COCHRANE CORNER
Surgical Versus Conservative Interventions for Displaced Intra-articular Calcaneal Fractures A Cochrane Nursing Care Field Corner Column Weihua Liu ▼ Yan Ma ▼ Binbin Yu ▼ Wang Jing
risk of bias for at least one domain. The primary outcomes were function (e.g., composite functional or gait scores, ability or distance walked without pain or difficulty, and other walking-related outcomes) and chronic pain (i.e., not minimal/infrequent pain). Secondary outcomes were health-related quality of life (QoL), return to work and former activities, postoperative complications and other postoperative morbidity or other serious adverse event, subsequent operation, objective measures of impairment, time to union, and radiological measurements. Follow-up was between 1 and 15 years following treatment. Meta-analysis was undertaken where possible.
What is the effect of surgical treatment compared with conservative treatment of displaced intraarticular calcaneal fractures in adults? REVIEW QUESTION:
Nursing Implications Displaced intra-articular calcaneal fractures (DIACFs) typically occur in younger working-age men as the result of high energy trauma. The economic impact of this injury to both the patient and the society is considerable resulting from extended hospital stay, treatment costs, residual pain, time to mobilization, and delayed return to work. Treatment can be surgical or nonsurgical; however, there is controversy in the literature over optimal management. Nurses play an active role in helping patients manage their calcaneal or heel fractures; so it is important to know which treatment approach is more effective.
Summary of Key Evidence The large multicenter trial (424 participants) demonstrated no statistically or clinically significant differences in functional ability, risk of chronic pain, and health-related QoL at 3 years follow-up after DIACF between surgical and conservative treatments. Pooled results from two small trials indicated a tendency for a higher return to previous employment following surgery compared with conservative treatments; however, this result was not statistically significant.
Study Characteristics This is a summary of a Cochrane systematic review. The review included four studies with a total of 602 participants; one trial was a large multicenter trial that provided the strongest evidence, and the other three trials were small single-center trials. All four trials were randomized by the individual rather than by fracture. Participants older than 14 years, considered as skeletally mature, with DIACFs were eligible for inclusion. The interventions of interest were surgical versus conservative treatments for DIACF. Surgical treatments could involve closed manipulation with percutaneous pin fixation and open reduction with internal fixation with or without bone graft or primary arthrodesis, and conservative treatments included ice and elevation, plaster cast immobilization, and early or delayed mobilization. The methodological quality of the included studies was generally poor. All trials had methodological flaws due to failure to conceal allocation and incomplete follow-up data, which put them at either unclear or high 336
Orthopaedic Nursing
•
November/December 2013
•
Volume 32
Weihua Liu, MMed, RN, Chief Professor in School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. Yan Ma, BN, Postgraduate Student, School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. Binbin Yu, BN, Postgraduate Student, School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. Wang Jing, BN, Postgraduate Student, School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. All authors are members of the Cochrane Nursing Care Field. The authors have disclosed no conflicts of interest. The full review is available at: http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD008628.pub2/abstract DOI: 10.1097/NOR.0000000000000008
•
Number 6
© 2013 by National Association of Orthopaedic Nurses
Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ632.indd 336
11/11/13 11:06 AM
No differences were found in the ability to wear normal shoes as before injury (one study), whereas another small trial found that surgery resulted in more people who were able to wear all shoes comfortably. The two studies were not pooled because of statistical heterogeneity. Results from Buckley’s study showed a significantly higher rate of major complications after surgery compared to conservative treatment (57/206 vs. 42/218; relative risk, 1.44, 95% confidence intervals, [1.01, 2.04]; one trial). Conversely, those having surgery were significantly less likely to have subtalar arthrodeses due to the development of subtalar arthritis (7/206 vs. 37/218; relative risk, 0.20, 95% confidence intervals, [0.09, 0.44]; one trial). No significant differences between the two groups in range of movement outcomes (3 trials) or radiological measurements (4 trials) were found in the review. Data on time to bone union were not reported in any of the included trials.
© 2013 by National Association of Orthopaedic Nurses
Best Practice Recommendations There is currently insufficient high-quality evidence to determine whether surgical or conservative treatment is better for adults with DIACF. Results from this systematic review (largely based on one multi-center trial) indicated no differences in functional ability and healthrelated QoL at 3 years after DIACF between surgical and conservative treatments. Further good-quality research as well as adequately powered randomized, multicenter controlled trials, assessing patient-centered and clinically relevant outcomes are recommended.
REFERENCE Bruce, J., & Sutherland, A. (2013). Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database of Systematic Reviews, 1, CD008628. DOI:10.1002/14651858.CD00 8628.pub2.
Orthopaedic Nursing
•
November/December 2013
•
Volume 32
•
Number 6
337
Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ632.indd 337
11/11/13 11:06 AM
Surgical Versus Conservative Interventions for Displaced Intra-articular Calcaneal Fractures A Cochrane Nursing Care Field Corner Column Weihua Liu ▼ Yan Ma ▼ Binbin Yu ▼ Wang Jing
risk of bias for at least one domain. The primary outcomes were function (e.g., composite functional or gait scores, ability or distance walked without pain or difficulty, and other walking-related outcomes) and chronic pain (i.e., not minimal/infrequent pain). Secondary outcomes were health-related quality of life (QoL), return to work and former activities, postoperative complications and other postoperative morbidity or other serious adverse event, subsequent operation, objective measures of impairment, time to union, and radiological measurements. Follow-up was between 1 and 15 years following treatment. Meta-analysis was undertaken where possible.
What is the effect of surgical treatment compared with conservative treatment of displaced intraarticular calcaneal fractures in adults? REVIEW QUESTION:
Nursing Implications Displaced intra-articular calcaneal fractures (DIACFs) typically occur in younger working-age men as the result of high energy trauma. The economic impact of this injury to both the patient and the society is considerable resulting from extended hospital stay, treatment costs, residual pain, time to mobilization, and delayed return to work. Treatment can be surgical or nonsurgical; however, there is controversy in the literature over optimal management. Nurses play an active role in helping patients manage their calcaneal or heel fractures; so it is important to know which treatment approach is more effective.
Summary of Key Evidence The large multicenter trial (424 participants) demonstrated no statistically or clinically significant differences in functional ability, risk of chronic pain, and health-related QoL at 3 years follow-up after DIACF between surgical and conservative treatments. Pooled results from two small trials indicated a tendency for a higher return to previous employment following surgery compared with conservative treatments; however, this result was not statistically significant.
Study Characteristics This is a summary of a Cochrane systematic review. The review included four studies with a total of 602 participants; one trial was a large multicenter trial that provided the strongest evidence, and the other three trials were small single-center trials. All four trials were randomized by the individual rather than by fracture. Participants older than 14 years, considered as skeletally mature, with DIACFs were eligible for inclusion. The interventions of interest were surgical versus conservative treatments for DIACF. Surgical treatments could involve closed manipulation with percutaneous pin fixation and open reduction with internal fixation with or without bone graft or primary arthrodesis, and conservative treatments included ice and elevation, plaster cast immobilization, and early or delayed mobilization. The methodological quality of the included studies was generally poor. All trials had methodological flaws due to failure to conceal allocation and incomplete follow-up data, which put them at either unclear or high 336
Orthopaedic Nursing
•
November/December 2013
•
Volume 32
Weihua Liu, MMed, RN, Chief Professor in School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. Yan Ma, BN, Postgraduate Student, School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. Binbin Yu, BN, Postgraduate Student, School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. Wang Jing, BN, Postgraduate Student, School of Nursing, Tai Shan Medical University, TaiAn City, Shandong Province, People’s Republic of China. All authors are members of the Cochrane Nursing Care Field. The authors have disclosed no conflicts of interest. The full review is available at: http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD008628.pub2/abstract DOI: 10.1097/NOR.0000000000000008
•
Number 6
© 2013 by National Association of Orthopaedic Nurses
Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ632.indd 336
11/11/13 11:06 AM
No differences were found in the ability to wear normal shoes as before injury (one study), whereas another small trial found that surgery resulted in more people who were able to wear all shoes comfortably. The two studies were not pooled because of statistical heterogeneity. Results from Buckley’s study showed a significantly higher rate of major complications after surgery compared to conservative treatment (57/206 vs. 42/218; relative risk, 1.44, 95% confidence intervals, [1.01, 2.04]; one trial). Conversely, those having surgery were significantly less likely to have subtalar arthrodeses due to the development of subtalar arthritis (7/206 vs. 37/218; relative risk, 0.20, 95% confidence intervals, [0.09, 0.44]; one trial). No significant differences between the two groups in range of movement outcomes (3 trials) or radiological measurements (4 trials) were found in the review. Data on time to bone union were not reported in any of the included trials.
© 2013 by National Association of Orthopaedic Nurses
Best Practice Recommendations There is currently insufficient high-quality evidence to determine whether surgical or conservative treatment is better for adults with DIACF. Results from this systematic review (largely based on one multi-center trial) indicated no differences in functional ability and healthrelated QoL at 3 years after DIACF between surgical and conservative treatments. Further good-quality research as well as adequately powered randomized, multicenter controlled trials, assessing patient-centered and clinically relevant outcomes are recommended.
REFERENCE Bruce, J., & Sutherland, A. (2013). Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database of Systematic Reviews, 1, CD008628. DOI:10.1002/14651858.CD00 8628.pub2.
Orthopaedic Nursing
•
November/December 2013
•
Volume 32
•
Number 6
337
Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ632.indd 337
11/11/13 11:06 AM
