SLR - May 2014 - Kathie J. Whitt
Reference: Agren H, Wretenberg P, Sayed-Noor A. (2013). Operative Versus Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures: A Prospective, Randomized, Controlled Multicenter Trial. J Bone and Joint Surgery, 95 (15): 1351-7.
Scientific Literature Review
Reviewed By: Kathie J. Whitt, DPM
Residency Program: Grant Medical Center
Podiatric Relevance: Calcaneal fractures are the most common tarsal fracture with approximately 75 percent being intra-articular. The optimal management of displaced intra-articular calcaneal fractures remains a matter of debate. Outcomes remain unclear as to whether surgical or nonsurgical management improves functional status, quality of life, and residual pain over an extended period of time. This prospective, randomized, controlled, multicenter trial evaluates these outcomes and compares the two approaches.
Methods: Eighty-two patients with an intra-articular calcaneal fractures with greater than 2 mm of displacement were randomized to operative or nonoperative treatment. Forty-two patients underwent operative treatment including the fracture being fixed with screws (n=2), reconstruction plates (n=29), or calcaneal plates (n=11). 40 patients underwent nonoperative treatment including rest, elevation, and non-weightbearing. Outcome measures were assessed at one-year and eight-to-twelve year follow-up by two unbiased surgeons not involved in the treatment. Outcome measures included the visual analog scale (VAS) pain and function score and the general health outcomes Short Form (SF)-36.
Results: Seventy-six patients were available for follow-up at one year and fifty-eight at eight to twelve years. At one year, no significant differences were found between the two treatment groups with respect to the VAS and SF-36 scores. CT scans revealed 12 patients in the operative group and 20 in the nonoperative group had signs of subtalar arthritis. At eight to twelve years of follow-up, there was a trend toward better scores on the VAS (p = 0.07) and the SF-36 (p = 0.06) in the operative group. The prevalence of radiographically evident posttraumatic subtalar arthritis was lower in the operative group with a risk reduction of 41%.
Conclusions: The results of the study showed that operative treatment was not superior in managing displaced intra-articular calcaneal fractures at one year of follow-up but appeared to have some benefits at eight to twelve years. Operative treatment was associated with a higher risk of complications but a reduced prevalence of posttraumatic arthritis evident on follow-up radiographs. However, the need for secondary subtalar arthrodesis was not increased following nonoperative treatment. The study has some limitations including a small sample size, however, compared with other randomized controlled trials, the number of included patients and the extent of drop-out make the present study valuable.