SLR - September 2014 - N. Jake Summers

Open Reduction and Internal Fixation Compared with ORIF and Primary Subtalar Arthrodesis for Treatment of Sanders Type IV Calcaneal Fractures: A Randomized Multicenter Trial

Reference: Buckley R, Leighton R, Sanders D, Poon J, Coles C, Stephen D, Paolucci EO.  Open Reduction and Internal Fixation Compared with ORIF and Primary Subtalar Arthrodesis for Treatment of Sanders Type IV Calcaneal Fractures: A Randomized Multicenter Trial.  J Orthop Trauma. 2014 June 30.

Scientific Literature Review

Reviewed By: N. Jake Summers, DPM
Residency Program: Mount Auburn Hospital, Cambridge, MA

Podiatric Relevance: Displaced intra-articular calcaneal fractures (DIACF) can cause significant morbidity and changes in function. There is a wide variety of literature advocating both conservative and surgical treatment, with no clear consensus on the best management and best predictors of patient outcomes and complications. Sanders type IV injuries have a significantly higher rate of requiring delayed subtalar joint fusions. The decision making process between isolated ORIF vs ORIF with primary subtalar arthrodesis (PSTA) can be difficult and complicated. There is evident need for further information to aid in predicting patient outcomes and the likelihood of progression to subtalar arthrodesis.

Methods: The authors performed a multicenter randomized trial including four different level one trauma centers and five experienced trauma surgeons. An appropriate power calculation and expected dropout rate were used to determine the necessary population for this study. Patients were excluded if surgery was medically contraindicated, previous calcaneal surgery, injury >three weeks old, head injuries, metal allergy, non-operable foot, or failure to discontinue tobacco use. The authors were only able to obtain approximately half of the desired patient enrollment.  Thirty-one patients with 31 Sanders type IV DIACFs were included in the study from 2004-2011. All patients were initially treated with splinting, rest, ice, elevation, and a CT scan. Patients were randomized into one of the two treatment groups via a computer generated random allocation sequence and opaque sealed envelopes. Seventeen patients were treated with ORIF, while 14 patients were treated with ORIF + PSTA. ORIF was performed via an extended lateral approach with internal fixation for all patients. PTSA was performed with internal screw fixation and iliac crest autograft or allograft when necessary. Patients were followed postoperatively for a minimum of two years.  Outcomes were measured with four different validated instruments (General Health Survey SF-36, Musculoskeletal Function Assessment, American Orthopaedic Foot and Ankle Society’s Ankle-Hindfoot Scale, and Visual Analog Scale).

Results: Of the 31 patients included, 26 were followed for a minimum of two years (81 percent) and five were lost to follow-up. A comparison of patient demographics was performed with a larger population of male patients overall. There were seven tobacco users in the ORIF group, while there were only four in the ORIF + PSTA group. One patient from the ORIF group went on to have a secondary subtalar fusion. A statistical analysis of each of the four outcome measures was performed between the two treatment groups. There was no statistical difference found with all four outcome measures between ORIF vs ORIF + PSTA, however ORIF + PSTA showed a trend of increased scores on the SF-36 instrument. The ORIF + PSTA group had a shorter recovery period and was able to advance to WB at six weeks, while the ORIF group did not advance to WB until 10 weeks.

Conclusions: There was no statistically significant difference between the outcomes of the two groups. The outcomes were comparable to previous individual studies of calcaneal fractures; however this is the first randomized study to compare these two groups directly. There may be a benefit to performing PSTA at the time of initial calcaneal ORIF in these severely comminuted fractures, with shorter recovery times and less likelihood of a secondary STJ fusion later, however the population size included in this study was small, and as the authors admit, did not meet the requirement of their own power calculations. More long-term outcomes and the progression of STJ arthritis requiring later arthrodesis would also be ideal to better determine the best treatment selection. Further, larger studies will need to be performed in order to better understand the best method of initial treatment for DIACFs.

Educational Opportunities