Surgical versus conservative interventions for displaced intra-articular calcaneal fractures

WarwickClinical TrialsUnit,University ofWarwick,Coventry,UK. .
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 02/2013; 1(1):CD008628. DOI: 10.1002/14651858.CD008628.pub2
Source: PubMed


Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures. These fractures are mostly caused by a fall from a height, and are common in younger adults. Treatment can be surgical or non-surgical; however, there is clinical uncertainty over optimal management.
To assess the effects of surgical compared with conservative treatment of displaced intra-articular calcaneal fractures in adults.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to July 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 3), MEDLINE (1948 to July 2011), EMBASE (1980 to 2011 Week 27), the WHO International Clinical Trials Registry Platform, Current Controlled Trials, and Orthopaedic Trauma Association annual meeting archives (1996 to 2011). Reference lists of retrieved articles were checked. No language restrictions were applied.
Randomised and quasi-randomised controlled clinical studies comparing surgical versus conservative management for displaced intra-articular calcaneal fractures.
Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. Primary outcomes were function (e.g. walking ability) and chronic pain. Risk ratios were calculated for dichotomous outcomes and mean differences for continuous outcomes. Missing standard deviations were calculated from P values.
Four trials were included (602 participants). Three trials were small single-centre trials, and the fourth a large multi-centre trial including 424 participants. All trials had methodological flaws, usually failure to conceal allocation and incomplete follow-up data, which put them at high risk of bias. Follow-up ranged from 1 to 15 years after treatment.Data for functional outcomes, including walking ability, from three trials could not be pooled. The strongest evidence was from the multi-centre trial. This showed no statistically or clinically significant differences between the surgical and conservatively treated groups at three years follow-up in the ''validated disease-specific" score (0 to 100: perfect result; 424 participants; mean difference (MD) 4.30, 95% confidence interval (CI) -1.11 to 9.71; P = 0.12). There was no significant difference between the two groups in the risk of chronic pain at follow-up (19/40 versus 24/42; risk ratio (RR) 0.79, 95% CI 0.53 to 1.18; 2 trials). The multi-centre trial found no statistically or clinically significant difference between the two groups in health-related quality of life at three years follow-up (SF-36 (0 to 100: best outcome): MD 4.00, 95% CI -1.16 to 9.16; P = 0.13).Two small trials provided some limited evidence of a tendency for a higher return to previous employment after surgery (27/34 versus 15/27; RR 1.45, 95% CI 0.75 to 2.81; I² = 55%; 2 trials). One small trial found no difference between the two groups in the ability to wear normal shoes, whereas another small trial found that surgery resulted in more people who were able to wear all shoes comfortably. There was a higher rate of major complications, such as surgical site infection, after surgery compared with conservative treatment (57/206 versus 42/218; RR 1.44, 95% CI 1.01 to 2.04; 1 trial). Conversely, significantly fewer surgical participants had subtalar arthrodeses due to the development of subtalar arthritis (7/206 versus 37/218; RR 0.20, 95% CI 0.09 to 0.44; 1 trial). There were no significant differences between the two groups in range of movement outcomes or radiological measurements (e.g. Bohler's angle).
The bulk of the evidence in this review derives from one large multi-centre but inadequately reported trial conducted over 15 years ago. This found no significant differences between surgical or conservative treatment in functional ability and health related quality of life at three years after displaced intra-articular calcaneal fracture. Though it reported a greater risk of major complications after surgery, subtalar arthrodeses for the development of subtalar arthritis was significantly greater after conservative treatment.Overall, there is insufficient high quality evidence relating to current practice to establish whether surgical or conservative treatment is better for adults with displaced intra-articular calcaneal fracture. Evidence from adequately powered randomised, multi-centre controlled trials, assessing patient-centred and clinically relevant outcomes is required. However, it would be prudent to reassess this need after an update of the review that incorporates new evidence from a currently ongoing multi-centre trial.

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    • "We did not use plaster for provisional fixation after the operation. Immobilisation in plaster adversely affects the end result [35,36]. Essex-Lopresti has stressed that exercise therapy has advantages over immobilisation [2]. "
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    BMC Surgery 04/2014; 14(1):19. DOI:10.1186/1471-2482-14-19 · 1.40 Impact Factor
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    ABSTRACT: The aim of the present study was to compare the outcomes of patients with a displaced calcaneal fracture treated by open reduction and internal fixation (ORIF), percutaneous treatment, or nonoperative methods. A retrospective cohort study was conducted at a level I trauma center of patients with a displaced intra-articular calcaneal fracture treated from January 1, 2002 to December 31, 2011. The patient-reported outcome measures included the Foot Function Index, American Orthopaedic Foot and Ankle Society hindfoot scale, Short Form-36, the EQ-5D from the EuroQol Group, and a 10-point visual analog scale. Clinical data were collected from 169 patients, and questionnaires were obtained from 78 patients (18 nonoperatively, 27 ORIF, and 33 percutaneously). The late intervention rate was significantly greater in the percutaneous group (n = 18; 30%) than in the ORIF group (n = 6; 12%) or the nonoperative group (n = 8; 13%; p = .030). Significantly more disability was reported in the nonoperative group (median Foot Function Index score, 40 points) than in the ORIF group (median, 16 points; p = .010) or in the percutaneous group (median, 21 points; p = .034). In conclusion, the operatively treated patients (ORIF and percutaneous treatment) reported better functional outcome scores (Foot Function Index and American Orthopaedic Foot and Ankle Society hindfoot scale) than did the nonoperatively treated patients.
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    ABSTRACT: Objective To investigate whether surgery by open reduction and internal fixation provides benefit compared with non-operative treatment for displaced, intra-articular calcaneal fractures. Design Pragmatic, multicentre, two arm, parallel group, assessor blinded randomised controlled trial (UK Heel Fracture Trial). Setting 22 tertiary referral hospitals, United Kingdom. Participants 151 patients with acute displaced intra-articular calcaneal fractures randomly allocated to operative (n=73) or non-operative (n=78) treatment. Main outcome measures The primary outcome measure was patient reported Kerr-Atkins score for pain and function (scale 0-100, 100 being the best possible score) at two years after injury. Secondary outcomes were complications; hindfoot pain and function (American Orthopaedic Foot and Ankle Society score); general health (SF-36); quality of life (EQ-5D); clinical examination; walking speed; and gait symmetry. Analysis was by intention to treat. Results 95% follow-up was achieved for the primary outcome (69 in operative group and 74 in non-operative group), and a complete set of secondary outcomes were available for 75% of participants. There was no significant difference in the primary outcome (mean Kerr-Atkins score 69.8 in operative group v 65.7 in non-operative group; adjusted 95% confidence interval of difference −7.1 to 7.0) or in any of the secondary outcomes between treatment groups. Complications and reoperations were more common in those who received operative care (estimated odds ratio 7.5, 95% confidence interval 2.0 to 41.8). Conclusions Operative treatment compared with non-operative care showed no symptomatic or functional advantage after two years in patients with typical displaced intra-articular fractures of the calcaneus, and the risk of complications was higher after surgery. Based on these findings, operative treatment by open reduction and internal fixation is not recommended for these fractures. Trial registration Current Controlled Trials ISRCTN37188541.
    BMJ Open 07/2014; 349(jul24 5). DOI:10.1136/bmj.g4483 · 2.27 Impact Factor
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