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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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In this study, what the authors have nicely demonstrated is that calcaneal fracture surgery by surgeons who do not perform high volumes of this complex surgery does not yield outcomes that are significantly better than non-operative treatment, and with higher complications. The methodology of the current study, allows it to only address a specific segment of the discussion, that being the advisability of surgery by non-specialist surgeons (defined as high-volume calcaneal fracture surgeons) to operate on calcaneal fractures. In this subset, their data strongly suggests that such surgery is not advantageous. However, it needs to be made clear in the manuscript that this result cannot be extended to the include surgery by high-volume specialist surgeons.

The reported distribution of treatment centers means that for at least half of the centers, the annual number of calcaneal fractures treated annually was 1.7per center. If there were more than a single surgeon participating at each center, then this number would be even lower when expressed as "annual rate per surgeon". It is hard to argue that surgeons who are so infrequently operating on calcaneal fractures should be considered "experts", since the literature has clearly shown a learning curve that extends well beyond a surgeon's first 100 cases.

The distribution of cases by quartile is interesting. The lowest half of the centers (referred to above) accounts for 55 cases. The next quartile accounts for approximately 42 cases (assuming an average of 7 cases per center - which means 2.3 cases/year/center). The top quartile therefore accounts for 54 cases, which average out to 12 cases/center, or 4 cases/center/year. In the most extreme configuration, where most of the cases came from one canter (8,8,8,8, and 30 cases per center), only one center would have what might be considered a high volume of cases (10 per year). Since precise numbers are not provided by the authors, some of the calculations here may be a bit off, but the conclusion doesn't change regarding the large number of centers that have very low numbers of cases. This makes the proposition that the care rendered is representative of the highest quality in "expert surgical treatment" very difficult to make. If the authors want to suggest that calcaneal fracture surgery by non-expert surgeons is problematic, that would be supported by their data.

The data about the surgeons paints a similar picture regarding the level of expertise of the surgeons. In such a complicated surgery, it is well known that higher volumes of surgery on annual basis lead to better outcomes (in the field of Orthopaedics this has been best studied for total joint replacement). In the present study, no surgeon operated on more than 6 patients over the course of 3 years. That does not constitute the level of experience that would characterize an expert in calcaneal fracture surgery.

The comment that this study reflects the expected outcome of surgery in "the real world" actually makes the point that these surgeries should not be done by surgeons who do not do these surgeries in high volume. It says nothing about the outcomes one would see if the surgeries were performed by truly expert surgeons with a high ongoing experience treating such fractures surgically.

Competing interests: No competing interests

08 August 2014
James D Michelson
Professor, Orthopaedic Surgery
University of Vermont College of Medicine
Stafford 418A, 95 Carrigan Dr., Burlington, VT 05401, US