SLR - May 2018 - David Liou
The Effect of Time to Postoperative Weightbearing on Functional and Clinical Outcomes in Adults with a Displaced Intra-Articular Calcaneal Fracture: A Systematic Review and Pooled Analysis
Reference: Boer, A.S., Lieshout, E.M., Moolenbroek, G.V., Hartog, D.D., & Verhofstad, M.H. The Effect of Time to Postoperative Weightbearing on Functional and Clinical Outcomes in Adults with a Displaced Intra-Articular Calcaneal Fracture: A Systematic Review and Pooled Analysis. Injury. 2018 Apr;49(4):743–752.
Scientific Literature Review
Reviewed By: David Liou, DPM
Residency Program: Cambridge Health Alliance, Cambridge, MA
Podiatric Relevance: After open reduction and internal fixation of displaced intra-articular calcaneal fracture, the standard protocol involves nonweightbearing to the surgical foot for six to nine weeks. This is to avoid fracture displacement during healing and rehabilitation. Nonweightbearing is also negatively associated with long-term rehabilitation and decreased physical condition. Despite improved surgical techniques, and materials for fixation, which allow stronger constructs, there is no change to the recommended nonweightbearing period. This study evaluates the effect of early weightbearing on radiographic and clinical outcomes of displaced intra-articular calcaneal fracture after open reduction.
Methods: A literature search was performed on January 24, 2017 in the Cochrane Library, Medline Ovid, Embase Web of Science, Google scholar and CINAHL for this systematic review. Studies reporting on operative treatment of displaced intra-articular calcaneal fracture and time to weightbearing were eligible for inclusion. Seventy-two studies fit the inclusion criteria, including eight randomized controlled trials, 31 prospect studies and 33 cohort studies. In total, 6,064 patients were included in the final analysis. Different postoperative weightbearing period on the radiographic parameter (Bohler’s angle), functional outcome (AOFAS Ankle-Hindfoot Scale), pain (VAS pain score) and complications were evaluated.
Results: After statistical analysis, the average Bohler’s angle at the final follow-up appointments do not show any statistical significant difference between the early (four to six weeks), intermediate (six to eight weeks) and late (eight to 12 weeks) partial weightbearing groups. The result does not suggest any difference in time to partial weightbearing and calcaneal height. There is also no statistical difference in the functional outcome measured by AOFAS ankle-hindfoot score for early, intermediate and late partial weightbearing groups. There is, however, higher pain level in patients who are late partial weightbearing, compared to patients who are early weightbearing (5.2 vs. 1.6). In terms of complication rate, most superficial and deep infections were found in the intermediate partial weightbearing group.
Discussion: The loss of correction with earlier partial weightbearing after internal fixation of calcaneal fractures within six weeks is not supported by literature data included in this systematic review. This systematic review suggests that early weightbearing does not result in impaired outcome. Given the findings in this study, and the known complications associated with nonweightbearing, earlier weightbearing might be beneficial after calcaneus ORIF. Furthermore, with improvement in surgical techniques and improved hardware, there is reduced risk of loss of correction with earlier weightbearing. Authors of this paper caution on the limitation of the study, including the heterogeneity in outcomes and reported data, the varying definition of partial weightbearing in the selected studies and insufficient insight into weightbearing compliance.