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.

1 Follower
38 Reads
  • Source
    • "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]. "
    [Show abstract] [Hide abstract]
    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 · 1.40 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Review question: What is the effect of surgical treatment compared with conservative treatment of displaced intra-articular calcaneal fractures in adults?
    Orthopaedic nursing / National Association of Orthopaedic Nurses 11/2013; 32(6):336-7. DOI:10.1097/NOR.0000000000000008 · 0.56 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Management of intra-articular calcaneal fractures during the past years has ranged from the nihilistic approach of no active treatment to open reduction and internal fixation or even to early subtalar arthrodesis. Operative treatment presents the surgeon with many challenges. Good results require atraumatic exposure, anatomic reduction, rigid fixation and early mobilization. We describe the use of a temporary external fixator as an intraoperative aid in the open reduction and internal fixation of intra-articular calcaneal fractures. We propose this operative strategy as an option for the treatment of calcaneal fractures. The controlled distractive force provides numerous benefits. These include improved exposure of the subtalar joint, correction of angulation and maintenance of temporary stability prior to definitive fixation. We have found this technique applicable and easily reproducible.
    Acta orthopaedica Belgica 12/2013; 79(6):738-41. · 0.65 Impact Factor
Show more