SLR - October 2014 - Merlan Ellis

Operative Versus Non-operative Treatment for Closed, Displaced, Intra-articular Fractures of the Calcaneus: Randomized Controlled Trial

Reference: Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, Lamb SE, UK Heel Fracture Trial Investigators. Operative Versus Non-operative Treatment for Closed, Displaced, Intra-articular Fractures of the Calcaneus: Randomized Controlled Trial. BMJ 2014; 349:g4483.

Scientific Literature Review

Reviewed By: Merlan Ellis, DPM
Residency Program: New York Hospital Queens

Podiatric Relevance: The calcaneus is the most commonly fractured tarsal bone. It makes up about 2 percent of all fractures of the body and constitutes 60 percent of all fractured tarsal fractures. The majority of fractures occur in males in their productive working years, most commonly as a result of a fall from a height.
Methods: The authors carried out a multicenter, two arm, parallel group, assessor blinded randomized controlled trial with 1:1 treatment allocation. Patients were eligible if they were aged 18 years or more, and able to give informed consent, with a recent (less than three weeks) closed, intra-articular, displaced (subtalar joint posterior facet displacement of at least 2 mm) calcaneal fracture. Exclusions were gross deformity of the hindfoot (which the author referred to as fibula impingement and defined as such severe calcaneal varus that after healing patients would walk on the tip of the fibula or such severe calcaneal valgus that the tip of the fibula was embedded in the lateral wall of the calcaneus), other serious leg injuries sufficient to affect outcome at two years, not fit for surgery, peripheral vascular disease, or inability to adhere to the trial procedures. The author included patients with bilateral fractures unless one or both of the fractures met the exclusion criteria.

Results: Two thousand and six patients presented to the collaborating centers with calcaneal fractures. Of these, 502 had severe fractures that met the eligibility criteria. Of the 502 eligible patients, 151 consented to participate and were randomized to the operative (n=73) and non-operative (n=78) groups, with a median of five participants per center. The mean age of participants was 46.5 years (range 18-80), and 24 (16 percent) were women. No significant differences were found between treatment groups in sex, age, body mass index, smoking, prevalence of diabetes, or baseline scores. Operations were performed by 27 surgeons across the 22 centers. No center had more than two surgeons; the median number of operations per surgeon was two with a maximum of six. Postoperative computed tomography was performed on 51 (72 percent) of those who received operative treatment; the remaining 20 participants did not attend their scan appointments. Accuracy of the operative reduction was rated on the scans as no more than a 2 mm step in the articular surface. Kerr-Atkins scores improved for 18 months after injury and were then stable to the trial endpoint at two years for the full population as well as for subgroups with type 2 fractures and with type 3 and 4 fractures according to Sanders classification at two years, Kerr-Atkins scores were in the range 60-80 and still considerably lower than before injury, indicating moderate pain and changes to normal walking. Significantly more patients experienced complications and reoperations in the operative group (17/73; 23 percent) than in the non-operative group (3/78; 4 percent); estimated odds ratio 7.5 (95 percent confidence interval 2.0 to 41.8, Fisher’s exact test P <0.001). The most common complication was surgical site infection. All of these infections occurred in the operative group, usually within six weeks, and 5/14 required remedial surgery. Three more patients had reoperations to remove painful, prominent screws and plates. By two years, three subtalar fusions for painful arthritis had been performed in the non-operative group, but none in the operative group.

Conclusion: Outcomes after open reduction and internal fixation of typical, closed, displaced intra-articular fractures of the calcaneus were no better than after non-operative care at two years. The author also showed that complications and reoperations were much more common in the operatively treated group. 

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