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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

Rapid Response:

Dear Sir,

We read with interest the article by Griffin et al, BMJ 2014;349 (24 July 2014) and would like to make the following points:

One of the aims of fixing calcaneal fractures is to minimise the late morbidity from malunion, subsequent arthritis and eventual fusion. The average patient in the group studied will likely live for around 30 years after fracture. A significant number of cases requiring fusion would present after the two year follow up of this study. Late reconstruction surgery rates may differ between the two groups. Did the authors consider longer follow up to allow evaluation of the late outcome?

The authors stated that CT scans showed intra-articular reduction up to a 2mm step. They also described less than perfect reductions in their cohort. Considering this, what would the results of surgery have been for fractures with a better reduction? We would be interested to see the long term results for the 40 patients who had less than a 2mm step after ORIF compared to the non-operatively managed group.

In this paper the definition of a specialist surgeon was not made clear. Including surgeons ‘recognised as specialists’ was in our opinion not sufficient. We would suggest that for this paper a specialist is a fellowship trained consultant foot and ankle surgeon who performs a high number of foot and ankle procedures each year and who has passed the learning curve for these operations. A median of two operations for each surgeon was surprisingly low. This may indicate that many included surgeons were not specialists as we define them.

We note that the selection criteria included only 502 of 2006 fractures encountered. It is difficult to know what the true selection criteria for operation were. Considering this and the above points we find it hard to agree with the sensationalist headline ‘surgery no longer justified for most intra-articular calcaneal fractures’. In our opinion this was a failure of the BMJ’s editorial process. In a journal widely read by non-specialists such a declaration was misleading. The true conclusions of the study were more nuanced: severe and open fractures require surgery. The important long term morbidity could not be determined from this study.

Finally, the trial was described as pragmatic. The word ‘pragmatic’ was mentioned 6 times in the text. We would welcome a definition of this term and how it affected the study.

Yours sincerely,

E Lindisfarne
D Wilson
B Rogers
D Ricketts

Competing interests: No competing interests

22 September 2014
Edward A O Lindisfarne
SpR Trauma & Orthopaedics
D Wilson, B Rogers, D Ricketts
Brighton & Sussex University Hospitals NHS
Brighton & Sussex University Hospitals NHS Trust, Brighton, UK.