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. 2023 Nov 7;11(11):CD008628.
doi: 10.1002/14651858.CD008628.pub3.

Surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures

Sharon R Lewis  1 , Michael W Pritchard  1 , Joshua L Solomon  2 , Xavier L Griffin  1 , Julie Bruce  3
Affiliations

Surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures

Sharon R Lewis et al. Cochrane Database Syst Rev. .

Abstract

Background: Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures. These fractures are mostly caused by a fall from a height, and are common in younger adults. Treatment can be surgical or non-surgical; however, there is clinical uncertainty over optimal management. This is an update of a Cochrane Review first published in 2013.

Objectives: To assess the effects (benefits and harms) of surgical versus conservative treatment of displaced intra-articular calcaneal fractures.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, Embase, and clinical trials registers in November 2022.

Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs comparing surgical versus non-surgical management of displaced intra-articular calcaneal fractures in skeletally mature adults (older than 14 years of age). For surgical treatment, we included closed manipulation with percutaneous wire fixation, open reduction with internal fixation (ORIF) with or without bone graft, or primary arthrodesis. For non-surgical treatment, we included ice, elevation and rest, or plaster cast or splint immobilisation.

Data collection and analysis: We used standard Cochrane methodological procedures. We collected data for the following outcomes: function in the short term (within three months of injury) or long term (more than three months after injury), chronic pain, health-related quality of life (HRQoL) and ability to return to normal activities, as well as complications which may or may not have led to an unplanned return to theatre.

Main results: We included 10 RCTs and two quasi-RCTs with 1097 participants. Sample sizes in studies ranged from 29 to 424 participants. Most participants were male (86%), and the mean age in studies ranged from 28 to 52 years. In the surgical groups, participants were mostly managed with ORIF with plates, screws, or wires; one study used only minimally invasive techniques. Participants in the non-surgical groups were managed with a plaster cast, removable splint or a bandage, or with rest, elevation, and sometimes ice. Risk of performance bias was unavoidably high in all studies as it was not possible to blind participants and personnel to treatment; in addition, some studies were at high or unclear risk of other types of bias (including high risk of selection bias for quasi-RCTs, high risk of attrition bias, and unclear risk of selective reporting bias). We downgraded the certainty of all the evidence for serious risk of bias. We also downgraded the certainty of the evidence for imprecision for all outcomes (except for complications requiring return to theatre for subtalar arthrodesis) because the evidence was derived from few participants. We downgraded the evidence for subtalar arthrodesis for inconsistency because the pooled data included high levels of statistical heterogeneity. We found that surgical management may improve function at six to 24 months after injury when measured using the American Orthopaedic Foot and Ankle Society (AOFAS) score (mean difference (MD) 6.58, 95% confidence interval (CI) 1.04 to 12.12; 5 studies, 319 participants; low-certainty evidence). We are not aware of a published minimal clinically important difference (MCID) for the AOFAS score for this type of fracture. Previously published MCIDs for other foot conditions range from 2.0 to 7.9. No studies reported short-term function within three months of injury. Surgical management may reduce the number of people with chronic pain up to 24 months after injury (risk ratio (RR) 0.56, 95% CI 0.37 to 0.84; 4 studies, 175 participants; low-certainty evidence); this equates to 295 per 1000 fewer people with pain after surgical management (95% CI 107 to 422 per 1000). Surgical management may also lead to improved physical HRQoL (MD 6.49, 95% CI 2.49 to 10.48; 2 studies, 192 participants; low-certainty evidence). This outcome was measured using the physical component score of the 36-Item Short Form Health Survey. We used a change in effect of 5% to indicate a clinically important difference for this scoring system and thus judged that the difference in HRQoL between people treated surgically or non-surgically includes both clinically relevant and not relevant changes for those treated surgically. There may be little or no difference in the number of people who returned to work within 24 months (RR 1.26, 95% CI 0.94 to 1.68; 5 studies, 250 participants; low-certainty evidence) or who require secondary surgery for subtalar arthrodesis (RR 0.38, 95% CI 0.09 to 1.53; 3 studies, 657 participants; low-certainty evidence). For other complications requiring return to theatre in people treated surgically, we found low-certainty evidence for amputation (2.4%; 1 study, 42 participants), implant removal (3.4%; 3 studies, 321 participants), deep infection (5.3%; 1 study, 206 participants), and wound debridement (2.7%; 1 study, 73 participants). We found low-certainty evidence that 14% of participants who were treated surgically (7 studies, 847 participants) had superficial site infection.

Authors' conclusions: Our confidence in the evidence is limited. Although pooled evidence indicated that surgical treatment may lead to improved functional outcome but with an increased risk of unplanned second operations, we judged the evidence to be of low certainty as it was often derived from few participants in studies that were not sufficiently robust in design. We found no evidence of a difference between treatment options in the number of people who needed late reconstruction surgery for subtalar arthritis, although the estimate included the possibility of important harms and benefits. Large, well-conducted studies that attempt to minimise detection bias and that measure functional outcomes using calcaneal-specific measurement tools would increase the confidence in these findings. Given that minimally invasive surgical procedures are already becoming more prevalent in practice, research is urgently needed to determine whether these newer surgical techniques offer better outcomes with regard to function, pain, quality of life, and postoperative complications for intra-articular displaced calcaneal fractures.

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Conflict of interest statement

SL (review author and Deputy Co‐ordinating Editor of the Bone, Joint and Muscle Trauma Group) has no known conflicts of interest. SL was not involved in the editorial process.

MP has no known conflicts of interest.

JS has no known conflicts of interest.

XG (Co‐ordinating Editor of the Cochrane Bone, Joint and Muscle Trauma Group) is funded by an National Institute for Health and Care Research (NIHR) Clinician Scientist Grant. Further funding from industry and charitable grants are and have been made available to his institution. All decisions relating to the design, conduct, analysis, write‐up, and publication of research are independent of these funders. He has ongoing expert consultancy with several companies; none involve the development of any implant for use in calcaneal fracture care. XG was not involved in the editorial process.

JB (guarantor) is Editor of the Cochrane Wounds Group. JB receives National Institute for Health and Care Research (NIHR) Health Technology Assessment and Programme Grants for Applied Research funding for non‐wound‐related rehabilitation research studies (2020 to present). JB is supported by NIHR Research Capability Funding via University Hospitals Coventry and Warwickshire NHS Trust. JB is a member of the NIHR Research for Patient Benefit Panel West Midland, UK.

Figures

1
1
PRISMA flow chart. Searches conducted in November 2022.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. We did not conduct risk of bias assessment in Chrintz 1993 because this study contributed no outcome data to the review.
1.1
1.1. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 1: Function in the long term; measured using AOFAS
1.2
1.2. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 2: Function in the long term; using measurement tools other than AOFAS score
1.3
1.3. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 3: Function in the long term; number of people with scores of excellent, good, or satisfactory/fair
1.4
1.4. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 4: Chronic pain; number of people with pain
1.5
1.5. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 5: Chronic pain; measured using VAS
1.6
1.6. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 6: HRQoL in the long term; measured using SF‐36 (PCS)
1.7
1.7. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 7: Return to normal activity (work)
1.8
1.8. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 8: Postoperative complications requiring unplanned return to theatre
1.9
1.9. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 9: Postoperative complications not requiring return to theatre
1.10
1.10. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 10: Ability to wear usual footwear
1.11
1.11. Analysis
Comparison 1: Surgical versus non‐surgical management, Outcome 11: Radiological measurements: Böhler angle
2.1
2.1. Analysis
Comparison 2: Surgical versus non‐surgical management: data reported using additional measurement tools, Outcome 1: Function in the long term
2.2
2.2. Analysis
Comparison 2: Surgical versus non‐surgical management: data reported using additional measurement tools, Outcome 2: Chronic pain
2.3
2.3. Analysis
Comparison 2: Surgical versus non‐surgical management: data reported using additional measurement tools, Outcome 3: HRQoL in the long term
2.4
2.4. Analysis
Comparison 2: Surgical versus non‐surgical management: data reported using additional measurement tools, Outcome 4: Return to normal activity
See this image and copyright information in PMC

Update of

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ACTRN12617001588381 {published data only}
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Baliga 2010
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