefPubMedGoogle Scholar
  • 34 Bland JM, Altman DG. Measurement error. BMJ 1996; 313 (7059): 744
    Google Scholar