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Calcaneal fractures (os calcis fractures) are very significant injuries. In the past, it used to be held to be the end of a working man’s productive career.
This is no longer the case; treatment has improved, and many manual jobs are now mechanized, allowing the employment of individuals even with a physical impairment.
Nevertheless, this recent quote illustrates just how significant these injuries still are:
‘The scores in eight SF-36 categories in patients with displaced intra-articular calcaneal fractures differed by more than five points from the population norms. This suggests that there is clinical and social relevance to this injury. Outcomes in patients with displaced intra-articular calcaneal fractures were not as good across most SF-36 categories as were outcomes of patients with other orthopaedic conditions. Outcomes in patients with intra-articular calcaneal fractures also were worse across most categories than outcomes in patients who had organ transplants or myocardial infarctions.
Conclusion: By comparing treatment for displaced intraarticular calcaneal fractures with treatment for orthopaedic problems or other disease processes, we concluded that intraarticular calcaneal fractures are serious life-changing events.’ Van Tetering et al, 2004.
Other recent authors have also described the injury as a ‘life-changing event’.
Below I have gathered some of the many papers dealing with this subject over the past 20 years. It is quite impossible, and would be very repetitive, to introduce every paper on the subject. If I have left out your favorite paper, please send me the reference & explain why you think it should be included. There is a comments section. The blog is modifiable.
As always on this blog, the focus is on long-term prognosis. We can change the surgical technique, but are we shifting the dial with respect to prognosis?
Let’s dive deeper…….
2000, Ceccarelli et al. ‘Surgical Versus Non-Surgical Treatment of Calcaneal Fractures in Children: A Long-term Results Comparative Study’. Foot & Ankle International: Vol 21,10, 825-832.
n= 32 fractures aged 3-17. Mean follow-up 22.8 years. Cases accumulated 1943-1990. Surgical techniques evolved during the nearly 50 years these cases accumulated, and are not therefore described.
Assessment: Maryland Foot Score.
Group A: 3-14 years
Group B: 15-17 years
Extra-articular fractures treated non-operatively; all satisfactory.
Articular fractures in Group A satisfactory regardless of treatment.
Articular fractures in Group B treated operatively; satisfactory.
Articular fractures in Group B treated non-operatively; mainly poor.
This paper is worth looking at just for Figure 1a & 1b; a 49 year follow-up of a displaced DIACF in a 9 year old treated non-operatively.
2001. Tufescu & Buckley. ‘Age, Gender, Work Capability, and Worker’s Compensation in Patients With Displaced Intraarticular Calcaneal Fractures’. Journal of Orthopaedic Trauma Vol. 15, No. 4, pp. 275–279
n= 169 patients with displaced intra-articular fractures. Assessments: return to work, change in work capability, SF-36, and visual analog scales.
Worse prognosis was associated with: male gender, medium/heavy work, workers’ compensation, & bilateral fractures. Males were always less able to return to work at the same level as before injury. RTW quicker after surgery.
2002, Thornes et al. ‘Outcome of calcaneal fractures treated operatively and non-operatively. The effect of litigation on outcomes.’ Irish Journal of i Medical Science • Volume 171 • Number 3; 155-157.
n=55; 33 operative, 21 conservative. Average follow-up 40 months (14-78).
30% were pursuing litigation.
The authors found:
‘Despite similar fractures, medical co-morbidity and trauma energy, significantly worse outcome scores were seen in litigants (p<0.0001). Footwear fitting problems were greater in litigants. Time off work was more than twice that of non-litigants (14.5 vs 6 months, p<0.01). Results were similar between the operative and non-operative groups in terms of functional score, footwear problems and time off work.
Conclusions: Litigation was the major determinant of outcome following calcaneal fracture repair, highlighting the unreliability of subjective evaluation in determining outcome in the face of litigation. No subset of patients appeared to significantly benefit from internal fixation of their fracture.’
2002. Buckley et al, ‘Operative compared with non-operative treatment of displaced intra-articular calcaneal fractures. A Prospective Randomized Controlled Multicenter Trial’. JBJS, 84-A, 10, 1733-1744.
n=512, at 4 trauma centers. 471 features in 424 patients enrolled. Follow-up was minimum 2 years, maximum 8 years. Assessments: SF-36, and a visual analog disease-specific scale.
Non-operative patient outcomes were not significantly different to operative patient outcomes, as a whole.
Non-operative treatment did not involve casting.
Within subgroups, some patients did better with surgery than non-operatively: individuals not receiving worker’s compensation (remember that this might be a mechanism effect or a litigation effect, or both); women; patients not receiving worker’s compensation less than 29 years old; moderately lower Bohler angle (0-14 degrees); a comminuted fracture; a light workload; a good reduction less than 2mm out (surprised?).
2002, Zmurko & Karges. ‘Functional outcome of patients following open reduction internal fixation for bilateral calcaneus fractures’. Foot & Ankle International/ Vol 23, No 10/October 2002, 917-921.
n=13, retrospective. Assessment = Musculoskeletal Functional Assessment, AOFAS ankle & hind foot score. Follow-up averaged 56 months.
Over half of patients required additional surgeries. Average MFA 31.1; average AOFAS 71.8.
The authors commented that results seemed to be worse than expected for unilateral fractures (although they did not study unilateral in the study).
2004, Berry et al. ‘Open Fractures of the Calcaneus A Review of Treatment and Outcome’. J Orthop Trauma 2004;18:202–206.
30 open fractures out of 177. 27 had associated injuries. 2 underwent urgent amputation due to severe crush injury. A variety of surgical strategies were employed for soft tissue closure and fixation. No deep infections or late amputations.
Average follow-up was 49 months (25-106). AOFAS ankle/hindfoot & Maryland Foot Scores were fair to poor. Average SF-36 were within 1 SD of published Canadian norms.
Worse function found in plantar wounds; severely comminuted fractures had the worst results. The combination of these two had particularly poor functional results.
2004, van Tetering et al. ‘Functional Outcome (SF-36) of Patients with Displaced Calcaneal Fractures Compared to SF-36 Normative Data’. Foot & Ankle International/Vol. 25, No. 10/October 2004 733- 738.
n=312, 25-64 years of age, with DIACF. Follow-up 2-8 years. Assessment = SF-36.
Findings: ‘The scores in eight SF-36 categories in patients with displaced intraarticular calcaneal fractures differed by more than five points from the population norms. This suggests that there is clinical and social relevance to this injury. Outcomes in patients with displaced intraarticular calcaneal fractures were not as good across most SF-36 categories as were outcomes of patients with other orthopaedic conditions. Outcomes in patients with intraarticular calcaneal fractures also were worse across most categories than outcomes in patients who had organ transplants or myocardial infarctions.
Conclusion: By comparing treatment for displaced intraarticular calcaneal fractures with treatment for orthopaedic problems or other disease processes, we concluded that intraarticular calcaneal fractures are serious life-changing events.’
2004, Kingwell, Buckley & Willis. ‘The Association Between Subtalar Joint Motion and Outcome Satisfaction in Patients with Displaced Intraarticular Calcaneal Fractures’. Foot & Ankle International/Vol. 25, No. 9/September 2004: 666-673.
244 calcaneal fractures had STJ motion measurements at >12 weeks post-fracture; patient reported outcomes were evaluated at 2 years.
To summarize – STJ motion correlates with patient satisfaction & clinical outcome measurements, however they have been treated.
2005, Herscovici et al, ‘Operative Treatment of Calcaneal Fractures in Elderly Patients’. JBJS 87-A: No 6,1260-1264.
N = 42 pts/44 frax. Average follow-up 44 months, minimum 24. Age 65 or over, average 70, range 65-84.
Assessments: SF-36 (average =52.8), AOFAS (average 82.4) & SMFA (average 20.4).
Posttraumatic subtalar arthritis developed in twelve patients.
There were twelve minor complications and four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully.
The authors concluded: Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. Careful patient selection is necessary because individuals presenting with severe osteopenia, those who are unable to walk or are able to walk only about the house, and those with a medical condition that precludes surgery may be better candidates for nonoperative care.
2005, Brauer et al, ‘An economic evaluation of operative compared with non-operative management of displaced intra-articular fractures’. JBJS, 87-A, 12; 2741-2749, 2005. doi:10.2106/JBJS.E.00166
n=309, based on a study by Buckley et al. The mean age of the patients was forty years, 37% had a work-related injury and were receiving Workers’ Compensation, and 90% were male.
Operative management resulted in a lower rate of subtalar arthrodesis and a shorter time off work than non-operative treatment. When indirect costs such as time off work were included, operative management was less costly (average Can$ 19,000) and ‘more effective’, making it the preferred strategy.
If costs such as time off work were excluded, operative treatment remained more effective, but with an increased cost averaging Can$ 2800.
2007, Ibrahim et al. ‘Displaced intra-articular calcaneal fractures: 15-Year follow-up of a randomised controlled trial of conservative versus operative treatment’. Injury, Int. J. Care Injured (2007) 38, 848—855.
n= 46 surviving patients of original study (82%); 26 agreed the review (57%).
Assessments: AOFAS hind foot, foot function index (FFI), calcaneal fracture score.
Clinical & radiological outcomes were not significantly different between groups.
The chief objection to the current relevance of the study was identified by the authors:
‘The operative treatment used in the original study has become historical. It can be argued that the limited lateral approach of Soeur and Remy does not reliably reduce all the fracture fragments and restore hindfoot biomechanics. The fixation technique was only provided by Kirschner wires which are now considered inadequate for intraarticular calcaneal fractures.’
2009, Radnay et al. ‘Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does Initial Operative Treatment Matter?’. JBJS 2009;91:541-6 d doi:10.2106/JBJS.G.01445
n= 69 pts with 75 frax. Follow-up 62 months for ORIF patients; 63 months after non-operative management.
(I note that this suggests that the ORIF did not affect the latency of the symptomatic arthritis to a significant extent, which is different to some fractures in other locations).
Assessments: Maryland Foot Score, AOFAS ankle/hindfoot score.
Short answer: Yes. Results are better when ST fusion carried out on a calcaneus where the anatomy has been restored by ORIF.
2009, Nunley & Potter. ‘Long-Term Functional Outcomes After Operative Treatment for Intra-Articular Fractures of the Calcaneus’. JBJS 91-A: No 8, 1854-1860.
n= 157. 73 pts with 81 fractures responded. Mean follow-up 12.8 years, minimum 5 years.
Assessments: AOFAS ankle/hindfoot score 65.4; Foot Function Index 20.5; calcaneal scoring system score = 69.3.
Mechanism MVA worse than after fall (RJM: a litigation effect?). Results similar to other studies reporting long-term outcomes.
2009, Gallino, Gray & Buckley. ‘The outcome of displaced intra-articular calcaneal fractures that involve the calcaneocuboid joint’. Injury, Int. J. Care Injured 40 (2009) 146–149
n= 59 with 64 fractures. >2 years post-injury. Pain & functional scores not different for fractures involving CCJ, compared to fractures that did not involve CCJ. Fractures where >50% of CCJ involved all had degenerative changes at 2 years post-injury.
2010, Gaskill. ‘Comparison of Surgical Outcomes of Intra-Articular Calcaneal Fractures by Age’. JBJS 2010;92:2884-9 d doi:10.2106/JBJS.J.00089
175 pts with 191 fractures. Follow-up 8.98 years. Group 1 was less than 50 years (average 36); Group 2 was above that age (average 58).
Assessments: AOFAS/ FFI/ calcanea fracture scoring system.
Each clinical outcome measurement showed better results in Group 2 than in Group1. Complication rates were similar. ST fusion as secondary surgery was 15% in Group 1; 8% in Group 2.
The key conclusion was that operative treatment was a reasonable option for older patients with these fractures. An individualized approach was advised.
2010, Basile. ‘Operative versus Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures in Elderly Patients’. The Journal of Foot & Ankle Surgery 49 (2010) 25–32.
n=33 pts aged 65-75. 18 treated operatively, 15 non-operatively. 2 years follow-up.
Patient selection was essentially by hospital of admission, which of course may conceal a number of inadvertent biases as hospitals, while apparently similar, may have dissimilar clienteles. One hospital treated these cases non-operatively; the other operated on some cases but not all. It is not crystal clear what the selection criteria were for surgery, and whether non-operative cases were similar or different from operative ones. Not clear whether it was non-op from hospital 1 -v- operative from hospital 2; or non-op from both hospitals -v- operative from hospital 2.
Non-operative cases were splinted for 3 weeks. I wonder why; there was no reduction to hold, and these fractures do not require immobilization to heal.
Operative cases had significantly better AOFAS ankle/hindfoot scores and less pain on a 10cm visual analog scale. Bohler’s angle restitution, quality of reduction & subtler motion correlated with outcome (regardless of treatment); gender and Sanders classification had less effect.
Complications similar to other series, except for subtalar arthritis (38.9% in operative group; 100% in non-operative group, most of which was severely symptomatic).
In my experience, this is a higher than expected level of severe symptoms at 2 years in the non-operative group.
I doubt the value of quoting percentages with less than 20 in each group. It was interesting that on Figures 1 & 2, none of the AOFAS or VAS measurements actually lay within the 95% CI.
A small retrospective study.
2010, Makki et al. ‘Osteosynthesis of displaced intra-articular fractures of the calcaneum’.
n=47. Single surgeon series. Retrospective. Follow-up mean 10 years (7-15). Assessments: AOFAS, Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36.
Results: 18 excellent, 17 good, 3 fair, 9 poor. The degree of arthritic change did not correlate with the outcome scores or Sanders classification.
5 infections, 5 others had subtalar arthrodesis.
2013, Cochrane Systematic Review. Bruce & Sutherland. ’Surgical versus conservative interventions for displaced intra‐articular calcaneal fractures’. https://doi.org10.1002/14651858.CD008628.pub2
This is easy to obtain & worth reading. A quick summary would be: ‘Good evidence is hard to come by’!
The authors’ conclusions:
‘The bulk of the evidence in this review derives from one large multi‐centre but inadequately reported trial conducted over 15 years ago. This found no significant differences between surgical or conservative treatment in functional ability and health related quality of life at three years after displaced intra‐articular calcaneal fracture. Though it reported a greater risk of major complications after surgery, subtalar arthrodeses for the development of subtalar arthritis was significantly greater after conservative treatment.
Overall, 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. Evidence from adequately powered randomised, multi‐centre controlled trials, assessing patient‐centred and clinically relevant outcomes is required. However, it would be prudent to reassess this need after an update of the review that incorporates new evidence from a currently ongoing multi‐centre trial.’
2013, Veltman et al. ‘Long-term Outcomes of 1,730 Calcaneal Fractures: Systematic Review of the Literature’.The Journal of Foot & Ankle Surgery 52 (2013) 486–490.
n= 1557 pts with 1730 frax. Mean follow-up = 4.6 years.
The authors concluded: ‘The findings from the present review support current clinical practice that displaced calcaneal fractures are treated surgically from 1 level I evidence study, 1 level II, and multiple studies with less than level II evidence, with open reduction and internal fixation as the method of choice. If the fracture is less complex, percutaneous treatment can be a good alternative according to current level 3 and 4 retrospective data.’
2014, Griffin et al. ‘Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial’. BMJ 2014;349:g4483 doi: 10.1136/bmj.g4483
Hooray – an RCT!
n=151. 73 operative, 78 non-operative. Primary outcome = Kerr-Atkins score. 0 (worst) – 100 (best). No significant difference in the Kerr-Atkins score, or in any of the secondary outcome measures.
The authors commented: ‘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).
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.
2015. De Boer et al. ‘Functional Outcome and Patient Satisfaction After Displaced Intra-Articular Calcaneal Fractures: A Comparison Among Open, Percutaneous, and Nonoperative Treatment’. J Foot Ankle Surg 2015 May-June 54-3 298-305
n= 169 patients between 2002-20011 with Sanders 2-4, aged 16-70 (some obvious exclusions). 108 questionnaires sent after exclusions, 78 questionnaires returned; appeared representative. Retrospective. Treatment by either non-operative means, percutaneous, or open reduction & internal fixation (ORIF). Selection: general orthopaedics chose non-op (79%), orthopaedic traumatologists chose to operate (72%). To start with the traumatologists performed percutaneous fixation but experienced a 30% need to re-operate, so changed to ORIF (in 67%).
More disability was reported in the non-operative group (median 40 Foot Function Index), when compared to the percutaneous (median 21) and ORIF groups (median 16). AOFAS hind foot scale mirrored this. The indications for surgery for each group of surgeons may not have been identical, making it difficult to generalise. Non-operative treatment included casting rather than early movement. It seems counter-productive to impose cast stiffness on these damaged joints when one neither needs immobilization to achieve bone healing, nor is there a reduction to be maintained. Had this not been done, I suspect the non-op results would have been better. Follow up in non-op group was less than a year, and 13 months for the operative groups. (Other studies have suggested that os calcis fractures improve for 2 years post-injury, making this a significant issue)!
It is important to appraise what is in the literature, but a retrospective paper such as this with brief follow-up and probably differences in indications/selection should not be relied upon when making treatment choices or prognoses.
2015, van Hoeve et al. ‘Gait Analysis and Functional Outcome After Calcaneal Fracture’. JBJS, J Bone Joint Surg Am. 2015;97:1879-88 d http://dx.doi.org/10.2106/JBJS.N.01279
13 pts with DIACF underwent gait analysis at >6 months. Clinical outcome assessments: SF-36, Foot & Ankle Disability Index.
The authors concluded: ‘This study demonstrated that the subtalar joint range of motion of patients after a calcaneal fracture was related both to the quality of the reduction of the subtalar joint as evaluated on postoperative CT scans and patient reported functional outcome’.
2015. Alexandridis, Gunning, & Leenen. ‘Patient-reported health-related quality of life after a displaced intra-articular calcaneal fracture: a systematic review’. World Journal of Emergency Surgery (2015) 10:62 DOI 10.1186/s13017-015-0056-z.
Review of 32 articles reporting HRQoL measures in DIACF. Displaced intra-articular calcanea fracture = DIACF. Health-related Quality of Life = HRQoL. The HRQoL measures were: SF-36, SF-36v2, EQ-5D or EQ-6D.
The authors concluded, not surprisingly: ‘This systematic review indicates that DIACF is a life-changing event for most patients. The HRQoL is substantially lower in comparison to the period before the trauma and to the general population, in particular the subdomains related to the physical domain are affected. In addition, this review reveals that the identified studies have a medium to high risk of bias. Consequently, it is challenging to make reliable and valid conclusions’.
2016, Biz et al. ‘Radiographic and functional outcomes after displaced intra-articular calcaneal fractures: a comparative cohort study among the traditional open technique (ORIF) and percutaneous surgical procedures (PS)’. Journal of Orthopaedic Surgery and Research (2016) 11:92. DOI 10.1186/s13018-016-0426-62018
n= 87 (5 bilateral). Mean follow-up 77 months. Assessments: AOFAS ankle/hindfoot scale, Maryland foot scale, Foot Function Index, & a VAS.
Patients were not randomised, and according to surgeon preference were treated by ORIF, percutaneous screw, or percutaneous wires. ORIF produced the best results, despite the risk of complications. Percutaneous screw was worse but not significantly so. K-wires percutaneously were worse.
I am not surprised.
2018, Alexandridis et al. ‘Association of pre-treatment radiographic characteristics of calcaneal fractures on patient-reported outcomes’. International Orthopaedics (2018) 42:2231–2241
https://doi.org/10.1007/s00264-018-3852-8
n= 396 with 442 frax. Retrospective from prospective database. 215 participated.
Patients with a calcaneal fracture into the talar surface reported a worse quality of life (p = 0.010), were less satisfied with their feet (p < 0.001), and had more complications (p = 0.001–0.006); extra-articular fractures had significantly opposite result. A negative Böhler’s or calcaneal compression angle was related with unfavourable outcomes. The Sanders classification was not related with any patient-reported outcome.
2018, van Vliet et al. ‘Factors Influencing Functional Outcomes of Subtalar Fusion for Posttraumatic Arthritis After Calcaneal Fracture’. Foot & Ankle International. 2018, Vol. 39(9) 1062–1069
DOI: 10.1177/1071100718777492
n= 159 met criteria, 84 completed questionnaire (59%).
Assessments: Foot and Ankle Ability Measure (FAAM), Maryland Foot Score (MFS), Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire, EuroQol 5-dimensional (EQ-5D) questionnaire, and EuroQol visual analog scale (EQ-VAS).
This study attempted to answer the question: what factors are associated with poorer outcomes after ST fusion after calcanea fractures?
Quality of Life was significantly lower when compared to a reference population. Smoking was independently associated with worse outcomes. High energy injury, ipsilateral associated injuries, & complications such as non-union, implant failure, & infection predicted poor outcome.
2018, Siebe de Boer et al. ‘The effect of time to post-operative weightbearing on functional and clinical outcomes in adults with a displaced intra-articular calcaneal fracture; A systematic review and pooled analysis’. Injury, Int. J. Care Injured 49 (2018) 743–752.
An extensively researched systematic review, which concluded:
‘The adverse sequelae which are assumed to be associated with starting partial weightbearing within six weeks after internal fixation of calcaneal fractures, is not supported by literature data. This systematic review suggests that early weightbearing does not result in impaired outcomes compared with more conservative weightbearing regimes’.
2020, Lee et al. ‘Bone density of the calcaneus correlates with radiologic and clinical outcomes after calcaneal fracture fixation’. Injury 51 (2020) 1910–1918
n=43, retrospective. Unilateral DIACF. CT & DEXA of both calcanei. Clinical outcomes assessed at 12 months using Foot & Ankle Outcome Scores.
The authors concluded:
Decreased preoperative bone density significantly correlated with decreased Böhler’s angle, widening of calcaneal width, and inferior short-term clinical outcomes after screw fixation of DIACF. By quantifying bone density using HU value in area where DXA cannot be performed, such foot bones, determining whether different fixation methods or systemic treatments can be tailored to bone density could help in optimizing clinical outcomes.
An interesting approach, a preliminary study attempting to measure calcaneus bone quality with the possibility of using the information in treatment selection one day.
2020, Van Der Vliet et al. ‘Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review’. The Journal of Foot & Ankle Surgery 59 (2020) 264−268.
The literature review revealed no clear superiority in the comparison between closed -v- open reduction. More wound infections occurred in the open reductions.Revision & hardware removal was commoner with closed treatment.
The authors recommend trying closed first, converting to open if a satisfactory position cannot be achieved.
2020, Allegra et al. ‘Intra-articular Calcaneus Fractures: Current Concepts Review’. Foot & Ankle Orthopaedics 2020, Vol. 5(3) 1-11
DOI: 10.1177/2473011420927334
An up-to-date review; though some of the recommendations might be held to be controversial rather than ‘settled with good evidence’.
Usefully the authors remind us regarding the associated injuries to pelvis & spine & opposite calcaneus.
Unfortunately, it advocates casts for non-operative management, when of course that makes stiffness worse and precludes the use of intermittent pressure etc etc.
It also advocates non-weightbearing for 10-12 weeks, when Siebe de Boer et al suggest this is unnecessary.
2020, Halm et al. ’Intraoperative Effect of 2D vs 3D Fluoroscopy on Quality of Reduction and Patient-Related Outcome in Calcaneal Fracture Surgery’. Foot & Ankle International. 2020, Vol. 41(8) 954–963
Intra-operative use of 3D -v- 2D fluoroscopy does not improve postoperative complications, quality of life, functional outcome, or posttraumatic osteoarthritis.
Summary
Surgeons have a natural bias towards surgery as intrinsically helpful. With many injuries, this bias is confirmed by improved results following intervention.
In displaced intra-articular calcaneus fractures (DIACF) the benefit of surgery is harder to discern, and some doubt it even exists.
Perhaps our technique or our complications are bringing us down. Is our patient selection & identification of sub-groups good enough? Have we got the timing of surgery right?
Overall the evidence on displaced intra-articular calcaneus fractures (DIACF) is limited and poor in quality, according to the Cochrane group. This is a familiar refrain, but I think in recent years we are making gradual progress.
Some points to bring out:
Subtalar joint movement does appear to be related to longer term clinical outcome.
If subtalar fusion is required, the results are better when it is performed in an anatomically restored calcaneus – ie after ORIF.
ORIF is cost-effective when societal costs are included with direct costs; when these are excluded, it is more costly, but not by much.
Some host/injury factors have an adverse effect on prognosis for the individual and his/her return to work:
Smoking
Low bone mineral density
Heavy work
Worker’s Compensation or litigation
Bilateral fractures
Open fractures, particularly if comminuted and/or open through the plantar surface
Some factors which aren’t related to prognosis, or where the relationship is controversial:
Sanders Classification
Gender
Age (unless a skeletally immature child)
Fractures which involve the calcaneocuboid joint
Time to weight-bearing
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