Böhler and Gissane angles: Approximation to normal values in the Colombian population

 Corresponding author: Andres Felipe Mayorga Chaparro Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Böhler and Gissane angles: Approximation to normal values in the Colombian population Andres Felipe Mayorga Chaparro 1, *, Nicolas Eladio Esguerra Romano 1, Jhon Alexander Muñoz Pinto 1, Gabriela Lozada Vega 2, Andrea Carolina Bustos Castellanos 2 and Alberto Enrique Vieco Reyes 3 1 Resident in Orthopedics and Traumatology, Faculty of Health Sciences, Universidad Libre, Barranquilla, Colombia. 2 Medical Student, Faculty of Health Sciences, Universidad Libre, Barranquilla, Colombia. 3 Foot and Ankle Surgeon, Orthopedic Surgeon, Clínica Iberoamérica, Barranquilla, Colombia. World Journal of Advanced Research and Reviews, 2025, 26(02), 762-766 Publication history: Received on 14 March 2025; revised on 03 May 2025; accepted on 06 May 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.2.1734 Abstract Introduction: Calcaneal fractures are a common tarsal injury, which remains a diagnostic and therapeutic challenge. Although tomography has optimized their evaluation, the measurement of Böhler and Gissane angles on conventional radiographs remains essential for initial diagnosis and follow-up. The normal values of these angles may vary according to the population, the present study is looking for reference values in the Colombian population. Methodology: A descriptive cross-sectional study was performed in an imaging center in Barranquilla, Colombia. Lateral ankle radiographs of patients older than 18 years without bone alterations were analyzed. Böhler and Gissane angles were measured by two investigators independently on two different occasions. Measures of central tendency and dispersion were calculated. Student's t-tests were applied to evaluate differences by sex, laterality and age group. Results: 240 radiographs of 189 patients were evaluated. The mean Böhler angle was 31.36° ± 6.03 and the mean Gissane angle was 117.23° ± 7.74. No statistically significant differences were observed according to sex, laterality or age group (p > 0.05). Discussion: The values obtained are similar to those reported in Latin American studies, although slightly lower than the classic ranges described in North American and European populations. These findings reinforce the importance of having local reference values for radiographic evaluation of the calcaneus. Conclusions: The Böhler and Gissane angles in the Colombian population present values comparable to those of other Latin American populations. It is suggested to use these values as a reference in local clinical practice for a more accurate diagnosis Keywords: Calcaneal Fractures; Radiography; Orthopedics; Anthropometry; Anatomy 1. Introduction Calcaneal fractures represent the most common tarsal injury, usually secondary to high-energy trauma [1]. Their complex anatomy, associated soft tissue complications and the multiple therapeutic strategies available make these fractures a challenge for orthopedists [2]. Since their initial description, Böhler and Gissane angles have been used for the diagnosis, preoperative planning and postoperative follow-up of calcaneal fractures, especially in settings where World Journal of Advanced Research and Reviews, 2025, 26(02), 762-766 763 computed tomography (CT) is not immediately available (Figures 1a and 1b) [3,4]. Although the routine use of CT has allowed for more detailed analysis, radiography remains the initial method of evaluation. [5] Figure 1 a Böhler angle measurement, b. Gissane angle measurement Classically, normal values for the Böhler and Gissane angles have been stipulated to be between 20-40° and 120-140° respectively. Works such as those of Hauser and Kroeker in the United States, Loucks and Buckley in Canada and Shoukry in Egypt have attempted to characterize more precisely these values in their population [6-8]. As for the Latin American population there are few antecedents with the same objective, the closest was performed in the Brazilian population by Louro and collaborators where they find values for the Böhler angle at 32.6°±6.1 and Gissane at 110.6°±11.9 [9]. Determining the reference values in the Colombian population and comparing them with those already established in the literature allows for an objective diagnosis and a search for results close to normality corresponding to our context 2. Material and methods A descriptive cross-sectional study was carried out in an imaging center in Barranquilla, Colombia. The study included lateral ankle radiographs of patients older than 18 years with adequate technique for the measurement of Böhler and Gissane angles. Radiographs with osteosynthesis devices, congenital or acquired deformities, sequelae of previous fractures or artifacts that prevented a correct measurement were excluded (Figure 2). Measurements were performed independently by two investigators, on two separate occasions, using calibrated digital measurement software. For statistical analyses, measurements with a value of 0 were excluded. The mean, median, mode and standard deviation of the Böhler and Gissane angles were calculated. For comparison between sex, laterality and age groups, Student's t-tests were applied. A value of p < 0.05 was considered statistically significant. Figure 2 Example of radiograph excluded from the study due to obvious deformity World Journal of Advanced Research and Reviews, 2025, 26(02), 762-766 764 3. Results A total of 240 radiographs corresponding to 189 patients were evaluated: 110 women (58.2%) and 79 men (41.8%). Of the studies, 138 were unilateral and 51 bilateral. The right foot was evaluated in 130 cases and the left foot in 110 cases. The age of the patients ranged from 18 to 85 years, with a mean of 46 ± 16.2 years (Table 1). The Böhler angle had a mean of 31.36° ± 6.03, with a range between 16.1° and 44°, while the Gissane angle presented a mean of 117.23° ± 7.74. When comparing the angles between sexes, no statistically significant differences were found (p > 0.05). Nor were significant differences found when comparing between right and left feet (p > 0.05) or between the different age groups (p > 0.05). The aforementioned results are summarized in Table 2 and 3. Table 1 Characteristics of the radiographs of the patients evaluated. n= 189 Total (n) Total (%) Age (years) 18 - 29 30 15.9% 30 - 39 45 23.8% 40 – 49 34 17.9% 50 – 59 37 19.5% 60 – 69 26 13.7% 70 – 79 13 6.8% 80 – 89 4 2.1% 189 100% Sex Female 110 58.2% Male 79 41.8% 189 100% Laterality Right 130 54.1% Left 110 45.9% 240 100% Table 2 Mean result of the Böhler and Gissane angles measured Right (°) Left (°) Total Mean (°) Standard Deviation Mean Böhler 30.81 31.91 31.36 6.03 Mean Gissane 117.83 116.64 117.23 7.74 Table 3 Comparison of the Böhler and Gissane angles measured according to age Female (°) Male (°) T Student P Value Mean Böhler 30.96 32.01 -1.187 0.8816 Mean Gissane 117.6 116.6 1.13 0.8701 World Journal of Advanced Research and Reviews, 2025, 26(02), 762-766 765 4. Discussion The evaluation of calcaneal fractures continues to rely heavily on conventional radiographic studies, despite the advent of computed tomography as a diagnostic tool. The Böhler and Gissane angles, initially described in a context prior to the widespread use of CT, continue to have clinical relevance for the diagnosis, surgical planning and follow-up of calcaneal fractures [1,3,4]. In the present study, the average values of the Böhler angle (31.36° ± 6.03) and Gissane angle (117.23° ± 7.74) were consistent with those reported in Latin American studies, such as that of Louro et al. in Brazil, who found an average Böhler angle of 32.6° ± 6.1 and Gissane angle of 110.6° ± 11.9 [9]. In contrast, our results showed slightly lower values with respect to those reported in North American and European populations, where the Gissane angle tends to be closer to 120°-130° [6,7]. These differences reinforce the hypothesis that anatomical parameters vary between populations, possibly influenced by genetic, environmental, ethnic and physical developmental factors. A strength of our work is the methodology employed with dual analysis by two independent observers and repeated measurements, a strategy that improves the reproducibility of the results and minimizes measurement bias. In addition, the inclusion of a relatively large sample, in comparison with previous studies in Latin America and worldwide, increases the statistical power of the study and the reliability of the confidence intervals obtained. Another favorable feature is the rigorous application of inclusion and exclusion criteria, eliminating radiographs with anatomical alterations, artifacts or previous post-traumatic conditions, ensuring that the measurements reflect unaltered normal anatomical values. However, this study also has relevant limitations. The single-center design limits the extrapolation of the findings to the entire Colombian population, especially considering the existing ethnic diversity in the country. Secondly, additional factors that could have an impact on anginal measurements, such as height, weight, body mass index, occupation or habitual physical activity of the patients, were not evaluated. Previous studies have suggested that these factors may influence bone morphology and radiographic measurements [10,11]. Additionally, a formal intraand interobserver agreement analysis (e.g., using intraclass correlation coefficients) was not performed, which would have further strengthened the validation of the measurements made. Also, the technical quality of some radiographs, inherent in the retrospective material, may have affected the accuracy of some measurements. Finally, although our study focused on establishing anatomical reference values, neither clinical nor functional correlation with these values was included. Future studies could investigate whether small differences in Böhler and Gissane angles in healthy individuals correlate with clinical symptoms, fracture predisposition, or surgical outcomes in trauma cases. In conclusion, our results support the need for local reference parameters to improve diagnostic accuracy and surgical planning of calcaneal fractures in the Colombian population. This work establishes a solid basis for future multicenter investigations, with larger samples and clinical correlations, which will further strengthen the anatomical knowledge applied to the treatment of this complex pathology 5. Conclusion The average values of Böhler's angle (31.36°) and Gissane's angle (117.23°) in the Colombian population are similar to those reported in Latin American populations. There were no significant differences according to sex, laterality or age. The use of these reference values in local clinical practice is suggested. Compliance with ethical standards Disclosure of conflict of interest The authors declare that they have no conflicts of interest to disclose. World Journal of Advanced Research and Reviews, 2025, 26(02), 762-766 766 Statement of informed consent Informed consent was obtained from all individual participants included in the study. References [1] Allegra PR, Rivera S, Desai SS, Aiyer A, Kaplan J, Gross CE. Intra-articular Calcaneus Fractures: Current Concepts Review. Foot Ankle Orthop. 2020;5(3). [2] Leigheb M, Codori F, Samaila EM, Mazzotti A, Villafañe JH, Bosetti M, Ceccarini P, Cochis A, Daou F, Ronga M, et al. Current Concepts about Calcaneal Fracture Management: A Review of Metanalysis and Systematic Reviews. Applied Sciences. 2023; 13(22) [3] Böhler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg Am. 1931. [4] Gissane W. Discussion on fractures of the os calcis. Proc R Soc Med. 1947. 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