Calcaneal Fractures

Chima D. Nwankwo MD
NewYork-Presbyterian Brooklyn Methodist Hospital
Department of Orthopedic Surgery Columbia University Irving Medical Center

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Objectives
• Describe the anatomy
• Understand initial clinical and radiographic assessment
• Describe the classification systems of calcaneal fractures
• Understand how patient, injury, and surgeon factors affect
treatment recommendation
• Understand the goals and indications for operative treatment
• Describe potential adverse outcomes related to calcaneal fractures

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 Introduction/Epidemiology
• Joseph-Francois Malgaigne described intra-
articular fx patterns of the calcaneus in 1843
• Most commonly fractured tarsal bone (65%)
• Occurs more commonly in active working
males (peak age 20 to 29)
• Most common mechanism is a fall from
height or MVC
• 25- 50% of have associated injuries

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 Tuberosity
Lateral

Anatomy
CFL tubercle
Peroneal
Peroneal tendons
tubercle

• Tuberosity Anterior
• Serves as attachment for Achilles tendon and process
plantar fascia
• Has tubercles for CFL and peroneal tendons (both
elevated during lateral approach)
• Anterior Process
• Articulates with cuboid (CC joint) Medial
• Origin for extensor digitorum brevis muscle
FHL Tendon
• Sustentaculum tali
• Supports middle facet of talus
• Fulcrum for FHL tendon
• Close relationship with posterior tibial vessels and
terminal branches of tibial nerve
Sustentaculum tali

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 AXIAL VIEW

Anterior +
Anatomy Middle
Facet

• Posterior Facet
• supports the talar body

• Anterior and Middle Facets Posterior

• Forms the sustentaculum tali Facet
• Called “constant fragment” because usually remains
attached to the talus via the deltoid, interosseous
ligament, and medial talocalcaneal ligament
• Bears more weight per unit area than posterior facet

• Normal function of the subtalar joint relies on restoration of

the articular relationships of these joints
Tuberosity

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 AXIAL VIEW

Anatomy
Sinus
• Tarsal Canal and Tarsal Sinus Tarsi
• Funnel-shaped areas situated anterior to the posterior
talocalcaneal joint and posterior to the
talocalcaneonavicular joint

• The larger tarsal sinus opens laterally, and tarsal canal

extends medially, posterior to the sustentaculum tali

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 Anatomy
• Lateral calcaneal artery (LCA)
• Terminal branch of peroneal artery
• Dominant blood supply to the corner of the
B
lateral extensile approach
A
C
• Lateral malleolar artery (LMA)
• Branch of Anterior tibial artery

• Lateral tarsal artery (LTA)

Photo of a chemically debrided specimen demonstrating the lateral calcaneal
• Branch of Dorsalis Pedis artery (A), the lateral malleolar artery (B), and the lateral tarsal artery (C).
Borrelli, Joseph Jr; Lashgari, Cyrus. Vascularity of the Lateral Calcaneal Flap: A Cadaveric Injection Study
Journal of Orthopaedic Trauma. 13(2):73-77, February 1999. (Fig1).

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 LCA
Anatomy LMA
LTA
• Lateral calcaneal artery (LCA)
• Lateral malleolar artery (LMA)
• Lateral tarsal artery (LTA)
Borrelli, Joseph Jr; Lashgari, Cyrus. Vascularity of the Lateral Calcaneal Flap: A Cadaveric Injection Study
Journal of Orthopaedic Trauma. 13(2):73-77, February 1999. (Fig3).

• Sural nerve and peroneal tendons at risk

with lateral dissection

Tim White, Kate Bugler. Ankle

Fractures.) In: Tornetta P, Ricci WM,
eds. Rockwood and Green's Fractures
in Adults, 9e. Philadelphia, PA.
Wolters Kluwer Health, Inc; 2019. (Fig
64-6 Core Curriculum V5
Initial Assessment - History
• A thorough history is important to determine appropriate treatment
• Pre-injury level of function/activity level
• Occupation – desk work? laborer?
• Habits - Smoker?
• Medical comorbidities – diabetes? peripheral vascular disease?

• 25-50% with at least one associated injury

• Thorough secondary evaluation is critical
• 6-20% of patients with lumbar spine fracture
• Up to 8% will have bilateral calcaneal fractures

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Initial Assessment - Physical
• Note condition of skin
• Fracture Blisters?
• Threatened skin?
• Open wounds?
• Detailed NV exam
• Associated injuries?
• Serial exams in the first hours
after presentation to monitor
for compartment syndrome

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 Initial Assessment - Physical
• Compartment syndrome following high-
energy calcaneal fx estimated in 10-50%
• Clinical presentation - pain out of
proportion, tense swelling, pain with
passive stretch, sensory changes on plantar
foot, and presence of blisters.
• Surgical decompression often complicated
by wound dehiscence, infection, nerve
injury, dry itchy skin, and chronic pain.
• Early cryotherapy and elevation may allow
soft tissue swelling to stabilize, and
alleviate pain in the acute period.

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 Initial Management
• Apply bulky splint in neutral
dorsiflexion or slight equinus

• Period of soft tissue rest to allow for

swelling to subside
• Await return of skin wrinkling and
resolution of blisters

• If skin at-risk e.g. tongue-type or

tuberosity avulsion fracture, urgent
surgery is indicated Resolution of blisters and swelling prior to surgery. Note skin wrinkles

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 Radiographic Evaluation
• Initial plain radiographs (XR)
• AP/Lateral/Oblique views of the foot
• Mortise view of ankle
• to r/o associated ankle pathology
• Axial (Harris) view

• CT scan of the foot

• Consider plain radiographs of the lumbar

spine and contralateral foot if warranted
to rule out associated injuries Intra-operative image of how Harris view is obtained.

Michel A. Taylor, Abdel Rahman Lawendy, David W. Sanders. Calcaneus

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Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in
Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019. (Fig 66-12)
 Lateral X-Ray
• Enables assessment of:
• Posterior facet
• Middle facet
PF – Posterior Facet, MF – Middle Facet , CC - Calcaneocuboid
• Calcaneocuboid joint
• Calcaneal length and height

• Can be used to classify the fracture as a joint

HEIGHT
depression or tongue type as described by
Essex-Lopresti

LENGTH
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 Lateral X-Ray
• Bohler’s Angle
• line from highest point on anterior process to highest
point on posterior facet and a line from this point to most
superior point of calcaneal tuberosity.

• Normal 25-40o

• Decreased angle indicates joint depression

• Bohler's angle will only change if entire posterior facet is

displaced

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 Lateral X-Ray
• Critical Angle of Gissane
• formed by two cortical struts that join and
intersect to form an obtuse angle

• Normal 120-145o

• In an intra-articular fx involving the posterior

facet, the lateral XR will typically show a loss
of calcaneal height, depression and rotation
of the posterior facet, and an increase in the
critical angle of Gissane

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 AP X-Ray
• Shows distal aspect of fracture line as it extends
into the CC joint (up to 48% of cases)

• Can be useful to assess lateral wall defect, bulge,

or blowout

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Axial (Harris Heel) View
• Can assess rotation of the
sustentaculum

• Shows increase in
calcaneal width

• Shows varus/valgus
Subtalar
Joint Displaced
Posterior Facet
angulation of the
tuberosity
Lateral Wall posterior Tuber in
Blowout varus angulation

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Broden’s View
• Oblique radiograph of the hindfoot used
intra-op to assess posterior facet

• IR foot 30-40 deg, aim beam at the angle of

Gissane, and take four views angling the
beam 40, 30, 20, 10 degrees cranial

• The sequential views are able to show the

posterior articular facet moving from
anterior to posterior and any associated
fracture displacement, depression, or
subluxation can be seen.

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 Coronal

CT Scan
• Technique: position the coronal plane Axial
perpendicular to the posterior facet of Sustentaculum

the calcaneus, 3mm cuts Lateral

wall
• Coronal: posterior facet, sustentaculum, Posterior

lateral wall, fibula impingement facet

• Axial: CC joint involvement, posterior

facet fracture lines, tuberosity Sagittal
displacement, lateral wall blowout CC joint
Anterior process

• Sagittal: posterior facet depression,

anterior process involvement,
Posterior
tuberosity assessment facet
Lateral wall

Tuberosity
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Classification – Essex-Lopresti

joint depression

tongue-type

Meinberg E, Agel J, Roberts C, et al. Fracture and Dislocation Classification Compendium–

2018, Journal of Orthopaedic Trauma. Volume 32: Number 1; Supplement, January 2018.
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 Joint Depression -

Classification – Essex-Lopresti Posterior Facet NOT

attached to tuberosity

• Based on plain radiographs

• Two main fracture types:
• intra-articular “joint depression”: articular facet
fragment is fractured and separate from the
displaced tuberosity. Tongue Type - Posterior
Facet attached to tuberosity
• extra-articular “tongue-type”: articular facet
remains attached to the main tuberosity
fragment
• Can be surgical emergency due to skin
compromise

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Classification – Sanders
• Based on the coronal CT scan
• Divided into four types (I-IV) indicating number
of posterior facet fragments
• Type I = all undisplaced fx, regardless of
number of fracture lines.
• Letters describe the location of the primary fx
lines from lateral to medial
• extra-articular fracture classified as IIC
• Demonstrated to have good therapeutic and
prognostic value (Launder et al, FAI 2006)
Michel A. Taylor, Abdel Rahman Lawendy, David
W. Sanders. Calcaneus Fractures. In: Tornetta P,
Ricci WM, eds. Rockwood and Green's Fractures
in Adults, 9e. Philadelphia, PA. Wolters Kluwer

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Health, Inc; 2019. (Fig 66-7)
 Pathoanatomy
• Intra-articular fx result from axial load
• Lateral process of talus is driven into “angle of
Gissane” creating primary fx line from
anterolateral to posteromedial
• Fx Location depends on hindfoot position
• valgus = lateral fx line; varus = medial fx
• Secondary fx line depends on direction of force
Fig. A-C: Joint depression fracture. Note slight posterior vector
• Posterior force = joint depression variant of force leading to separation of posterior facet Fig. D-F:
• Pure axial force = tongue type variant Tongue-type. Secondary fracture line results from a pure axial
force

Michel A. Taylor, Abdel Rahman Lawendy, David W. Sanders. Calcaneus Fractures. In: Tornetta P, Ricci
WM, eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc;
2019. (Fig 66-12)
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 Pathoanatomy
• Posterior calcaneal tuberosity avulsion fractures
are a subset of extra-articular calcaneus fxs
Meinberg E, Agel J, Roberts C,
et al. Fracture and Dislocation
Classification Compendium–
2018, Journal of Orthopaedic

• Calcaneal bone strength ↓ with age Trauma. Volume 32: Number 1;

Supplement, January 2018.

• peak incidence: women in 7th decade

• Mechanism - violent pull from the
gastrocnemius-soleus complex coupled with
forced dorsiflexion
• Posterior skin at severe risk

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Michel A. Taylor, Abdel Rahman Lawendy, David W. Sanders. Calcaneus
Fractures. In: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in
Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc; 2019. (Fig 66-4)
 Pathoanatomy
• Anterior process fractures happen in isolation or as
extension of an intra-articular fracture
• anterior process contributes to anterior facet and CC.
• Proposed mechanisms:
• forced hindfoot dorsiflexion and eversion with
compression of the anterior process between the
cuboid and the talus
• sudden ankle inversion w/ plantarflexed foot.
• Most do well with conservative management
• Large (>25% CC joint with displacement)  ORIF

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Indications for Non-Operative Treatment
• Nondisplaced intra-articular or extra-articular fractures
• Minimally displaced (<1 cm) extra-articular fractures
• Anterior process fractures <25% CC joint involvement
• Other Treatment considerations:
• Patient factors
• Injury factors
• Surgeon factors

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Treatment Considerations – Patient Factors
Patient Age:
• Essex-Lopresti (BrJS 1952) – 40% of pt >50 with unacceptable outcome
• Herscovici et. al (JBJS 2005) – 4/37 major complications in pt>65 yo;
outcomes correlated more with presence of comorbidities than age
• Gaskill et al (JBJS 2010) - Outcomes in pt >50 yo comparable to younger
patients if no prohibitive comorbidities

Medical Comorbidities:
• Consider less invasive management in the presence of:
• Insulin Dependent Diabetes, Peripheral Vascular Disease
• Neuropathy, Organic Brain Disease
• ESRD, CHF
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Treatment Considerations – Patient Factors
Social Factors:
• Drug/Alcohol Abuse
• Unable to cooperate with NWB/PWB
• Smoking
• 70% complication rate in smokers vs 15% in
nonsmokers (Assous et al, Injury 2001)
• 3X rate of deep infection (Soni et al, FAS 2014)

Worker’s Compensation:
• after removing pts on WC, outcomes better
in some groups of surgically treated
patients (Buckley et al, JBJS 2002)

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Treatment Considerations – Injury Factors
Higher degree of soft tissue injury:
• Open Calcaneus Fractures (Mehta et al, JOT 2010)
• rate of wound complications (19% to 67%)
• rate of osteomyelitis (10% to 33%)

Higher degree of osseous injury:

• Sanders Type IV more likely to be fused than Type II;
25% at 2 years (Buckley et al, JBJS 2002)
• Böhler angle on presentation <0° 10x more likely to
require secondary subtalar fusion than >15° (Csizy
et al, JOT 2003)

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Treatment Considerations – Injury Factors
• Significant learning curve
• Challenging fracture to treat operatively
• Surgical Complications may be worse than nonoperative treatment
• Consideration for care by “experts” or specialty centers
(Court-Brown et al, Injury 2009), (Schepers et al, JFAS 2013)

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Technique - External Fixation
• Medial frame can be placed temporarily
to preserve lateral soft tissues for
exposure after soft tissues heal
• Can also be definitive treatment to get
overall morphology (height, length,
remove varus)
• subsequent limited exposures can
be done laterally for articular
reduction/fusion

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Technique - External Fixation
• Place Shanz pins:
• Medial cuneiform to middle of
lateral cuneiform
• Medial distal tibia
• Medial calcaneal tuberosity
• Reduce Tuberosity:
• Height
• Length
• Translation
• Angulation

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Goals of Operative Treatment
Restoration of Anatomy
• Articular congruency – minimize arthritis
• Calcaneal morphology
• Restore Width
• allow for shoe wear
• minimize sub-fibular impingement
• Restore height for ankle function
• anterior ankle impingement from
dorsiflexed talus
• Restore length for foot alignment
• Lever arm for propulsive gait
through the gastrocnemius-soleus
• Post-traumatic pes planus
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Surgical Approaches - Extensile Lateral
Pros:
• Visualization of entire lateral calcaneus
• Good view of posterior facet
• Direct reduction of ant. process + tuberosity
• Easy to address lateral wall “blow-out”
• Stable fixation with lateral plate

Cons:
• Increased risk of wound healing problems

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Technique - Extensile Lateral
Positioning
• Lateral on a beanbag
• Blankets or foam ramp as
platform for operative limb
• Ensure adequate external
rotation of hip for Broden’s and
Harris views
• C-ARM comes in at an angle
from the foot of the bed

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 Technique
• Full thickness sub-periosteal flap
• Care not to damage sural nerve
• Elevate calcaneofibular ligament
and peroneal tendons w/ flap
• “No touch” technique for flap
retraction with wires in fibula,
talar neck and cuboid
• Not all surgeons advocate use of wires for flap retraction

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Technique - Reduction AP translates
dorsally

Significant variability in the fx pattern of intra-

articular calcaneal fx
BUT there are consistent features:
• The sustentaculum typically remains attached
to the talus
ST remains
• The anterior process translates dorsally attached to
talus
• The tuberosity translates laterally, displaces
superiorly (pull of Achilles), rotates into varus,
and shortens into the fracture

Tuberosity Displaces
superiorly and rotates into varus

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Meinberg E, Agel J, Roberts C, et al. Fracture and Dislocation Classification Compendium–2018, Journal of Orthopaedic
Trauma. Volume 32: Number 1; Supplement, January 2018.
 K-Wires
from AP

Technique - Reduction to ST

• Lateral wall is reflected

• Reduction proceeds from anterior to
posterior typically
• Anterior process to sustentaculum
• Tuberosity is levered out of varus
• Reduce tuberosity to the
sustentaculum Shanz pin to lever
tuber out of varus

K-Wires:
Tuberosity to ST Core Curriculum V5
Technique - Reduction
• Lateral wall is reflected
• Reduction proceeds from anterior to
posterior typically
• Anterior process to sustentaculum
• Tuberosity is levered out of varus
• Reduce tuberosity to the
sustentaculum
• Reduce lateral posterior facet joint
fragments to sustentaculum and to
talar facet above

Michel A. Taylor, Abdel Rahman Lawendy, David W. Sanders. Calcaneus Fractures.

In: Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e.
Philadelphia, PA. Wolters Kluwer Health, Inc; 2019. (Fig 66-16)

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 Technique - Plating
• Plate(s) is then applied. Serves as a washer for the screws, to compress
the lateral wall, and acts to resist the deforming varus forces.

Best bone for fixation:

• Subchondral posterior facet
• Subchondral angle of Gissane
• Subchondral CC joint
• Sustentaculum
• Tuberosity near Achilles insertion

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Michel A. Taylor, Abdel Rahman Lawendy, David W. Sanders. Calcaneus Fractures. In: Tornetta Michel A. Taylor, Abdel Rahman Lawendy, David W. Sanders. Calcaneus Fractures. In: Tornetta P, Ricci
Michel A. Taylor, Abdel Rahman Lawendy, David W. Sanders. Calcaneus Fractures. In: Tornetta P, WM, eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA. Wolters Kluwer Health, Inc;
P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA. Wolters
Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA. Wolters Kluwer 2019. (Fig 66-20)
Kluwer Health, Inc; 2019. (Fig 66-17)
Health, Inc; 2019. (Fig 66-19)
Technique - Closure
• Careful soft tissue handling is critical
• Place all periosteal subcutaneous
sutures
• Reduce flap to apex

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Surgical Approaches - Sinus Tarsi
Pros:
• Lower risk of wound complications
• Operate earlier (fracture mobile)
• Good view of posterior facet
• Direct reduction of anterior process

Cons:
• Indirect reduction of tuberosity
• Harder to address lateral wall blowout
• Limited fixation options

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Technique - Sinus Tarsi
• 2- to 4-cm incision from the tip of the
fibula to base of the fourth metatarsal .
• EDB is retracted cephalad to permit
visualization of posterior facet
• Schantz pin is placed through a stab
incision in the posteroinferior calcaneal
tuberosity from lateral to medial to
allow for tuberosity manipulation
• Hold reduction with K-Wires. Fixation
can be done with cannulated or solid
screws

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Technique - Sinus Tarsi
• Small screws to compress articular
Fx +/- small plate to span angle of
Gissane
• Medial Wall Screw
• Into sustentaculum
• “Articular Support Screw”/
“Kickstand” Screw
• Support depressed articular
fragment
• Lateral Column Screw
• Into anterior process

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Technique - Percutaneous Reduction and Fixation

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 Consideration – Primary Subtalar Arthrodesis
• Two roles for subtalar arthrodesis:
• Late: to manage post traumatic
arthritis, ankle impingement, correct
deformity
• Acute: to manage fractures with severe
comminution and/or cartilage damage

• Sanders IV fx do worse clinically, and have

higher rates of late fusion
• In the 2002 Buckley RCT, 25% of ALL
Sanders IV patients go on to ST fusion
within 2 years.

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 FAI 1996

• 108 patients with 112 calcaneal treated b/w 1989 – 1992

• 15% (16 pts) w/ ORIF (to restore height and width) and primary ST
arthrodesis
• 14 patients (12 males and 2 females; mean age, 40 years) were
available for f/u at a mean time of 26 months after surgery
• Of the 12 patients employed before the injury, 11 returned to their
original occupations at a mean time of 8.8 months after injury
• The mean AOFAS score 72.4

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 JOT 2014

• 31 pts with 31 Sanders IV calcaneal fractures (4 centers)

• 17 patients received lateral approach for ORIF. 14 with ORIF + PSTA
• From 2004 to 2011, 26 patients were followed for a minimum of 2 years (81% f/u)
• 1 ORIF patient needed secondary fusion (1/17)
• No statistical difference was found between the results for ORIF, compared with
ORIF + PSTA (SF-36, AOFAS 64 vs 62, VAS)
• Possibility of Type 2 error (Underpowered study)

Authors Conclusions: “ORIF + PSTA however, should be considered for patients with
Sanders type IV fractures, and the health care system as they heal at a much more
rapid rate, and will not require additional surgery. This must be considered, as the
choice of treatment may have profound economic effects on the patient.”
• (Healing based on time to Weight bearing --10wks in ORIF vs 6 wks in PSTA )
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 JBJS 2010

• 69 pts w/ 75 DIACF underwent subtalar arthrodesis for post-traumatic arthritis.

• Group A – 34 pts (36 fx) initially managed ORIF at an average of 22.6 months later.
• Group B - 35 pts (39 fx) initially managed nonoperatively
• There were three nonunions per group.
• Group A had less wound complications and significantly higher Maryland Foot Scores
(90.8 vs 79.1; p < 0.0001) and AOFAS ankle-hindfoot scores (87.1 vs 73.8; p < 0.0001)
than did Group B.

Authors conclusions: “Initial open reduction and internal fixation restores

calcaneal shape, alignment, and height, which facilitates the fusion procedure
and establishes an opportunity to create a better long-term functional result.”

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Summary
• Calcaneus fractures can be extremely debilitating injuries
• Thorough radiographic assessment needed
• Operative indications must be carefully considered – with particular
attention to patient, injury and surgeon factors
• Host and injury factors affect choice of surgical approaches
• Remember, do no harm.

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Key References
• Hansen, S.T. Functional Reconstruction of the Foot and Ankle. Philadelphia, Lippincott Williams & Wilkins, 2000,pp. 1–512
• Rockwood and Green’s Fractures in Adults, 9th Edition
• Banerjee, R., Chao, J. C., Taylor, R., & Siddiqui, A. (2012). Management of Calcaneal Tuberosity Fractures. Journal of the American Academy of Orthopaedic
Surgeons, 20(4), 253-258. doi:10.5435/jaaos-20-04-253
• Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39:395-419
• Herscovici D Jr, Widmaier J, Scaduto JM, Sanders RW, Walling A. Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am. 2005
Jun;87(6):1260-4
• Gaskill T, Schweitzer K, Nunley J. Comparison of surgical outcomes of intra-articular calcaneal fractures by age. J Bone Joint Am. 2010 Dec 15;92(18) 2884-9
• Soni A, Vollans S, Malhotra K, Mann C. Association Between Smoking and Wound Infection Rates Following Calcaneal Fracture Fixation. Foot Ankle Spec.
2014;7(4):266-270.
• Assous, M., and Bhamra, M. S.: Should Os calcis fractures in smokers be fixed? A review of 40 patients. Injury, 32(8): 631-2, 2001
• Mehta, Samir MD*; Mirza, Amer J MD†; Dunbar, Robert P MD‡; Barei, David P MD‡; Benirschke, Stephen K MD‡ A Staged Treatment Plan for the Management
of Type II and Type IIIA Open Calcaneus Fractures, Journal of Orthopaedic Trauma: March 2010 - Volume 24 - Issue 3 - p 142-147 doi:
10.1097/BOT.0b013e3181b5c0a4
• Csizy M, Buckley R, Tough S, et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003;17(2):106-112.
doi:10.1097/00005131-200302000-00005
• Court-Brown CM, Schmied M, Schutte BG. Factors affecting infection after calcaneal fracture fixation [published correction appears in Injury. 2011 Jul;42(7):725.
Schmidt, Matthias [corrected to Schmied, Matthias]]. Injury. 2009;40(12):1313-1315. doi:10.1016/j.injury.2009.03.044
• Schepers T, Den Hartog D, Vogels LM, Van Lieshout EM. Extended lateral approach for intra-articular calcaneal fractures: an inverse relationship between
surgeon experience and wound complications. J Foot Ankle Surg. 2013;52(2):167-171. doi:10.1053/j.jfas.2012.11.009

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