Effect of Bone Grafting in Short and Long Term Outcomes of Displaced Intra-Articular Calcaneal Fractures: A Prospective Comparative Study

Ashutosh Singh, Nidhi Narsaria, Indreswar Verma

Ashutosh Singh, Nidhi Narsaria, Indreswar Verma, Department of Orthopaedics, Government Medical College, Banda, Uttar Pradesh, India
Correspondence to: Ashutosh Singh, Department of Orthopaedics, Government Medical College, Banda, Uttar Pradesh, India

Email: ashutosh.orthopaedics@gmail.com
Telephone: +91-5222725888
Received: July 16, 2015
Revised: January 1, 2016
Accepted: January 9, 2016
Published online: February 26, 2016


Aim: This prospective comparative study was done to evaluate effect of autologous bone grafting in outcomes and complications of displaced intra-articular calcaneal fractures.

Material and Methods: Seventy-two patients with displaced intra-articular calcaneal fractures were treated with open reduction and internal fixation with plate. Osteosynthesis of 36 patients were supplemented with bone graft and other 36 patients did not receive bone graft. All patients were followed for 2 years and clinico-radiological assessment was done using the Maryland foot score and plain radiography as-well-as CT scan. Bohler’s angle, the crucial angle of Gissane, calcaneal height and width in the preoperative, immediate postoperative period and at the 2-year follow-up were compared.

Results: There was no significant difference found in terms of clinical results as assessed by Maryland foot score between both the groups (p > 0.05). No significant difference was found between both the groups in terms of loss of Bohler’s angle, the average change in the crucial angle, calcaneal height and width (p > 0.05). No significant difference was found between the groups regarding complications like infection rate, skin necrosis, wound dehiscence, postoperative osteoarthritis and subtalar fusion (p > 0.05).

Conclusion: There was no significant difference between both the groups regarding functional outcomes and complications.

© 2016 ACT. All rights reserved.

Key words:Angle of Gissane; Bohler’s angle; Displaced intra-articular calcaneal fractures: Subtalar arthrosis

Singh A, Narsaria N, Verma I. Effect of Bone Grafting in Short and Long Term Outcomes of Displaced Intra-Articular Calcaneal Fractures: A Prospective Comparative Study. International Journal of Orthopaedics 2016; 3(1): 505-511 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/1295


The calcaneus is the most frequently fractured of the tarsal bones, and represents 1% to 2% of all fractures[1,2]. Calcaneus fractures can be broadly classified into intra-articular and extra-articular types. Intra-articular fractures are more common, representing 60- 75% of all calcaneal fractures, with a wide spectrum of fragment patterns[2,3]. The mechanism of injury is usually through axial loading of the calcaneus, causing a blowout of the lateral wall of the calcaneus downward and fracture through the posterior facet with various degrees of comminution bohler angle[3,4]. Displaced intra-articular fractures carry a high morbidity representing a significant therapeutic challenge, and despite their frequency, no clear consensus exists on treatment protocol for this class of fractures[5,6,7,8]. Plate osteosynthesis of the intra-articular fractures is a standard treatment method. Lenormant first described the use of bone graft to fill the space created after open reduction of calcaneal fracture in 1928. Cancellous core of calcaneus, the thalamus[9], is usually compressed during calcaneal fracture. It has been a common practice during open reduction and internal fixation for fracture of the calcaneus to supplement the fixation with bone graft, most commonly using an autograft from the iliac crest[10,11,12]. Other options available to supplement osteosynthesis includes allogenous cancellous bone graft and synthetic bone substitutes. Morbidity at the donor site from iliac crest autograft is well known and the benefits of using a bone graft in displaced intra-articular calcaneal fractures is still controversial[13]. Earlier studies has shown that bone grafting in intra-articular calcaneal fractures could increase stimulation of fracture healing for early full weight bearing and add mechanical strength to avoid significant late collapse and post-traumatic subtalar arthrosis[14,15]. It has been shown also that autologous bone grafting increases the infection rate, blood loss and postoperative pain[16,17] along with the donor site morbidity and complications of harvesting autograft[18,19].

We were interested in determining if the use of autologous bone grafting would work best for management of displaced intra-articular calcaneal fractures. We hypothesized that supplementing osteosynthesis with autologous bone grafting would provide better outcomes and early rehabilitation in management of patients of displaced intra-articular calcaneal fractures. Our primary aim was to measure patient satisfaction in terms of outcome scores following calcaneal fracture fixation, and our secondary aim was to determine the range of motion at subtalar joint, infection rate, incidence of subtalar arthrosis and other radiographic parameters (Calcaneal height and corresponding angles). We undertook a prospective comparative study to compare outcomes and complications in patients who had undergone osteosynthesis with bone grafting to those who had undergone only osteosynthesis in management of displaced intra-articular calcaneal fractures.

Material and Methods

We performed a prospective comparative study of the cases with displaced intraarticular calcaneal fractures treated by open reduction and internal fixtion (ORIF), with and without bone graft and compared the outcomes and complications of the two groups. This study was authorized by the local ethical committee and was performed after approval of istituitional review board. Informed consent was taken from all the patients. A power analysis, with a power of 90% to detect Maryland foot score difference of 10 as being significant at the 5% level, determined that a sample size of sixty four patients was needed. It was anticipated initially that 10% to 15% of the patients would drop out or not fully meet the criteria for long-term follow-up and that sample size of 72 patients. Each group required at least 36 participants. From January 20011 to January 2013, 84 patients with displaced intra-articular calcaneal fractures were admitted. Out of these cases, 72 patients with unilateral, isolated, closed, displaced intra-articular calcaneal fracture in patients of more than 18 years old age were included in this study according to inclusion criterias. We used Sanders’ classification[20] developed on the basis of coronal and axial CT scan sections for calcaneal fractures. Sanders computed tomography (CT) scan classification is based on articular fracture lines of the posterior articular calcaneal facet (A, lateral; B, central; C, medial), and the severity of the fracture (Sanders types I–IV) depends on the number of lines and their courses.

Inclusion criterias: (1) Age more than 18 years; (2) Closed, unilateral Sanders displaced intra-articular calcaneal fractures;(3)Posterior articular facet step off more than 2 mm.

All the patients included in this study were randomly allocated to two groups using sealed envelop method, group A having 36 patients treated by ORIF with autologous bone graft and group B having another 36 patients treated by ORIF without autologous bone graft. All the cases were operated upon by a single surgeon. The average age in group A was 36.2 (range, 19–74) years and in the group B was 40.8 (range, 18–75) years. Average body mass index (BMI) in group A was 28.6 ± 6.0 (range 21.26 to 42.14) kg/m2 and in group B was 29.4 ± 5.8 (range 20.18 to 44.28) and there was no significant difference found (p = 0.28). Twelve patients in group A and 14 patients in group B were smokers. Seven cases in group A and 9 cases in group B were diabetic patients. Gender proportions in the two groups were similar (p = 0.44). All the patients in both the group were followed for minimum duration of 2 years.

The majority of calcaneus fractures are high-energy injuries so all the cases were treated initially with ice and elevation until soft tissue swelling subsided and skin wrinkles were apparent (Figure. 1A and 1B). All the patients were operated from the sixth to tenth day after injury (range 4–18 days, average 8.0 days). All the operations were performed under spinal anaesthesia with the patient placed in lateral decubitus position,using the extended L-shaped lateral approach. The posterior facet, angle of Gissane, bohler's angle, calcaneal height, width and length were meticulously restored (Figure 1B, 1C, 2A, 2B and 2C) and the reduction was temporarily maintained with Kirschner wires. Locking calcaneal plate (Synthes) was used in all the cases for internal fixation (Figure 1C, 1D, 2C and 2D). In the patients receiving bone graft, cancellous autograft was taken from the ipsilateral iliac crest and filled in the bony defect, present just below the posterior facet at the area of the neutral triangle (Figure 1C and 1D) and then the lateral cortical wall of the calcaneus was reduced and internal fixation with plate was completed. The wound was closed over a drain that was removed the following day.

Active and passive range of motion exercises were carried out at the first day after surgery. Postoperatively, non–weight-bearing walking was started on the third postoperative day. Patients were allowed to bear weight partially (25% weight) on affected side, 6 weeks after the surgery. Clinical and radiological assessment was done at every follow-up visit. The preoperative, immediate postoperative and two year follow-up visit x-rays were compared to assess changes in Bohler’s angle, the crucial angle, height and width of the calcaneus.

Time to full weight-bearing, range of motion and outcome scores were recorded for all the patients. Posterior facet incongruity and subtalar joint fusion were assessed radiologically. For the evaluation of subtalar joint reduction, Sanders criteria[20] and, for posttraumatic posterior facet degenerative changes, Allmachers Arthrosis Rating Scale[21] was used in this study. Clinical outcome was assessed by the Maryland foot score[20]. The Maryland Foot Score is a disability index that derives a score from 0 to 100 points (excellent, 90 to 100; good, 75 to 89; fair, 50 to 74; failure, less than 50). It evaluates subjective and objective elements such as pain (maximum score 45), function (maximum score 40, subdivided into gait, stability, use of walking aids, limp, type of shoes required, walking distance), cosmesis (maximum score 10), and movement of the ankle, subtalar, midfoot and metatarsophalangeal joints (maximum score 5). Range of motion of the subtalar joint was measured according to the method of Morrey and Wiedeman[22].

Absolute values of the differences were used for statistical analysis. Statistical significance was taken as 0.05. The t test for equality was used to test for significance of difference.


The average overall duration of follow-up was 2 ± 0.3 years (range, 1.4 -2.7 years). The patients of group A had an average hospital stay of 20.20 ± 3.2 days (range, 15-25 days) and the group B patients had an average hospital stay of 19.02 ± 4.8 days (range, 14-24 days). There was no significant difference between two groups (p = 0.68). All patients were able to wear normal footwear; no orthotic devices were required.

The mean time to full weight-bearing in bone graft group A (5.2 ± 1.2 months; range, 3-7 months) was insignificantly lower (p = 0.09) as compared to the non-graft group B (6.3 ± 1.6 months; range, 3.5-18 months). In group A, there were 20 cases who were manual labourer by occupation and in these cases, mean time to full-weight-bearing was 6.0 ± 1.4 months (range 3.5-7 months). In group B, there were 18 cases who were manual labourer by occupation and in these cases, mean time to full-weight-bearing was 6.4 ± 1.8 months (range 4-8 months). There were insignificant difference (P=0.34) found in terms of mean time to full-weight-bearing in manual labourers between both the groups. There was insignificant difference(P=0.28) found between both the groups in terms of mean time to full weight-bearing in patients with non-demanding job (group A, mean 4.8 ± 1.3 months, range 3-6.9 months and group B, mean 5.2 ± 1.5 months, range 4-9.1 months). Immediate post-operative and 2 year follow-up Bohler's angle was significantly higher in the group A (p = 0.042). The Bohler's angle loss after 2 year was insignificantly lower in the bone graft group A ( 3.5° ± 1.4°; range, 2°-6°) as compared to the non-graft group B (4.2° ± 2.1°; range, 3°-7°); (p = 0.14). The overall subtalar joint reduction was found to be satisfactory. No significant difference was found between the two groups on comparing the good reduction rate. Comparison of the immediate postoperative and the 2 year follow-up radiological results showed the change in Bohler’s angle, crucial angle, width and the height of the calcaneus (Table 2). The average change in crucial angle was 3.8° ± 1.8° (range, 2°-6°) for the group A and 3.6°± 2.1° (range, 1°-6°) for the group B. The difference was not statistically significant (p = 0.48). The average change in calcaneal height was 2.8 ± 1.4 mm (range, 1-4 mm) for the group A and 2.5 ± 1.2 mm (range, 1-4 mm) for the group B. This difference was statistically not significant (p = 0.68). The average change in calcaneal width for the group A ( 2.01 ± 0.34 mm; range, 1.5-2.5 mm) was insignificantly higher (p = 0.42) than patients of group B (1.98 ± 0.22 mm; range, 1.75-2.25 mm) (Table 2).

Mean Maryland foot score was lower (76.4; range, 66-88 points) in the group B than in group A (81.6; range, 74-92 points) but this difference was not significant (p = 0.82). In the studies of group A, the result was excellent in 30% of the patients, good in 36%, fair in 25%, and poor in 8% of the patients. In the non-graft Group B, the outcomes were excellent in 27%, good in 33%, fair in 27%,and poor in 11% cases. No significant difference was found on comparing both groups (p = 0.09) (Table 3).

In this study, incidence of infection was 6.94%. The infection rate in group A (8.33%) was higher as compared to group B (5.66%) but no statistical significant difference was found (p = 0.22). Three patients (4.16%) had superficial wound dehiscence. There were no donor site wound complications. Subtalar arthrosis developed in 5 patients of group A (13.8%) and in 7 patients of group B (19.4%) and there was no significant difference found between both the groups (p = 0.08). The incidence of postoperative subtalar fusion was insignificantly higher in group B ( 5.56%) as compared to group A ( 2.77 %).


Displaced intraarticular calcaneal fractures pose a challenge to orthopaedic surgeons and the most appropriate management remains controversial. The results of open reduction and internal fixation after intra-articular calcaneal fractures have varied, with good and excellent results ranging from 33% to 85%[11,23,24,25,26]. The need for bone grafting in the surgical management of calcaneal fractures is still controversial. Some authors have supported role of bone grafting in earlier studies[11,12,14,27] while many authors do not prefer to supplement osteosynthesis with bone graft[28,29,30]. A nationwide survey in the Netherlands reported that the definite use of bone grafts in the ORIF group was 20%, a total of 42% used grafting when deemed necessary, and 38% did not use bone grafts at all[31]. Letournel demonstrated that rigid plate fixation with lag screws adequately supported the articular surface and therefore bone grafting was unnecessary[25]. Sanders et al[20] and Stephenson et al[30] in their studies reported good results without the use of bone graft. Lowery et al. reviewed treatment of calcaneal fractures extensively and did not recommend the use of bone graft[32]. Longino et al. had compared cases of displaced intraarticular fractures with locking plate osteosynthesis with and without bone grafting and did not find any significant difference[33]. Zwipp et al[34] also achieved good results without the use of bone graft.

Benirschke et al[35]. recommended supplemental bone grafting to fill large defects, which otherwise remained after rigid plate fixation. Leung et al recommended open reduction with rigid internal fixation with primary bone grafting as the preferred treatment method for calcaneal fracture[11,12].

Huang et al[28]. did not use bone graft in their series and there was no late collapse, but they emphasized that it is critical to keep the patients strictly nonweightbearing for at least 10 weeks to prevent any possible loss of joint reduction. In our study, both groups had similar clinical and radiological outcomes. Higher Infection rate was reported for the intraarticular calcaneal fractures treated with bone grafts in many studies[16]. In our study, no significant difference was found between the patients with bone grafts and without bone grafts on comparing the infection rates. It was observed in many studies that restoration of Bohler's angle was associated with a better outcome[13,36,37,38]. The mean postoperative Bohler's angle was significantly higher and the mean loss of reduction of the angle was insignificantly lower in the bone graft group. Biomechanical and clinical studies have shown that even a minor stepoff of 1 to 2 mm in the posterior facet leads to a significant load shift within the subtalar joint with the possible development of post-traumatic arthritis[39]. In our study, the subtalar joint reduction achieved during surgery was maintained during long-term follow-up in both groups.

The efficacy outcomes in the two groups showed no significant difference. For the reported scores, the patients in bone graft group reached a lower mean Maryland foot score. Sanders et al[20], using both subjective and objective criteria, reported 67% good and excellent results for their Type II, Type III and Type IV fractures. Similarly, Zwipp et al[34], using their own classification system and rating scale, reported 61% good and excellent results in 123 operatively treated fractures. The Maryland foot score, which evaluates both subjective and objective elements was used in our study. However, 92% good and excellent results were observed in our study.

Bone grafts have been commonly used in calcaneal fracture surgeries for the filling of bone cavities. However, the use of autograft is associated with morbidity, including the risk of infection, bleeding, and increased postoperative pain and there is a limit to the amount of bone that can be harvested[28,36]. Another form of bone graft, allograft is a major form of bone graft substitute used clinically. Human demineralized bone matrix, calcium sulfate, calcium phosphate cement and nanocrystalline hydroxyapatite have been used as reasonable alternatives to autograft in calcaneal fractures[40,41].

The primary limitation of our study was that it was a small prospective comparative study including small number of patients and done at a single-center. Larger randomized controlled trials are needed to further evaluate usefulness of bone grafting in displaced intraarticular calcaneal fractures.

This study concludes that bone grafting leads to better anatomical restoration of calcaneal anatomy and earlier return to full weight-bearing. Though intermediate and long-term efficacy outcomes in both the groups were similar, it can be suggested that bone grafting should be added to plate osteosynthesis of intra-articular calcaneal fracrtures with large fracture void and cancellous bone collapse.


Despite its rarity, a tumor involving the subscapularis should be considered for any young patients presenting with an isolated loss of external rotation of the glenohumeral joint. A high index of suspicion based on clinical examination and MRI study may contribute to earlier diagnosis of these tumors.

Conflict of interest



1RW, Clare MP. Fractures of the calcaneus. In: Bucholz RW, Heckman JD, Court-Brown CM, pp 2293-2336, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia 2006.

2Sanders R, Hansen S, Reynolds I. Fractures of the calcaneus. In: Jahhs M, ed. Disorders of the Foot and Ankle, pp 2326-2354, Medical & Surgical Management. 2nd ed. Philadelphia 1992.

3Lowery RBW, Calhoun JH. Fractures of the calcaneus, I. anatomy, injury mechanism, and classification. Foot Ankle Int 1996; 17(4): 230-235.

4Palmer I. The mechanism and treatment of fractures of the calcaneus. J Bone Joint Surg Am 1948; 30: 2-8.

5Buckley R, Tough S, McCormack R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002; 84(10):1733-44.

6Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma 1992; 6(2): 216-222.

7Kundel K Funk E, Brutscher M, Bickel R. Calcaneal fractures: operative versus non operative treatment. J Trauma 1996; 41(5):839-845.

8Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma 1992; 6(2):252-265.

9Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg Br 1975; 57: 413-421

10Palmer I. The mechanism and treatment of fractures of the calcaneus. Open reduction with the use of cancellous grafts. J Bone Joint Surg Am 1948; 30: 2-8

11Leung KS, Chan WS, Shen WY, Pak PL, So WS, Leung PC. Operative treatment of intra-articular fractures of the os calcis — the role of rigid internal fixation and primary bone grafting: preliminary results. J Orthop Trauma 1989; 232-240

12Leung KS, Yuen KM, Chan WS. Operative treatment of displaced intra-articular fractures of the calcaneus. Mediumterm results. J Bone Joint Surg Br 1993; 75: 196-201

13Loucks C, Buckley R. Bohler’s angle: correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma 1999; 13: 554–558

14Elsner A, Jubel A, Prokop A, Koebke J, Rehm KE, Andermahr J. Augmentation of intraarticular calcaneal fractures with injectable calcium phosphate cement: densitometry, histology, and functional outcome of 18 patients. J Foot Ankle Surg 2005; 44: 390–395

15Jiang SD, Jiang LS, Dai LY. Surgical treatment of calcaneal fractures with use of beta-tricalcium phosphate ceramic grafting. Foot Ankle Int 2008; 29:1015–1019

16Baumgaertel FR, Gotzen L. Two-stage operative treatment of comminuted os calcis fractures. Primary indirect reduction with medial external fixation and delayed lateral plate fixation. Clin Orthop Relat Res 1993; 290:132–141

17Laurie SW, Kaban LB, Mulliken JB, Murray JE. Donorsite morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 1984; 73:933–938

18Banwart JC, Asher MA, Hassanein RS Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine 1995; 20: 1055–1060

19Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop Relat Res 1997; 339: 76–81

20Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intra-articular calcaneal fractures. Clinical Orthop Relat Res 1993; 290: 87–95

21Allmacher DH, Galles KS, Marsh JL Intra-articular calcaneal fractures treated nonoperatively and followed sequentially for 2 decades. J Orthop Trauma 2006; 20(7): 464-469

22Morrey BF, Wiedeman GPJ: Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am 1980; 62: 777–784

23Bezes H, Massart P, Delvaux D, Fourquet JP, Tazi F: The operative treatment of intraarticular calcaneal fractures. Indications, technique, and results in 257 cases. Clin Orthop Relat Res 1993; 290: 55–59

24Fernandez DL, Koella C. Combined percutaneous and “minimal” internal fixation for displaced articular fractures of the calcaneus. Clin Orthop Relat Res 1993; 290: 108–116

25Letournel E. Open treatment of acute calcaneal fractures. Clin Orthop Relat Res 1993; 290: 60–67

26Monsey RD, Levine BP, Trevino SG, Kristiansen TK. Operative treatment of acute displaced intra-articular calcaneus fractures. Foot Ankle Int 1995; 16: 57–63

27Di Schino M, Bensaida 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 Reparatrice Appar Mot 2008; 94: 8–16

28Huang PJ, Huang HT, Chen TB, Chen JC, Lin YK, Cheng YM. Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus. J Trauma 2002; 52: 946–950

29Thornes BS, Collins AL, Timlin M, Corrigan J. Outcome of calcaneal fractures treated operatively and non-operatively: The effect of litigation on outcomes. Ir J Med Sci 2002; 171: 155–7

30Stephenson JR. Treatment of displaced intra-articular fractures of the calcaneus using medial and lateral approachesinternal fixation, and early motion. J Bone Joint Surg Am 1987; 69: 115-130

31Schepers T, van Lieshout EM, van Ginhoven TM, Heetveld MJ, Patka P. Current concepts in the treatment of intra-articular calcaneal fractures: Results of a nationwide survey. Int Orthop 2008; 32: 711–5

32Lowery RBW, Calhoun JH. Fractures of the calcaneus [current topic review]. Foot Ankle Int 1996; 17: 230-235

33Longino D, Buckley RE. Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: Is It Helpful? J Orthop Trauma 2001; 15: 280–6

34Hsu SW, Wang WJ. Tai chi and internal secretion. China J Phy Med 1986, 5(3): 150-153.

35Benirschke SK, Sangeorzan BJ: Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop Relat Res 1993; 292: 128–134

36Schnee CL, Freese A, Weil RJ, Marcotte PJ. Analysis of harvest morbidity and radiographic outcome using autograft for anterior cervical fusion. Spine 1997; 22: 2222-2227

37Paul M, Peter R, Hoffmeyer P. Fractures of the calcaneum.A review of 70 patients. J Bone Joint Surg Br 2004; 86: 1142–5

38Shuler FD, Conti SF, Gruen GS, Abidi NA. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: Does correction of Böhler’s angle alter outcomes? Orthop Clin North Am 2001; 32: 187–92

39Gavlik JM, Rammelt S, Zwipp H: Percutaneous, arthroscopically assisted osteosynthesis of calcaneus fractures. Arch. Orthop Trauma Surg 2002; 122: 424–428 5

40Bibbo C, Patel DV: The effect of demineralized bone matrix-calcium sulfate with vancomycin on calcaneal fracture healing and infection rates: a prospective study. Foot Ankle Int 2006; 27: 487–493

40Huber FX, Hillmeier J, McArthur N, Kock HJ, Meeder PJ: The use of nanocrystalline hydroxyapatite for the reconstruction of calcaneal fractures: Preliminary results. J Foot Ankle Surg 2006; 45: 322–328

Peer reviewer:Nabil A.S Eid, Department of Anatomy and Cell Biology, Division of Life Sciences, Osaka Medical College, Daigaku machi, Takatsuki, Osaka 569-8686, Japan; Devendra Mahadevan, Leicester Orthopaedics, University Hospitals of Leicester, Leicester General Hospital, LE5 4PW, UK.


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.