SLR - August 2021 - Stuardo Trigueros

Open Reduction and Internal Fixation Versus Nonoperative Treatment for Closed, Displaced, Intra-Articular Fractures of the Calcaneus: Long-Term Follow-Up from the Heft Randomized Controlled Trial

Reference: Dickenson EJ, Parsons N, Griffin DR. Open Reduction and Internal Fixation Versus Nonoperative Treatment for Closed, Displaced, Intra-Articular Fractures of the Calcaneus: Long-Term Follow-Up from the Heft Randomized Controlled Trial. Bone Joint J. 2021 Jun;103-B(6):1040-1046.

Level of Evidence: I

Scientific Literature Review 

Reviewed By: Stuardo Trigueros, DPM 
Residency Program: Kaiser North Bay Consortium - Vallejo, CA

Podiatric Relevance: With foot and ankle trauma injuries, podiatric surgeons share the decision-making to determine whether benefits of surgical management outweigh the risks of perioperative complications. This study attempts to answer whether open reduction and internal fixation (ORIF) of closed, displaced, intra-articular calcaneal fractures is superior to nonoperative management. 

Methods: This is an assessor-blinded, multicentre, randomized controlled trial in which 151 patients aged 16 years or older who suffered closed, displaced, intra-articular calcaneal fractures were evaluated. Subjects within the ORIF group had surgical intervention within three weeks of injury. Exclusion criteria were fibular impingement due to gross deformity, involvement of other serious leg injuries and peripheral vascular disease. The randomized patients were allocated to either ORIF or nonoperative care. ORIF was performed via extensile lateral approach. Both postoperative management and nonoperative care consisted of six weeks non-weightbearing and six weeks partial weightbearing with early active mobilization of ankle joint. Outcomes quantifying pain and function were measured using the Kerr-Atkins scoring system at 36, 48 and 60 months.  

Results: One hundred eighteen patients (78 percent) completed the final 60 month follow-up (52 ORIF, 66 nonoperative). Kerr-Adkins scores were not statistically significantly different between the two groups at final follow up (95 percent confidence interval; p = 0.495). At 60 months, the mean Kerr-Atkins scores were 79.2 (standard deviation (SD) 21.5) for the ORIF group and 76.4 (SD 22.5) for the nonoperative group. There was no statistical significance between the groups in terms of difficulty walking (p = 0.175) or in the type of shoe worn (p = 0.432) at 60 months. However, the study found that there was significantly more additional surgical procedures in the ORIF group (10/52; 19 percent) compared to the nonoperative group (4/66; 6 percent) (p = 0.043). The study noted that the most common complication of the ORIF group was surgical site infection.

Conclusions: The authors of this study concluded that ORIF of closed, displaced, intra-articular calcaneal fractures without fibular impingement did not have significant difference in outcomes at 60 months compared to nonoperative management, however, the ORIF group had an increased risk of additional surgery. It is worth noting that the extensile lateral approach was used for each surgical intervention. Functional outcomes of nonoperative management compared to the alternative, minimally invasive sinus tarsi approach may differ as it may minimize wound complications and post-operative infections. However, there is no clear consensus on a definite superior approach for calcaneal fractures in the literature. This study’s robust design simply cannot be disregarded and may sway a podiatric surgeon’s decision-making when encountering this type of fracture.

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