Calcaneus Fractures: To Fix Or Not To Fix - Is That Really The Question?

Brad A. Petrisor, MSc, M.D., FRCSC
Associate Professor, Division of Orthopaedic Surgery,
Department of Surgery, McMaster University
Hamilton Health Sciences: General Hospital

Mohit Bhandari, M.D., PhD, FRCSC
Professor, Canada Research Chair in Musculoskeletal Trauma
Academic Chair, Division of Orthopaedic Surgery,
Department of Surgery, McMaster University
Hamilton Health Sciences: General Hospital
Hamilton, ON

To Fix or Not? A PubMed search inquiry using the term "calcaneus fracture" produces 2666 "hits" going back to 1948, including a 1950 article written by Dr. F. Day from Edmonton published in the Canadian Medical Journal1,2. The debate over calcaneal fractures however, started in the late 1800's. Move forward to 2013 and there are now over 600 patients with displaced intra-articular calcaneus fractures who have been randomized in over five trials to non-operative or operative management and six systematic reviews on the subject including a recent Cochrane Collection. In this latter review, the authors state that "there is insufficient high-quality evidence relating to current practice to establish whether surgical or conservative treatment is better for adults with displaced intra-articular calcaneal fracture." The data from systematic reviews on this subject is muddled by the inclusion of trials using different outcome measures and having differing risks of bias3. The largest and most robust trial done by the Canadian Orthopaedic Trauma Society with 424 patients randomized and 309 patients followed for two years, inevitably influences the results of these meta-analyses7. They and others have observed no significant difference in functional outcomes between the operative and non-operative groups with some differences noted in subgroup analysis4,5.

So where do we stand? Some surgeons may feel there is no role for operative fixation, yet those who have an inclination towards fixing these fractures feel that there is a subset of patients who may benefit. The purported benefits of operative fixation include restoration of the joint surface and subsequent decrease in early and late subtalar fusion rates, release of peroneal impingement and a technically easier subtalar fusion post fixation with potentially improved function after the fusion compared to those with no fixation pre-fusion4,6.

How then do we determine who may benefit and who may not? With clinical uncertainty being driven by a lack of definitive surgical literature, the values and preferences of the patients we are treating may help us in our decision making11. This approach brings in the final circle of the evidence-based medicine paradigm. That is, evidence-based medicine is the juxtaposition of clinical acumen, best available evidence and the patients values and preferences. Therefore, we can take data from the best available evidence and have a discussion with the patient to ascertain what, in fact, may be the "best" treatment for them. One approach is to discuss all patient-important risks as well as benefits as gleaned from this evidence. Using data from the latest systematic review which included four randomized trials, as well as data from a fifth trial published after the review was completed, patient-important outcomes in regard to calcaneus fractures would be (but not limited to): post-treatment function, issues of chronic pain, reoperation, infection and return to work3. Even though all trials used different functional outcome scores, no trial found a significant difference in function among those who received operative versus non-operative management, nor did the trials find a difference in chronic pain between groups3,4,5. Only a single trial reported the results of early subtalar fusion5. Buckley et al., reported an 80% risk reduction in the occurrence of subtalar fusion within two years (Relative Risk 0.20, 95% Confidence Interval of 0.09-0.44)5. This suggests that for every seven patients treated with surgical fixation, one early subtalar fusion can be avoided. These patients in this trial were removed from the final analysis of function7. The most recent trial by Agren et al., suggests that there may be a 41% reduction in the risk of late stage radiographic arthrosis in operatively managed patients, but they also found no functional differences at one year between operatively and non-operatively managed calcaneal fractures6.

Operative management of course comes at the expense of potential wound healing problems and infection which, in the included trials, ranged from 7% - 22%3. Further surgical complications including DVT and the general risks of an anaesthetic may occur but at a much lower incidence rate3,5-9.

Some surgeons who manage calcaneal fractures are moving to minimally invasive techniques and thus far, retrospective cohort data suggests that the risks of postoperative infection may be decreased (some argue at the expense of reduction) while maintaining similar results as standard open approaches, however this has yet to be studied with high-quality randomized trials. As well, not all fracture patterns are amenable to this treatment.

Finally, up front, it is very important to mention that with or without operative management, functional limitations will exist and Tomesen et al., have observed that patients with calcaneal fractures fall below population norms as measured by the Short Function 36 outcome score10.

Thus, calcaneal fractures, while presenting us with clinical uncertainty around management, provide a good forum for a discussion with patients which may help surgeons to incorporate their values and preferences into the decision making. Patients may ultimately need to decide the balance of risk: reoperation for early subtalar fusion with non-operative treatment versus operative risks of infection and wound healing problems?  Patients are unique in their perceptions of risks and the surgeon-patient relationship may indeed benefit from transparent dialogue about treatment options. The question of greatest importance is not "to fix or not to fix"; rather, which option considers best the values and preferences of our patients with the best available evidence?

Key References

  1. Palmer, I. The mechanism and treatment of fractures of the calcaneus; open reduction with the use of cancellous grafts. J Bone Joint Surg Am 30A, 2-8 (1948).
  2. Day, F. G. Treatment of fractures of os calcis. Can Med Assoc J 63, 373-376 (1950).
  3. Gougoulias, N., Khanna, A., McBride, D. J. & Maffulli, N. Management of calcaneal fractures: systematic review of randomized trials. Br Med Bull 92, 153-167 (2009).
  4. Bajammal, S., Tornetta 3rd, P., Sanders, D. & Bhandari, M. Displaced intra-articular calcaneal fractures. J Orthop Trauma 19, 360-364 (2005).
  5. Buckley, R. et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 84-A, 1733-1744 (2002).
  6. Agren, P. H., Wretenberg, P. & Sayed-Noor, A. S. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 95, 1351-1357 (2013).
  7. Csizy, M. et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma 17, 106-112 (2003).
  8. Radnay, C. S., Clare, M. P. & Sanders, R. W. Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? J Bone Joint Surg Am 91, 541-546 (2009).
  9. Tomesen, T., Biert, J. & Frolke, J. P. Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am 93, 920-928 (2011).
  10. Van Tetering, E. A. & Buckley, R. E. Functional outcome (SF-36) of patients with displaced calcaneal fractures compared to SF-36 normative data. Foot Ankle Int 25, 733-738 (2004).

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