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Randomized Controlled Trial
. 2014 Jul 24:349:g4483.
doi: 10.1136/bmj.g4483.

Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial

Damian Griffin  1 , Nick Parsons  2 , Ewart Shaw  2 , Yuri Kulikov  2 , Charles Hutchinson  2 , Margaret Thorogood  2 , Sarah E Lamb  2 ; UK Heel Fracture Trial Investigators
Collaborators, Affiliations
Randomized Controlled Trial

Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial

Damian Griffin et al. BMJ. .

Abstract

Objective: To investigate whether surgery by open reduction and internal fixation provides benefit compared with non-operative treatment for displaced, intra-articular calcaneal fractures.

Design: Pragmatic, multicentre, two arm, parallel group, assessor blinded randomised controlled trial (UK Heel Fracture Trial).

Setting: 22 tertiary referral hospitals, United Kingdom.

Participants: 151 patients with acute displaced intra-articular calcaneal fractures randomly allocated to operative (n=73) or non-operative (n=78) treatment.

Main outcome measures: The primary outcome measure was patient reported Kerr-Atkins score for pain and function (scale 0-100, 100 being the best possible score) at two years after injury. Secondary outcomes were complications; hindfoot pain and function (American Orthopaedic Foot and Ankle Society score); general health (SF-36); quality of life (EQ-5D); clinical examination; walking speed; and gait symmetry. Analysis was by intention to treat.

Results: 95% follow-up was achieved for the primary outcome (69 in operative group and 74 in non-operative group), and a complete set of secondary outcomes were available for 75% of participants. There was no significant difference in the primary outcome (mean Kerr-Atkins score 69.8 in operative group v 65.7 in non-operative group; adjusted 95% confidence interval of difference -7.1 to 7.0) or in any of the secondary outcomes between treatment groups. Complications and reoperations were more common in those who received operative care (estimated odds ratio 7.5, 95% confidence interval 2.0 to 41.8).

Conclusions: Operative treatment compared with non-operative care showed no symptomatic or functional advantage after two years in patients with typical displaced intra-articular fractures of the calcaneus, and the risk of complications was higher after surgery. Based on these findings, operative treatment by open reduction and internal fixation is not recommended for these fractures.Trial registration Current Controlled Trials ISRCTN37188541.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Trial profile
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Fig 2 Kerr-Atkins scores for calcaneal fracture and 95% confidence intervals at baseline (before injury) and 6, 12, 18, and 24 months after injury for all participants and for those with type 2 and with type 3 or 4 fractures (Sanders classification)
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Fig 3 Range of motion in degrees (group means and 95% confidence intervals) and gait symmetry data at 24 months post-injury for injured and non-injured feet
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Fig 4 Gait metrics (group means and 95% confidence intervals) at 24 months post-injury for injured and non-injured feet
See this image and copyright information in PMC

Comment in

References

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    1. Dhillon MS, Aggarwal S, Dhatt S, Jain M. Epidemiological pattern of foot injuries in India: preliminary assessment of data from a tertiary hospital. J Postgrad Med Edu Res 2012;46:144-7.
    1. Tadros AM, Eid HO, Abu-Zidan FM. Epidemiology of foot injury in a high-income developing country. Injury 2010;41:137-40. - PubMed

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