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J Bone Joint Surg Am. 2014 May 7;96(9):e72. doi: 10.2106/JBJS.L.01220.

Intraoperative three-dimensional imaging in the treatment of calcaneal fractures.

Author information

  • 1MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, D-67071 Ludwigshafen, Germany. E-mail address for J. Franke: jochen.franke@bgu-ludwigsh.
  • 2BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, D-67071 Ludwigshafen, Germany. E-mail address for A.J. Suda: E-mail address for P.A. Grützner:
  • 3Sportopädie Zentrum für Orthopädie Heidelberg, Max-Reger-Strasse 5-7, D-69121 Heidelberg, Germany. E-mail address:



Displaced intra-articular calcaneal fractures are frequently treated by open reduction and internal fixation. The usual intraoperative monitoring by means of fluoroscopy does not always provide complete intraoperative information for the surgeon. The aims of this study were to analyze the percentage of patients for whom intraoperative three-dimensional imaging leads to intraoperative revision and whether the avoidance of an intra-articular step or gap influences the clinical outcome.


From August 2001 to June 2009, 377 consecutive, operatively treated calcaneal fractures were identified in a retrospective chart review. The results of the intraoperative three-dimensional scans were analyzed for the rate of and the reason for intraoperative revision. For the clinical evaluation, all patients with Sanders type-II and III fractures who were seen from October 2002 to January 2006 were included. When the outer shape of the calcaneus was successfully restored, the fractures were divided into two groups according to the reduction outcome for all joint surfaces (a step-off or gap of <2 mm or ≥2 mm).


The intraoperative revision rate was 40.3%. An additional fracture reduction was performed in 19.6% of the patients. Seventy-seven fractures were followed clinically. The American Orthopaedic Foot & Ankle Society (AOFAS) score indicated that postoperative joint surface congruence had a significant influence on clinical outcome, in both the bivariate and the multivariate analysis. The same relationship was shown between the joint surface congruence and the degree of osteoarthritis.


In many cases, intraoperative three-dimensional imaging identifies intra-articular incongruence and implants that are not detected by fluoroscopy. Due to the resulting options for better joint surface reconstruction, clinical outcomes may be improved, at times requiring repeat reduction, and posttraumatic osteoarthritis may be reduced.

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