Surgical versus conservative interventions for displaced intra-articular calcaneal fractures
ABSTRACT 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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ABSTRACT: To compare the effect of open reduction internal fixation and conservative treatment combined with open reduction internal fixation for subjects with calcaneal fractures, 130 patients with calcaneal fractures were divided into observation group and control group. Observation group were treated with open reduction internal fixation and conservative treatment, control group treated as open reduction internal fixation. The healing related indicators, daily life activities ability score of observation group after treatment 6 months were significantly higher than that of the control group, there was no significant difference for the healing rate of excellent and good rate, the daily life activities ability score after one and three year between two groups. Open reduction internal fixation combined with conservative treatment in treatment of calcaneal fractures can clear anatomic structure and have fast function recovery. Thus, it should be as the preferred method for the treatment of calcaneal fractures.International Journal of Clinical and Experimental Medicine 01/2014; 7(11):4479-82. · 1.42 Impact Factor
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ABSTRACT: Bony destructive injury of the calcaneus (BDIC) represents one of the most severe comminuted fractures of the calcaneus in which soft tissue coverage remains intact. The features of this injury include a collapsed articular surface, significant widening, severe loss of height and an unrecognisable outline of the calcaneus. This study aims to present the long-term outcomes of BDIC treated in a minimally invasive fashion followed by supervised early exercise. Twelve patients with unilateral BDICs were treated at our institution. The main surgical procedures included percutaneous traction and leverage reduction and internal compression fixation with anatomic plates and compression bolts. Early functional exercise was encouraged to mould the subtalar joint. The height, length and width of the calcaneus; Bohler's and Gissane's angles; reduction of the articular surfaces; and functional recovery of the affected feet were assessed. The height, length and width of the calcaneus were substantially restored. The mean Bohler's and Gissane's angles of the affected calcaneus were 24.5 and 122.8 degrees, respectively. Five patients regained anatomical or nearly anatomical reduction of their posterior facets. Residual articular displacement of more than 3 mm was noted in three patients. Patients were followed for a mean of 93.9 months. The mean American Orthopaedic Foot and Ankle Society score was 83.8. Nine patients showed excellent or good results. Radiographic evidence of post-traumatic subtalar arthritis was observed in four cases. However, no subtalar arthrodesis was required. BDICs can be treated effectively with percutaneous reduction and internal compression fixation followed by early active exercise. This protocol resulted in satisfactory radiological and functional outcomes.BMC Surgery 04/2014; 14(1):19. DOI:10.1186/1471-2482-14-19 · 1.24 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.The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons 05/2014; 54(3). DOI:10.1053/j.jfas.2014.04.014 · 0.98 Impact Factor