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

BMJ 2014; 349 doi: (Published 24 July 2014) Cite this as: BMJ 2014;349:g4483

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As a practicing clinician who fell foul of this injury some 8 ½ years ago (bilateral fractures), I was interested to read this study and the accompanying editorial. I have a number of concerns.

The first is numeric! Appreciating the power calculations, and this undoubtedly well planned, well conducted and well presented study; how is it that only 151 patients, across a wide spectrum of fracture severity (Sanders 2 – 4) were recruited by 22 surgeons? How is it possible to draw conclusions on the outcome of a median of 2 operations per surgeon over the study period with a maximum of six per operator? In most specialities this would be viewed as ‘occasional practice’. Accepting that the techniques and principles of restorative trauma surgery are similar irrespective of the anatomy goes some way to alleviating this; but not far enough. If 2721 patients in the UK had similar fractures in 2010, randomising 151 over the preceding 2 years does not imply a particularly representative sample or sample size. Since around half of the recruits were less serious fractures, and since the study was not powered for subtype analysis, I believe this introduces a serious flaw.

The second is length of follow-up; 2 years provides information about the need for early re-intervention only and possibly incomplete rehabilitation. One of the main current justifications for surgery appears to be to reduce the likelihood of later, eg subtalar joint, complications at some cost of increased risk of early ones. This study cannot yet address this.

The third is the foot itself. It is not clear from this study, as presented, that the measures of deformity and gait utilised fully capture the potential disability produced by injuries less extreme than those causing fibular impingement but none-the-less very significant. Although integrity of the bony structure of the hindfoot may be assured by either means, cosmesis, mobility within or outwith footwear and ability to wear shoes at all, are also important to those affected. Notwithstanding this, since the differences for a number of the parameters studied approach statistical significance, might this not also suggest that this study is underpowered.

I am not in a position to comment on the surgical approach itself but as with any pathology where there are multiple available treatment modalities, might this study also suggest that perhaps it is the type, or the performance of the surgery, that is questionable, rather than the principle of restorative surgery itself. The accompanying editorial further highlights the lack of efficacy of non-operative treatment for this injury, so with more than 2000 cases per year in the UK alone, surely this study should be defining the need for an improved surgical approach, more centralisation of this very difficult surgery, and further, larger, trials?

Competing interests: No competing interests

07 August 2014
Frances A Bu'Lock
Consultant Paediatric Cardiologist
East Midlands Congenital Heart Centre, Glenfield Hospital
Groby Rd, Leicester, UK