SLR - July 2021 - Shayla Robinson

The Effect of Calcaneal Fractures on Functional and Economic Outcome in the Industrial Patient
Reference: Scherer MA. The Effect of Calcaneal Fractures on Functional and Economic Outcome in the Industrial Patient. Clin Surg. 2021; 6: 3171

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Shayla Robinson, DPM
Residency Program: Emory University School of Medicine – Decatur, GA

Podiatric Relevance: Calcaneal fractures, though not as common as other foot and ankle fractures, can lead to many complications, economic challenges, and long term sequalae in many individuals, especially the working class. The conversation on whether surgical or conservative care leads to better outcomes is often debated. Industrial workers are commonly injured on the job which can lead to loss of work, financial challenges and functional decline. Many of these patients often resort to Workers Compensation to cover the costs of the devastating injury. The current study evaluates the functional and economic outcomes of calcaneal fractures in the industrial patient covered by the Worker's Compensation Board in Germany.

Methods: A retrospective chart review of industrial workers who sustained calcaneal fractures at work from January 1990 through July 2005 in Munich, Germany was performed.  All health costs are covered by the Workers' Compensation Board per German law. Patients were either treated surgically or conservatively. The American Orthopaedic Foot and Ankle Score (AOFAS) hindfoot questionnaire, Short Form 36 (SF-36), time off work, impairment rate and costs associated with injury were evaluated. The impairment rate is assigned based on German evaluation guidelines. A calcaneal fracture as a sole pathology can cause between a 10 percent-40 percent impairment rate based on the Bohler angle, arthritic changes, rigidity of the subtalar joint and/or hindfoot deformity. Non-weight bearing results in an impairment rate of 40 percent. Fractures were classified as fracture type A: extraarticular fractures; B: body fractures not involving the joint; C: intraarticular fractures.  A total of 85 patients with 93 calcaneal fractures were included.

Results: The mean follow up time was 21 months. From radiographs, there were 17 extraarticular fractures, 33 calcaneal body fractures with no joint involvement, and 35 intraarticular fractures. Thirty-eight fractures were treated surgically and 47 conservatively. Overall, despite fracture type, conservative treatment resulted in less time lost from work (p=0.01), a lower impairment rate (p=0.01), and lower inpatient and outpatient costs (p=0.01/p=0.02). Functional outcomes as assessed with AOFAS and SF-36 were higher in the conservative treatment group, but those results were not statistically significant. When treated non-surgically, extraarticular fractures demonstrated better results. Intraarticular fractures when treated surgically, resulted in better AOFAS and SF-36 scores, but worse in socioeconomic parameters, compared to non-surgical intraarticular fractures.

Conclusions: Calcaneal fractures can have severe socioeconomic and functional outcomes for many patients, especially industrial workers. Conservative management of calcaneal fractures can result in less time off work, lower costs, and overall better functional results and patient satisfaction. Due to increasing healthcare costs and high complication rates with calcaneal fractures such as wound healing, post traumatic arthritis, limb deformity and resulting hindfoot fusions, surgeons should consider nonsurgical treatment for calcaneal fractures, especially for fractures not involving the joint. While intraarticular fractures result in better functional outcomes when treated surgically, they can create financial burden which must be a consideration in treatment selection. 

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