Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trialBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4483 (Published 24 July 2014) Cite this as: BMJ 2014;349:g4483
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Re: Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial
We read with interest in Griffin and colleagues’s excellent study1, which concluded that “operative treatment by open reduction and internal fixation is not recommended for for closed,displaced, intra-articular fractures of the calcaneus. This seriously challenges current orthopaedic practice, where all displaced (>2mm) intra-articular fractures are anatomically reduced and fixed with screws and plates, to facilitate earlymobilisation of the joint and reduce the long term risk of osteoarthritis2. However, we have some concerns regarding the paper and wish to share them.
Firstly, the operation was performed through an extensile lateral approach,with interfragmentary screws and application of a neutralisation plate or plates to the lateral wall of the calcaneus.The authors said that this surgical technique was chosen because it is considered to be the standard of care in the United States, United Kingdom, and most centres around the world. And they gave a reference of Epstein N3. However, in this reference we could not find evidence to support the above reason. But Epstein said that “Open reduction and internal fixation through an extensile approach achieves acceptable results in carefully selected patients. The use of a limited exposure with minimally invasive techniques may decrease the incidence of wound complications”. As we know, the complication rate of the extensile lateral approach has been reported to be as high as 30% in patients treated with this approach4,5. The soft-tissue envelope over the lateral wall of the hindfoot is particularly thin and vulnerable, potentially creating a high risk for wound-related complications. Now using the minimally invasive approaches to treat displaced intra-articular calcaneal fractures is the mainstream approach6-11.Among of various minimally invasive approaches, the sinus tarsi approach has become one of the most frequently applied approaches because of its ability to provide adequate exposure for the posterior facet, the anterolateral fragment, and the lateralwall. Wound complication rates with this approach have beenreported to range from 0% to 15.4%12. We used sinus tarsi approach for sixty-seven patients with displaced, intra-articular fractures of the calcaneus, and the wound-healing complications were 12.5%. While used an improved approach based on sinus tarsi approach, the wound-healing complications were only 2.9%. This detailed study was published in J Bone Joint Surg Am this year10. However, the complication rate was as high as 23% by the extensile lateral approach in Griffin and colleagues’s study, where the operation was finished by the best surgeons in UK, who were good at calcaneal fractures treatment. So if the author choose the minimally invasive sinus tarsi approach, the conclusions of this study maybe may be reversed, which approve of surgical treatment.
Secondly, in the “Results” part, the author said “Of these, 502 had severe fractures that met the eligibility criteria”. The word “severe fracture” used here is not appropriate. Generally speaking, severe calcaneal fracture is used to describe Sanders type-Ⅲ and IV fractures, which especially for IV fractures9,13. However, in this study, there were a considerable of Sanders type-Ⅱfractures (70/141). It means that Sanders type-Ⅱfracture accounted for 49.6% of the total in the study. The Sanders type-Ⅱcalcaneal fracture is recognized as easy to treat through either surgery or conservative treatment. The real dilemma of how best to treat calcaneal fracture usually refers to Sanders type-Ⅲ and IV fractures. So the increased proportion of Sanders type-Ⅱfractures in this study will affect the credibility of the conclusion.
Thirdly, The author measured the primary outcome at two years after injury. It is based on at least two thirds of the patients would be expected to have reached maximal recovery two years after injury13. However, we downloaded the original reference 13 of Pozo JL, which was published in 198 4 of JBJS. And we found Pozo JL said “Although two-thirds of the patients reached a point of maximal recovery at two to three years, 24% continued to improve for six years”. Pozo JL’s “two to three years” was arbitrarily changed to “two years” in this study. This is contrary to the spirit of science. In addition, as orthopedic trauma doctors, we are also confused on this issue. Because we often met a considerable of patients with a stiff, painful, deformed foot continuted to even 7 years after injury. So the choice of 2 years is needed to be confirmed in future study.
1. Griffin D, Parsons N, Shaw E,et al.Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial.BMJ 2014;349:g4483.
2. Scammell BE.Calcaneal fractures.BMJ 2014;349:g4779
3. Epstein N, Chandran S, Chou L. Current concepts review: intra-articular fractures of the calcaneus. Foot Ankle Int 2012;33:79-86.
4. Abidi NA, Dhawan S, Gruen GS, Vogt MT, Conti SF. Wound-healing risk factors after open reduction and internal ﬁxation of calcaneal fractures. Foot Ankle Int 1998;19:856-61.
5. Lim EV, Leung JP. Complications of intraarticular calcaneal fractures. Clin Orthop Relat Res 2001;391:7-16.
6. Rammelt S, Amlang M, Barthel S, Zwipp H. Minimally-invasive treatment of calcaneal fractures. Injury 2004;35(Suppl 2):SB55-63.
7. Labbe JL, Peres O, Leclair O, Goulon R, Scemama P, Jourdel F.Minimally invasive treatment of displaced intra-articular calcaneal fractures using the balloon kyphoplasty technique: preliminary study.Orthop Traumatol Surg Res 2013;99:829-36
8. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE.Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures.Foot Ankle Int 2013;34:773-80.
9. Su Y, Chen W, Zhang Q, Liu S, Zhang T, Zhang Y.Bony destructive injuries of the calcaneus: long-term results of a minimally invasive procedure followed by early functional exercise: a retrospective study.BMC Surg 2014;14:19.
10. Zhang T, Su Y, Chen W, Zhang Q, Wu Z, Zhang Y.Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach.J Bone Joint Surg Am 2014;96:302-09.
11. Chung KJ, Hong DY, Kim YT, Yang I, Park YW, Kim HN. Preshaping Plates for Minimally Invasive Fixation of Calcaneal Fractures Using a Real-Size 3D-Printed Model as a Preoperative and Intraoperative Tool.Foot Ankle Int. 2014 Jul 22. [Epub ahead of print]
12. Schepers T. The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop 2011;35:697-703.
13. Pozo JL, Kirwan EO, Jackson AM.The long-term results of conservative management of severely displaced fractures of the calcaneus.J Bone Joint Surg Br. 1984;66:386-90.
Yueju Liu, MD and Yingze Zhang Professor
Department of Orthopedic Center
Key Orthopaedic Biomechanics Laboratory of Hebei Province
Third Hospital of Hebei Medical University,
No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, P.R. China
Competing interests: No competing interests