|Year : 2019 | Volume
| Issue : 2 | Page : 31-36
Comparative study of operative versus nonoperative management of intra-articular calcaneum fractures
Ravi Kumar1, Chandan Kumar2, Neeraj Kumar3
1 Department of Orthopaedics, NMCH Patna, Madhubani, Bihar, India
2 Department of Orthopaedics, Madhubani Medical College and Hospital, Madhubani, Bihar, India
3 Department of Orthopaedics, Neeraj Hospital, Siwan, Bihar, India
|Date of Submission||15-Sep-2019|
|Date of Decision||22-Sep-2019|
|Date of Acceptance||01-Oct-2019|
|Date of Web Publication||21-Oct-2019|
Dr. Ravi Kumar
Laxmi Villa Apartment, Ramjaipal Road, Aparna Bank Colony, Phase-2, Danapur, Patna - 801 503, Bihar
Source of Support: None, Conflict of Interest: None
Purpose: The treatment of intra-articular fractures of the calcaneum remains controversial. There is no consensus in the current literature regarding the optimal treatment of intra-articular fractures of the calcaneum. In the current study, we intend to compare the outcome of operative and conservative management for intra-articular calcaneum fractures based on the objective criteria, i.e., restoration of Bohler's angle, subtalar range of motion, and subjective criteria such as pain, return to work, return to physical activity, and change in shoe wear. Materials and Methods: This retrospective cum prospective study was conducted in a government hospital at Patna, Bihar, during the period extending from April 2016 to March 2019. Twenty-four patients with 25 intra-articular calcaneum fractures were included in the study. The outcome of conservative and operative management was compared using the Creighton-Nebraska Health Foundation Assessment Score (C-N scoring system). Pretreatment and posttreatment (at follow-up) Bohler's angle were also compared. Results: Restoration of the Bohler's angle was better with operative management as compared to conservative management. In our study, the results of type I fractures managed conservatively had a better outcome than those of displaced fractures and the difference was statistically significant. Furthermore, type II and type III fractures had a better outcome with operative management, but the difference was not statistically significant. In type IV fractures, operative management was significantly better than conservative management. A significant correlation was seen between the posttreatment Bohler's angle and C-N scores. Conclusions: Conservative management has better functional outcome for undisplaced fractures. For displaced and comminuted fractures, anatomical reduction and restoration of Bohler's angle is very important. Bohler's angle has a prognostic importance and correlates well with the functional outcome.
Keywords: Bohler's angle, conservative, intra-articular calcaneum fracture, operative
|How to cite this article:|
Kumar R, Kumar C, Kumar N. Comparative study of operative versus nonoperative management of intra-articular calcaneum fractures. J Orthop Dis Traumatol 2019;2:31-6
|How to cite this URL:|
Kumar R, Kumar C, Kumar N. Comparative study of operative versus nonoperative management of intra-articular calcaneum fractures. J Orthop Dis Traumatol [serial online] 2019 [cited 2019 Dec 6];2:31-6. Available from: http://www.jodt.org/text.asp?2019/2/2/31/269580
| Introduction|| |
The calcaneus is the largest and most often fractured tarsal bone. With a bone so vital to the normal mechanics of locomotion, it is easy to see why a fracture of the calcaneus is attended by considerable morbidity. Despite the physicians extensive experience with this injury, its major socioeconomic impact in regard to the time lost from work and recreation, and the attention given to it for many years globally, still there is no method of treatment that yields consistently good results.
Cave pointed out that fractures of the calcaneus is one injury that has not increased in frequency with the advent of mechanized industry, automobile travel, and war. It has been a common, often disabling injury since humans assumed the erect posture and began to defy gravity.
Cotton as early as 1908 wrote, “ordinarily speaking the man who breaks his heel bone is done,” so far as his industrial future is concerned. Bankart et al. 35 years later, wrote, “the results of treatment of crush fractures are rotten.” The best result that can be expected from a fracture of the sub-astragloid joint is a completely stiff but painless foot of a good shape with free movement of the entitled joint.
Conn wrote that fractures of calcaneus and “serious and disabling injuries in which the end results continue to be incurably bad.” Bohler et al. began to advocate the open reduction of calcaneal fractures in 1931 based on his experience with the French methods. Despite this, forcible closed reduction with tongs and hammers or traction followed by manual manipulation and casting, were the standard treatments of his time, because of technical problems associated with surgery. During 1950s, subtalar fusion emerged as the most commonly performed treatment as it was easiest to perform.
Over the past 25 years, however, marked advances in anesthesia, prophylactic antibiotics, computed tomography (CT) scanning, and fluoroscopy have allowed surgeons improve outcomes when operating on fractures, and these techniques have been applied to calcaneal fractures as well. Overall, the operative treatment of acute fractures has become the standard of care with many surgeons who have critically evaluated their results and concluded that good outcomes are possible.
The objective of the present study was to evaluate if operative management of intra-articular calcaneum fracture has a better outcome in comparison to conservative management.
The objectives were determined by the following parameters:
- Functional scoring system which includes
- Pain on activity
- Pain on rest
- Range of inversion/eversion
- Return to work
- Change in shoe size
- Activity level.
- Radiographic assessment in the form of X-rays and CT scan.
| Materials and Methods|| |
This is a retrospective cum prospective (from April 2016 to March 2019) study of 25 intra-articular fractures in 24 patients. It includes the patients who had already undergone treatment for this fracture and also the patients who were newly diagnosed with intra-articular calcaneum fracture. Follow-up period ranged from 6 months to 3 years with an average follow-up period of 2 years.
When the patients were seen for the first time after injury, a thorough history and clinical evaluation were performed.
Routine investigations were done as necessary. The diagnosis was confirmed using routine radiograph and CT scan. Bohler's angle was measured. Open fractures were classified according to the Gustilo Anderson classification.
Majority of the cases were treated as inpatients and a few as outpatients. The form of treatment, conservative or operative was decided depending on the type of fracture, patients' age, condition of soft tissues, associated injuries, comorbidities, patients' occupation, affordability as well as surgeon's decision. Of 25 fractures, 13 were managed conservatively and 12 were surgically managed.
Conservative management was in a form of below-knee plaster cast initially if there was no gross swelling. If there was a swelling present, first it was reduced by limb elevation, local ice packs, and anti-inflammatory drugs and once the swelling reduced then cast was put. All the patients were advised nonweight walking. Cast was removed after 8 weeks of application. Patients were assessed for fracture union radiologically. Once the fracture has united, partial weight-bearing was advised which was gradually increased to full weight-bearing.
The main indication for operative management was displaced intra-articular fractures with incongruous subtalar joint and reduced Bohler's angle. Closed reduction with or without fixation was done within 24–48 h of injury, and open reduction and fixation were done once the skin condition was good but within 3 weeks of injury. The basic idea was to achieve near anatomical reduction and a congruous subtalar joint.
Essex-Lopresti reduction was done in two cases. With patients in prone position under c arm guidance a Steinmann pin was inserted through the posterior end of calcaneus into the tongue fragment. This fragment was levered into reduced position using a pin. Then, pin was driven into anterior process. A below-knee cast was applied following this.
Closed reduction and k wire fixation were done for three patients. In this, after achieving the reduction and maintaining the Bohler's angle, the reduction was secured with k wires. B/K cast was put following this.
In both the above methods, at the end of 8 weeks cast and pins were removed, and check X-rays were taken to assess fracture union.
Open reduction and internal fixation (ORIF) was used in three patients. It was done as an elective procedure. Before patients were taken up for surgery, they were put on foot elevation, local ice packs, glycerine magsulf dressing, and anti-inflammatory drugs for a few days to reduce foot swelling. For all three cases, Seligson's lateral approach was used. The fracture was reduced and temporarily fixed with K wires, if needed. The definitive fixation was done with the help of calcaneum plate in 2 cases and reconstruction plate in 1 case. Postoperatively, limbs were immobilized in plaster cast, patients were put on antibiotics and analgesics and limbs were elevated. Wounds were inspected on the third postoperative day by creating a window over the wound in the cast, and sutures were removed on average on 25th day. Once the wound were healed well, window was closed and cast reinforced. Patients were advised strict nonweight with axillary crutches and then discharged. Cast was removed at 8 weeks and fracture was assessed radiologically for union. Physiotherapy exercises for of ankle and subtalar movements were started on the removal of cast. Once the fracture united radiologically, patients were started on partial weight-bearing walking which was gradually increased to full weight-bearing.
There were 7 open calcaneum fractures, 3 of which were managed conservatively as the fracture fragments were undisplaced (Sander's type I fracture). For one patient with open IIIA injury with ankle subluxation after wound debridement, fracture and ankle was stabilized using A-O external fixator and wound was covered with split skin graft (SSG). For another patient with open IIIA injury with medial malleolus fracture, Joshi's external stabilisation system (JESS) was applied and wound covered with SSG. There were two open type I injuries of which closed reduction internal fixation with K wires was done and for another ORIF with reconstruction plate was done. For 5 out of seven patients, primary closure was done and for another 2 patients with open IIIA injury, SSG was applied as a second sitting procedure after 48 h.
For patients newly diagnosed with having calcaneum fracture, follow-up was done every 2 weeks and then at 6 months since the time of treatment for clinical and radiological evaluation.
For all patients (newly diagnosed and earlier treated), follow-up period ranged from 6 months to 3 years with an average follow-up of 2 years.
Assessment of results
Criegton Nebrasaka (C-N score) health foundation scoring system was used to evaluate the patients. Follow-up X-rays were taken to assess fracture union, the condition of the implant (in operated cases), to look for subtalar arthritis and any deformities. Pretreatment and follow-up Bohler's angle was also compared using the Student's t-test. Finally, correlation between C-N score and mean Bohler's angle was evaluated.
Method of statistical analysis
Excel and SPSS (SPSS Inc., Chicago, USA) software packages were used for data entry and analysis. The results were averaged (mean + standard deviation) for each parameter for continuous data in Table. Proportions were compared using the Chi-square test of significance. The Student's t-test was used to determine whether there was a statistical difference between Group 1 and Group 2 in the parameters measured. P < 0.05 was accepted as indicating statistical significance.
| Results|| |
A total of 25 cases were enrolled in the study. Of which 13 cases of intra-articular fractures managed conservatively and 12 cases managed operatively. Majority of the patients were in the age group of 30–50 years. The mean age in both the groups was similar.
Of all the patients in the study, most of the patients were males (88.0%).
Of all the fractures, 56% were present on the left side and 44% on the right side.
Most of the patients had fall from height, i.e., in 72% of all the fractures, whereas 28% of all the fractures had a history of road traffic accident (RTA).
Most of the patients in either of the groups had closed fracture (72%), 12% had type 1 open fracture, whereas type II and type III were 8% each of all the fractures [Table 1].
There was a statistically significant difference in pre and posttreatment of Bohler's angle in the operative group. [Table 2] shows there is a significant increase in the Bohler's angle from a mean value of 10.25° preoperatively to mean value of 24.08° postoperatively which is within the normal limits of Bohler's angle, i.e., between 20° and 40°.
|Table 2: Comparison of pre- and post-treatment (at follow-up) of Bohler's angle|
Click here to view
[Table 3] shows statistical significance difference in mean Bohler's angle of the operative and conservative group. It shows operative management is better than conservative management for restoration of Bohler's angle.
All type I, i.e., undisplaced fractures were treated conservatively. Type II was treated equally while the majority of Type III and Type IV were treated surgically.
According to [Table 4], while comparing the mean Bohler's angle both in type II and type III fractures, operative management is better than conservative management, but it is not statistically significant. In type IV fractures, comparing the mean Bohler's angle operative management is better than conservative management and is statistically significant.
Comparison of the mean C-N score of the two groups revealed a higher mean score in the operative group, but it was not statistically significant (P = 0.339).
[Table 5] shows that in type II and type III fractures comparing the mean C-N score operative management is better than conservative management, but it is not statistically significant. In type IV fractures, operative management is better than conservative management which is statistically significant.
In our series, with conservative management most of the patients had good outcome with type I fractures, fair outcome with type II fractures, and poor outcome with type III and type IV fractures.
In the operative group, among the patients with type II fractures, one patient had a good result and other had excellent result. With type III fracture, most of them had fair result and with type IV fracture, most of them had good results which were statistically significant [Table 5].
[Table 6] shows a good correlation between posttreatment Bohler's angle and C-N score for conservative group and a fair correlation in the operative group. Overall also there is a good correlation between posttreatment Bohler's angle and C-N score which is statistically significant.
|Table 6: Post treatment Bohler's angle versus Creighton-Nebraska score correlation|
Click here to view
| Discussion|| |
The treatment of calcaneal fractures remains controversial. In this study, the outcomes of operatively managed and conservatively managed calcaneal fractures was compared in order to find the better method for a different type of fracture. Two different parameters were used to compare the outcome, and finally, correlation between the two parameters was evaluated. The results of the present study are compared with those of previous similar studies.
Majority patients were male in their active age. [Table 7] shows a comparison between the present study and previous ones. Comparing to other similar series the results of conservative management in the present study are bad. This may be due to early weight-bearing, lack of immobilization for the required time due to noncompliance of patients or due to improper selection of patients for conservative management.
The outcome of surgically managed cases is comparable to the results in other studies such as Sanders et al. and Zwipp et al. However, the size of the present study group is too small to make a conclusion.
[Table 8] shows comparison between conservative and operative methods. It is seen from the table that the results of operatively managed calcaneal fractures are slightly better than those of the conservative group when comparison is done irrespective of the fracture type. However, this does not have any statistical significance, as proved by Chi-square test.
On comparing C-N score according to fracture type as per [Table 5]. With conservative management, most of the patients had good outcome with type I fractures, fair outcome with type II fractures, and poor outcome with type III and type IV fractures.
With operative management in patients with type II fractures, one patient had a good result and other had excellent result. With type III fracture, most of them had fair result and with type IV fracture, most of them had good results, which were statistically significant (P = 0.03).
There are proponents for conservative and operative treatment of calcaneal fractures. Pozo et al. were proponents of conservative management of calcaneal fractures. Out of the 21 patients managed by conservative methods in their series, 76% of patients got good results with only minor symptoms, which did not interfere with their occupation or daily activities.
Among the proponents of operative treatment were Letournel, Sanders et al., and Zwipp et al. Their results are given in [Table 9].
There were studies which compared the outcomes of operative and nonoperative modes of treatment such as Buckley et al., Järvholm et al., Parmar et al., and Thermann et al. However, none could conclusively prove that one method is better than the other. Thermann et al. analyzed six studies done previously in which results of conservative and operative management of calcaneal fractures were compared. He concluded that it is different to interpret these comparisons due to the lack of consensus among different series.
In our study, the results of type I fractures managed conservatively had a better outcome than those of displaced fractures, and the difference was statistically significant.
Furthermore, type II and type III fractures had a better outcome with operative management, but the difference was not statistically significant. However, in type IV fractures operative management was significantly better than conservative management.
Randle et al. performed a meta-analysis of articles between 1980 and 1996 dealing with calcaneal fractures. Of the 1845 articles, 6 compared operative versus nonoperative treatment for displaced calcaneal fractures. Statistical analysis of the 6 articles concluded that surgically treated patients were more likely to return to the same type of work as compared with nonoperatively treated individuals.
Comparison between pre- and post-treatment Bohler's angle [Table 2] showed that there was a more statistically significant difference in pre- and post-treatment Bohler's angle in operative group in comparison to conservative group. Our study showed that Bohler's angle can be restored with operative management.
Makki et al. in 2010 carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by ORIF in 45 patients by a single surgeon. They concluded that restoration of Bohler's angle was associated with a better outcome and that prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum to restore the shape of the hindfoot and Bohler's angle.
There was a good correlation of posttreatment Bohler's angle with functional outcome [Table 6] for conservative group and a fair correlation in operative group. Overall also there is a good correlation between posttreatment Bohler's angle and C-N score which is statistically significant.
This indicated that with the restoration of Bohler's angle, the functional outcome is much better and if post treatment Bohler's angle is not restored then the outcome will be poor.
Similar study was done by Paul et al. in 2004. They assessed the long-term results after operative and nonoperative treatment of undisplaced and displaced calcaneal fractures. They reviewed 70 patients at an average period of 6.5 years and concluded that patients with undisplaced calcaneal fractures had a good outcome. Among the surgically managed displaced fractures who presented at follow-up with a Bohler's angle >10° had a satisfactory functional outcome as compared to those with displaced fractures who had nonoperative treatment. Patients who were managed operatively without restoration of Bohler's angle had poor outcome. They also concluded that Bohler's angle has prognostic importance.
In another study done by Makki et al. in 2010, a retrospective review of 47 intra-articular fractures of the calcaneum treated by ORIF in 45 patients by a single surgeon was carried out. They concluded that restoration of Bohler's angle was associated with a better outcome.
| Conclusions|| |
- In our conservative group, results and functional outcome of undisplaced fractures are better than displaced fractures
- Displaced and comminuted fractures managed surgically have a relatively better functional outcome as compared to conservative managed provided Bohler's angle is restored
- The outcome of surgically managed cases is comparable to the results in other studies. However, the size of the present study group is too small to make a conclusion
- In the case of displaced and comminuted calcaneal fractures, the aim of the treatment should be anatomical reduction and restoration of Bohler's angle. Surgery perhaps is the solution to achieve that goal
- Posttreatment Bohler's angle has prognostic importance on functional outcome
- In our study, the average period of follow-up is 2 years, and long-term problems of early degenerative arthritis are not taken into consideration.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]