SLR - April 2014 - Amanda Wiest
Reference: Agren PH, Wretenberg P, Sayed-Noor AS. J Bone Joint Surg Am. 7;95(15):1351-7, 2013.
Scientific Literature Review
Reviewed By: Amanda Wiest, DPM
Residency Program: Temple University Hospital
Podiatric Relevance: Numerous studies in the past decade have investigated the optimal treatment and complications of both operative and nonoperative treatment calcaneal fractures, which often present with an intra-articular component. The researchers hypothesized that operative treatment would result in greater improvement in pain, functional outcomes, and quality of life as primarily assessed by a visual analog scale and SF-36. This data is important for podiatric surgeons who treat these challenging injuries.
Methods: Patients who presented to any of five emergency hospitals in Stockholm between 1994 and 1998 with an intra-articular fracture of the calcaneus measuring ≥ 2mm was evaluated for inclusion, resulting in 42 patients treated operatively and 40 patients treated nonoperatively. Patients were excluded if they presented with an open fracture, PVD, uncontrolled DM, and contraindications to surgery, although the number of patients excluded was not reported. Operative treatment varied and included screws, reconstruction and calcaneal plates, and supplemental bone graft. Both treatment groups were nonweightbearing for 6 weeks. Seventy-six of 82 patients were evaluated at one year and 58 of 82 were available for follow-up between 8 and 12 years. Primary outcomes were patient’s responses on a visual analog scale and self-administered SF-36. Additionally, researchers evaluated complications, shoe gear, radiographic findings of alignment and STJ arthritis.
Results: Immediate postoperative complications of the operative group were significant and included superficial wound infections in eight patients, an MRSA infection requiring amputation in one patient, and implant removal in one patient. Approximately 20 percent of patients in each group had difficulty with shoe gear, and the operative group showed a 41 percent risk reduction of developing STJ arthritis despite the fact that the degree of displacement had been reduced to <2mm in only 24 of 42 patients. Visual analog scale and SF-36 data did not differ between the two groups at one year. There was a slight improvement in the operative group at 8 to 12 years, but this did not reach statistical significance. 5 patients in the operative and 4 patients in the non-operative group went on to eventual arthrodesis.
Conclusions: This study did not support the authors’ hypothesis that surgical intervention was superior to nonoperative treatment of displaced intra-articular calcaneal fractures. The treatment arms were comparable in outcomes measures and had a similar number of patients go on to STJ fusion. The authors were concerned about the high rate of postoperative infections and complications and feel there may be a place for further research of percutaneous surgical approaches.