INVITED COMMENTARY
An Update on the Treatment of Calcaneal Fractures
T
his issue of the Journal of Orthopaedic Trauma features four excellent articles from three continents on the management of displaced, intra-articular calcaneal fractures (DIACF’s). This topic continues to generate controversy among orthpaedic surgeons worldwide and virtually every article concludes that more evidence from high-quality studies is needed to allow for more focused treatment recommendations. The article by Sanders et al.13 provides a landmark for further studies. The authors managed to reevaluate 93 patients with 108 operatively treated DIACF’s at an impressive follow-up of 10 to 21 years. The author is intrinsically tied to the treatment of calcaneal fractures. He introduced an easy to use classification in 199211 that has become the most widely used worldwide, and was proven to be of prognostic value by several authors since then.9, 10, 12 He developed new techniques and implants and was also one of the few surgeons to publish his own learning curve and caution others about the pitfalls when treating these challenging injuries.11 The long-term results published in this issue show that type III fractures are 4 times more likely to require a later fusion than the type II fractures. It is also shown that both reduction and results are maintained over time without necessarily needing locking plates or bone grafting. I fully agree with the conclusions that minimal alterations of ADL’s and work can result from anatomic reduction (“joint first”) if subtalar arthritis does not occur. The latter may be inevitable in the presence of severe joint destruction that occurred at the time of the injury which leads us to the second article in this issue. The randomized prospective multicenter study by Buckley et al.3 deals with the most severe DIACF’s, namely the Sanders type IV fractures. With different collaborators, Dr. Buckley has published several randomized controlled trials (RCT’s) over the last years with tremendous efforts and he continues to strive for the best possible evidence to provide surgeons with sound recommendations for their practice.4 In their present study the authors did not find a statistically significant difference between open reduction and internal fixation (ORIF) alone or ORIF with primary subtalar fusion in the most severe calcaneal fractures. Thus, it remains the choice of the treating surgeon which option is best for the individual patient. However the authors did remark that a primary fusion in the presence of a type IV fracture heals quickly and a secondary fusion maybe prevented, allowing return to work sooner. In their series, one of 17 patients randomly allocated to ORIF went on to a secondary fusion. The post-hoc analysis of a prospective, randomized, controlled multicenter trial by Ågren et al.1 with a follow-up of 8-12 years is of special interest. Their original study,2 revealing only minor differences between operatively and non-operatively treated DIACF’s, received mixed responses.17 It showed the dilemma of randomized controlled trials in orthopaedic surgery with seemingly underpowered studies given the many variables contributing to specific outcomes. The frequently cited long-term RCT by Ibrahim et al.5 is a vivid example of that “evidence trap”. These authors when comparing operative to nonoperative treatment for DIACF’s used K-wire fixation via a small sinus tarsi approach and without any attempt to anatomically reduce the joint surface. This type of operative treatment without anatomic reduction combines the worst of both worlds and would not be encouraged today. The post-hoc analysis of Dr. Ågren’s group finally reveals prognostic factors that can be influenced by the treating surgeon. When dividing the patients of their RCT into a group with superior and inferior results, operative treatment, higher postoperative Böhler’s angle and articular surface restoration, light labor and the absence of injury insurance were significantly more common in the superior group. This confirms the results of the large RCT by Buckley et al.4 revealing significantly better results in certain subgroups treated operatively: women, younger patients, patients with a lighter workload, patients not involved in workers’ compensation claims, patients with a higher initial Böhler’s angle, and those with an anatomic reduction on postoperative CT scans. In this way, the studies by Ågren and Buckley provide the orthopaedic surgeons with some real The author reports no conflicts of interest. Copyright © 2014 by Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 10, October 2014
www.jorthotrauma.com |
549
J Orthop Trauma Volume 28, Number 10, October 2014
Rammelt
guidance for patient selection and confirm the necessity of restoring the overall shape and joint surfaces of the calcaneus rather than the fatalistic conclusions that one might draw from reading the abstracts of several earlier RCT’s and meta-analyses. The development of minor and major wound complications is another concern when using extensile approaches for operative treatment of DIACF’s. As the study by Sivakumar and colleagues15 demonstrates, minimally-invasive fixation of calcaneal fractures significantly reduces the risk of soft-tissue complications and is particularly feasible in patients with less severe fracture patterns (Sanders Type II). As has been shown since 2002,8 control of the articular reduction with subtalar arthroscopy combines the benefit of percutaneous fixation with anatomic joint reduction. Consequently, the authors’ short-term results with zero infections and good to excellent outcome scores in 9 patients at 14 months follow-up compare favourably with other reported percutaneous reduction techniques, most of them involving traction.15 The authors do not discuss earlier studies using arthroscopically-assisted percutaneous reduction and screw fixation for DIACF’s, but the results from these studies involving 13 to 24 patients followed for 1 to 10 years showed that excellent results can also be obtained in the medium term.6, 7, 14, 16 I can only agree with the authors’ conclusions that proper patient selection is a key to success. An indifferent use of one method of treatment – be it nonoperatively, minimally-invasive or open – for all types of calcaneal fractures will inevitably lead to unsatisfactory results in a subset of patients with these diverse and challenging injuries. I believe that the four articles presented in this issue of JOT will help choosing the best approaches and provide a well-founded prognosis for the individual patient.
Stefan Rammelt, MD, PhD Dresden, Germany Foot & Ankle Section Editor
4.
5.
6.
7. 8. 9. 10. 11. 12.
13.
14.
15.
REFERENCES 1. Ågren PH, Mukka S, Tullberg T, Wretenberg P, Sayed-Noor AS. Factors Affecting Long-Term Treatment Results of Displaced Intra-Articular Calcaneal Fractures A Post-hoc Analysis of a Prospective, Randomized, Controlled Multicenter Trial. J Orthop Trauma. 2014;28:564–568. 2. Ågren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2013;95:1351–7. 3. Buckley R, Leighton R, Sanders D, Poon J, Coles CP, Stephen D, et al. Open Reduction and Internal Fixation Compared with ORIF and Primary
550
| www.jorthotrauma.com
16.
17.
Subtalar Arthrodesis for Treatment of Sanders Type IV Calcaneal Fractures: A Randomized Multicenter Trial. J Orthop Trauma. 2014; 28:577–583. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intra- articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84A:1733–44. Ibrahim T, Rowsell M, Rennie W, Brown AR, Taylor GJ, Gregg PJ. Displaced intra-articular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury. 2007;38:848–55. Nehme A, Chaminade B, Chiron P, Fabie F, Tricoire JL, Puget J. Percutaneous fluoroscopic and arthroscopic controlled screw fixation of posterior facet fractures of the calcaneus [French]. Rev Chir Orthop Reparatrice Appar Mot. 2004;90:256–64. Rammelt S, Amlang M, Barthel S, Gavlik JM, Zwipp H. Percutaneous treatment of less severe intraarticular calcaneal fractures. Clin Orthop Relat Res. 2010;468:983–90. Rammelt S, Gavlik JM, Barthel S, Zwipp H. The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures. Foot Ankle Int. 2002;23:906–16. Rammelt S, Zwipp H, Schneiders W, Durr C. Severity of injury predicts subsequent function in surgically treated displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 2013;471:2885–98. Rubino R, Valderrabano V, Sutter PM, Regazzoni P. Prognostic value of four classifications of calcaneal fractures. Foot Ankle Int. 2009;30: 229–38. Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992;6:252–65. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993: 87–95. Sanders R, Vaupel Z, Erdogan M, Downes K. The Operative Treatment of Displaced Intra-articular Calcaneal Fractures (DIACFs): Long Term (10–20 years) Results in 108 Fractures using a Prognostic CT Classification. J Orthop Trauma. 2014;28:551–563. Schuberth JM, Cobb MD, Talarico RH. Minimally invasive arthroscopicassisted reduction with percutaneous fixation in the management of intraarticular calcaneal fractures: a review of 24 cases. J Foot Ankle Surg. 2009;48:315–22. Sivakumar BS, Wong P, Dick CG, Steer RA, Tetsworth K. Arthroscopic Reduction & Percutaneous Fixation of Selected Calcaneus Fractures: Surgical Technique & Early Results. J Orthop Trauma. 2014;28: 569–576. Woon CY, Chong KW, Yeo W, Eng-Meng Yeo N, Wong MK. Subtalar arthroscopy and flurosocopy in percutaneous fixation of intraarticular calcaneal fractures: the best of both worlds. J Trauma. 2011; 71:917–25. Younger A. A calcaneal fracture study illustrates a need for better statistical methods for orthopaedic outcomes: Commentary on an article by PerHenrik Agren, MD, et al.: “Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures. a prospective, randomized, controlled multicenter trial”. J Bone Joint Surg Am. 2013;95:e111.
Ó 2014 Lippincott Williams & Wilkins
An Update on the Treatment of Calcaneal Fractures
T
his issue of the Journal of Orthopaedic Trauma features four excellent articles from three continents on the management of displaced, intra-articular calcaneal fractures (DIACF’s). This topic continues to generate controversy among orthpaedic surgeons worldwide and virtually every article concludes that more evidence from high-quality studies is needed to allow for more focused treatment recommendations. The article by Sanders et al.13 provides a landmark for further studies. The authors managed to reevaluate 93 patients with 108 operatively treated DIACF’s at an impressive follow-up of 10 to 21 years. The author is intrinsically tied to the treatment of calcaneal fractures. He introduced an easy to use classification in 199211 that has become the most widely used worldwide, and was proven to be of prognostic value by several authors since then.9, 10, 12 He developed new techniques and implants and was also one of the few surgeons to publish his own learning curve and caution others about the pitfalls when treating these challenging injuries.11 The long-term results published in this issue show that type III fractures are 4 times more likely to require a later fusion than the type II fractures. It is also shown that both reduction and results are maintained over time without necessarily needing locking plates or bone grafting. I fully agree with the conclusions that minimal alterations of ADL’s and work can result from anatomic reduction (“joint first”) if subtalar arthritis does not occur. The latter may be inevitable in the presence of severe joint destruction that occurred at the time of the injury which leads us to the second article in this issue. The randomized prospective multicenter study by Buckley et al.3 deals with the most severe DIACF’s, namely the Sanders type IV fractures. With different collaborators, Dr. Buckley has published several randomized controlled trials (RCT’s) over the last years with tremendous efforts and he continues to strive for the best possible evidence to provide surgeons with sound recommendations for their practice.4 In their present study the authors did not find a statistically significant difference between open reduction and internal fixation (ORIF) alone or ORIF with primary subtalar fusion in the most severe calcaneal fractures. Thus, it remains the choice of the treating surgeon which option is best for the individual patient. However the authors did remark that a primary fusion in the presence of a type IV fracture heals quickly and a secondary fusion maybe prevented, allowing return to work sooner. In their series, one of 17 patients randomly allocated to ORIF went on to a secondary fusion. The post-hoc analysis of a prospective, randomized, controlled multicenter trial by Ågren et al.1 with a follow-up of 8-12 years is of special interest. Their original study,2 revealing only minor differences between operatively and non-operatively treated DIACF’s, received mixed responses.17 It showed the dilemma of randomized controlled trials in orthopaedic surgery with seemingly underpowered studies given the many variables contributing to specific outcomes. The frequently cited long-term RCT by Ibrahim et al.5 is a vivid example of that “evidence trap”. These authors when comparing operative to nonoperative treatment for DIACF’s used K-wire fixation via a small sinus tarsi approach and without any attempt to anatomically reduce the joint surface. This type of operative treatment without anatomic reduction combines the worst of both worlds and would not be encouraged today. The post-hoc analysis of Dr. Ågren’s group finally reveals prognostic factors that can be influenced by the treating surgeon. When dividing the patients of their RCT into a group with superior and inferior results, operative treatment, higher postoperative Böhler’s angle and articular surface restoration, light labor and the absence of injury insurance were significantly more common in the superior group. This confirms the results of the large RCT by Buckley et al.4 revealing significantly better results in certain subgroups treated operatively: women, younger patients, patients with a lighter workload, patients not involved in workers’ compensation claims, patients with a higher initial Böhler’s angle, and those with an anatomic reduction on postoperative CT scans. In this way, the studies by Ågren and Buckley provide the orthopaedic surgeons with some real The author reports no conflicts of interest. Copyright © 2014 by Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 10, October 2014
www.jorthotrauma.com |
549
J Orthop Trauma Volume 28, Number 10, October 2014
Rammelt
guidance for patient selection and confirm the necessity of restoring the overall shape and joint surfaces of the calcaneus rather than the fatalistic conclusions that one might draw from reading the abstracts of several earlier RCT’s and meta-analyses. The development of minor and major wound complications is another concern when using extensile approaches for operative treatment of DIACF’s. As the study by Sivakumar and colleagues15 demonstrates, minimally-invasive fixation of calcaneal fractures significantly reduces the risk of soft-tissue complications and is particularly feasible in patients with less severe fracture patterns (Sanders Type II). As has been shown since 2002,8 control of the articular reduction with subtalar arthroscopy combines the benefit of percutaneous fixation with anatomic joint reduction. Consequently, the authors’ short-term results with zero infections and good to excellent outcome scores in 9 patients at 14 months follow-up compare favourably with other reported percutaneous reduction techniques, most of them involving traction.15 The authors do not discuss earlier studies using arthroscopically-assisted percutaneous reduction and screw fixation for DIACF’s, but the results from these studies involving 13 to 24 patients followed for 1 to 10 years showed that excellent results can also be obtained in the medium term.6, 7, 14, 16 I can only agree with the authors’ conclusions that proper patient selection is a key to success. An indifferent use of one method of treatment – be it nonoperatively, minimally-invasive or open – for all types of calcaneal fractures will inevitably lead to unsatisfactory results in a subset of patients with these diverse and challenging injuries. I believe that the four articles presented in this issue of JOT will help choosing the best approaches and provide a well-founded prognosis for the individual patient.
Stefan Rammelt, MD, PhD Dresden, Germany Foot & Ankle Section Editor
4.
5.
6.
7. 8. 9. 10. 11. 12.
13.
14.
15.
REFERENCES 1. Ågren PH, Mukka S, Tullberg T, Wretenberg P, Sayed-Noor AS. Factors Affecting Long-Term Treatment Results of Displaced Intra-Articular Calcaneal Fractures A Post-hoc Analysis of a Prospective, Randomized, Controlled Multicenter Trial. J Orthop Trauma. 2014;28:564–568. 2. Ågren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2013;95:1351–7. 3. Buckley R, Leighton R, Sanders D, Poon J, Coles CP, Stephen D, et al. Open Reduction and Internal Fixation Compared with ORIF and Primary
550
| www.jorthotrauma.com
16.
17.
Subtalar Arthrodesis for Treatment of Sanders Type IV Calcaneal Fractures: A Randomized Multicenter Trial. J Orthop Trauma. 2014; 28:577–583. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intra- articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84A:1733–44. Ibrahim T, Rowsell M, Rennie W, Brown AR, Taylor GJ, Gregg PJ. Displaced intra-articular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury. 2007;38:848–55. Nehme A, Chaminade B, Chiron P, Fabie F, Tricoire JL, Puget J. Percutaneous fluoroscopic and arthroscopic controlled screw fixation of posterior facet fractures of the calcaneus [French]. Rev Chir Orthop Reparatrice Appar Mot. 2004;90:256–64. Rammelt S, Amlang M, Barthel S, Gavlik JM, Zwipp H. Percutaneous treatment of less severe intraarticular calcaneal fractures. Clin Orthop Relat Res. 2010;468:983–90. Rammelt S, Gavlik JM, Barthel S, Zwipp H. The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures. Foot Ankle Int. 2002;23:906–16. Rammelt S, Zwipp H, Schneiders W, Durr C. Severity of injury predicts subsequent function in surgically treated displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 2013;471:2885–98. Rubino R, Valderrabano V, Sutter PM, Regazzoni P. Prognostic value of four classifications of calcaneal fractures. Foot Ankle Int. 2009;30: 229–38. Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992;6:252–65. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993: 87–95. Sanders R, Vaupel Z, Erdogan M, Downes K. The Operative Treatment of Displaced Intra-articular Calcaneal Fractures (DIACFs): Long Term (10–20 years) Results in 108 Fractures using a Prognostic CT Classification. J Orthop Trauma. 2014;28:551–563. Schuberth JM, Cobb MD, Talarico RH. Minimally invasive arthroscopicassisted reduction with percutaneous fixation in the management of intraarticular calcaneal fractures: a review of 24 cases. J Foot Ankle Surg. 2009;48:315–22. Sivakumar BS, Wong P, Dick CG, Steer RA, Tetsworth K. Arthroscopic Reduction & Percutaneous Fixation of Selected Calcaneus Fractures: Surgical Technique & Early Results. J Orthop Trauma. 2014;28: 569–576. Woon CY, Chong KW, Yeo W, Eng-Meng Yeo N, Wong MK. Subtalar arthroscopy and flurosocopy in percutaneous fixation of intraarticular calcaneal fractures: the best of both worlds. J Trauma. 2011; 71:917–25. Younger A. A calcaneal fracture study illustrates a need for better statistical methods for orthopaedic outcomes: Commentary on an article by PerHenrik Agren, MD, et al.: “Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures. a prospective, randomized, controlled multicenter trial”. J Bone Joint Surg Am. 2013;95:e111.
Ó 2014 Lippincott Williams & Wilkins
