Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Marc F. Swiontkowski, MD*,
University of Minnesota, Minneapolis, Minnesota
Posted August 2009
Potter and Nunley have provided the orthopaedic community with reliable long-term outcome data on a large cohort of patients treated operatively for intra-articular calcaneal fractures. The experimental design is retrospective and thus is subject to problems of potential selection bias and detection bias. Of 157 patients treated at Duke University Medical Center between 1989 and 2003, seventy-three patients who were managed operatively (eight bilateral) responded to a questionnaire. The adjusted American Orthopaedic Foot and Ankle Society ankle-hindfoot scale subjective component has been validated. The composite instrument includes clinical outcome measures that can make the composite score more difficult to interpret. The Foot Function Index has been validated in an appropriate manner.
The orthopaedic community remains interested in the management of these complex fractures. Recent studies by Buckley et al.1 have increased our focus. What seems to be well accepted is that the outcome with regard to the ability to wear normal shoes and the outcome regarding cosmesis are superior with operative management. What is subject to debate is the longer-term outcome with regard to pain and function. The data from this patient cohort represent the first quality information we have along these lines.
The results confirm that patients with operatively treated displaced intra-articular calcaneal fractures have substantial functional problems in the long term. The authors separate out the mechanisms of injury involving motor-vehicle accidents and falls as being different from crush injuries. In my opinion, this differentiation is somewhat arbitrary, as precise information regarding the vector and amount of force involved in the injury is unavailable. One thing that is unclear from the paper is whether or not patients with multiple injuries, specifically those with injuries in the ipsilateral limb, were included in the cohort. It is well known that functional outcome is worse in patients who have multiple injuries than in patients who have a single injury, especially when multiple injuries have occurred in a single limb.
This information will be quite useful to clinicians who manage patients with displaced intra-articular calcaneal fractures. We all struggle to inform our patients appropriately about outcome expectations, and these data will be helpful in that regard. The data will also be useful in planning future trials. The foot-and-ankle community may consider using these data to once again plan a multicenter randomized control trial that is modeled after the one by Buckley et al.1, but any new study should include only centers with experienced foot-and-ankle surgeons and skilled clinicians who are experienced in managing these fractures conservatively. The model given to us by the SPORT trial, which followed patients who declined randomization utilizing the same outcome measures and time frames for follow-up, would be appropriate2. An alternative design for the foot-and-ankle community to consider may be a paired cohort study in which patients are matched with injury classification and severity and in which patients are enrolled at centers where experienced foot-and-ankle surgeons perform open reduction and internal fixation frequently. The matched cohort (for injury severity) should originate from centers experienced in the conservative management of these patients, and the follow-up intervals should ideally be one, two, five, and ten years. This would provide comparative clinical information that could be used in the shared decision-making process with patients. The information provided by Potter and Nunley is extremely helpful in considering future endeavors in this regard.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
1. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trail. J Bone Joint Surg Am. 2002;84:1733-44.
2. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H; SPORT Investigators. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358:794-810.
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