- Email: [email protected]
Calcaneal Fractures: Looking Beyond the Meta-Analyses
Perspectives on Anatomy, Medicine and Surgery
Calcaneal Fractures: Looking Beyond the Meta-Analyses In this issue of The Journal of Foot & Ankle SurgeryÒ, Luo et al present the results of an updated meta-analysis on displaced intra-articular calcaneal fractures (1). They conclude, “The small sample size and the great heterogeneity of included studies make it difficult to draw conclusions in some combined results.” Over the years, more meta-analyses have been published than randomized trials (Table). And most have concluded that there is still insufficient evidence to promote one therapy over another. There is substantial variation in included studies. Some metaanalyses include non- or quasi-randomized trials, whereas others include multiple studies on the same patients (subgroup analysis on the 2002 Buckley study [13,18,21]), or same patients longer follow-up (12,22). One might question if the final answer will ever emerge, considering the best treatment of displaced intra-articular calcaneal fractures, as the number of randomized trials appears sufficient. Upon closer look however, almost all randomized trials have flaws to some extent. Flaws included, for example, inclusion of patients with less severe fractures (14,15) or with fewer than 2 surgically treated patients per year per surgeon (14,15). In these studies, the postoperative step-off was more than 2 mm in 22% to 40% of cases (14,15), which is a predictor of poorer outcome (13) and might underline the need for centralization in this complex injury (34–36). One thing all randomized trials included in this meta-analysis have in common is that they compare the so-called gold standard extended lateral approach (ELA) with a nonoperative regimen. The largest drawback of the ELA is the number of wound complications. In the 3 largest studies, the percentage of wound complications was 19% to 23% (13–15). In a recent retrospective series, it was shown that wound complications had a (clinically) significant negative effect on outcome, even after a median follow-up of almost 6 years (37). In addition to these randomized trials and frequently updated meta-analyses there have been several recent non-randomized comparative trials, often showing more favorable outcome with surgery (20,23,25,38–40). Of course, these studies have methodologic drawbacks, including selection bias. Recently, several studies comparing the extended lateral approach with a less invasive technique have been published (41–45). A large difference in postoperative wound infections is
seen, without compromising reduction, and some showed a significant difference in functional outcome favoring the less invasive procedure. Besides less invasive procedures, a technique re-emerging from the past is the primary arthrodesis. Following anatomic restoration of the calcaneus the subtalar joint is debrided and an arthrodesis is performed. One randomized trial compared ELA to the primary fusion in Sanders type 4 calcaneal fractures (46). Even though patients showed no difference in outcome, patients with a primary arthrodesis tend to heal more quickly than those with a joint reconstruction, and there was less need for secondary procedures (e.g., subtalar arthrodesis), which might be as high as 47% to 72% in Sanders type 3 and 4 fractures (35,47). One of the conclusions of the currently published meta-analysis is the significant lower subtalar fusion rate in the operatively treated patient. The outcome of these patients is frequently not reported, and it is not included in the final analysis on outcome (13). Radnay et al showed an improved outcome if the secondary arthrodesis was performed following initial operative management, compared with nonoperatively treated patients (48). In addition, a secondary in situ fusion in a previously anatomically restored calcaneus is a far less complicated procedure than a bone block distraction arthrodesis, which is often performed with the use of a tricortical bone-block from the iliac crest (49). Albeit circumstantial evidence, a less complicated salvage procedure in case of persistent complaints, with a possibly favorable outcome following initial operative treatment, might be a reason to opt for primary operative management. With so-called new techniques dethroning the current standard of ELA, one can argue that we are still in need of yet another meta-analysis comparing ELA with nonoperative treatment. With the use of a sinus tarsi approach, the rate of wound complications is about 5%, with most complications being superficial (50,51). In addition, a lower complication rate is found with experience (34,36). And the experience with less invasive procedures is increasing rapidly. By restoring the anatomy of the calcaneus, at a far lower complication risk as before, one can prevent a more complex reconstruction if needed in the future. When more studies comparing the ELA and the less invasive procedures (i.e., the sinus tarsi approach) show favorable results considering wound complications, adequate reduction and
Table Overview of existing meta-analysis on displaced intra-articular calcaneal fractures Meta-Analysis
Included Studies
Total No. of Patients
Main Conclusion
Luo, 2016 (1)
12–17,22
824
Liu, 2015 (2) Zhang, 2016 (3)
13–15,18 13–17,19,20
966 908
Dhillon, 2014 (4) Bruce, 2013 (5) Jiang, 2012 (6) Gougoulias, 2009 (7) Bondi, 2007 (8)
12,13,15–18,21–23 12,13,17,24 12,13,16,17,22,23,25–28 12,13,17,22,23,29,30 12,13,17,18,23,29,31,32
703 602 891 611 557
Bajammal, 2005 (9) Randle, 2000 (10)
12,13,17,23 12,17,23,26,27,33
534 242
Bridgman, 2000 (11)
12,17,23,29
134
Less subtalar fusions after ORIF More complications after ORIF Insufficient evidence Surgery offers protection against early subtalar arthrodesis in displaced intraarticular calcaneal fractures When the surgery is performed correctly, better shoe wear and improved gait patterns can be expected. This appears to be based on surgical experience, in order to obtain an acceptable reduction Insufficient evidence There is insufficient high quality evidence Surgery is probably the optimal choice in DIACF treatment Still a need for a carefully designed large-scale study comparing ORIF and nonoperative management It is not possible at the moment to provide a definitive conclusion regarding the better results of operative management There is insufficient evidence to determine with certainty whether operative treatment is superior Trend for return to same work in ORIF Nonoperative trend to more pain Some evidence of benefit of operative treatment. Unclear whether advantages outweigh the risks
DIACF, displaced intra-articular calcaneal fracture; ORIF, open reduction internal fixation. 1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.05.009
898
T. Schepers / The Journal of Foot & Ankle Surgery 55 (2016) 897–898
outcome, we might have to declare a new gold standard in the treatment of displaced intra-articular calcaneal fractures, which will most likely be the conclusion of the next meta-analysis on displaced intra-articular calcaneal fractures. Tim Schepers, MD, PhD Trauma Unit, Department of Surgery Academic Medical Center Amsterdam, The Netherlands E-mail address: [email protected] References 1. Luo X, Li Q, He S, He S. Operative versus nonoperative treatment for displaced intra-articular calcaneal fractures: a meta-analysis of randomized controlled trials. J Foot Ankle Surg 55:816–823, 2016. 2. Liu Y, Li Z, Li H, Zhang Y, Wang P. Protective effect of surgery against early subtalar arthrodesis in displaced intra-articular calcaneal fractures: a meta-analysis. Medicine (Baltimore) 94(45):e1984–0, 2015. 3. Zhang W, Lin F, Chen E, Xue D, Pan Z. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a meta-analysis of randomized controlled trials. J Orthop Trauma 30(3):e75–81, 2016. 4. Dhillon MS, Gahlot N. Are results of surgical treatment for calcaneal fractures better than non-operative treatment? Journal of Foot and Ankle Surgery (AsiaPacific) 1(1):17–23, 2014. 5. Bruce J, Sutherland A. Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database Syst Rev 1:CD008628, 2013. 6. Jiang N, Lin QR, Diao XC, Wu L, Yu B. Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. Int Orthop 36:1615–1622, 2012. 7. Gougoulias N, Khanna A, McBride DJ, Maffulli N. Management of calcaneal fractures: systematic review of randomized trials. Br Med Bull 92:153–167, 2009. 8. Bondì R, Padua R, Bondì L, Battaglia A, Romanini E, Campi A. Treatment of calcaneal fractures: the available evidence. Journal of Orthopaedics and Traumatology 8(1):36–41, 2007. 9. Bajammal S, Tornetta P 3rd, Sanders D, Bhandari M. Displaced intra-articular calcaneal fractures. J Orthop Trauma 19:360–364, 2005. 10. Randle JA, Kreder HJ, Stephen D, Williams J, Jaglal S, Hu R. Should calcaneal fractures be treated surgically? A meta-analysis. Clin Orthop Relat Res (377):217–227, 2000. 11. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. Interventions for treating calcaneal fractures. Cochrane Database Syst Rev (2):CD001161, 2000. 12. Parmar HV, Triffitt PD, Gregg PJ. Intra-articular fractures of the calcaneum treated operatively or conservatively. A prospective study. J Bone Joint Surg Br 75:932– 937, 1993. 13. 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 trial. J Bone Joint Surg Am 84-A:1733–1744, 2002. 14. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, Lamb SE, UK Heel Fracture Trial Investigators. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ 349:g4483, 2014. 15. Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 95:1351–1357, 2013. 16. Nouraei MH, Moosa FM. Operative compared to non-operative treatment of displaced intra-articular calcaneal fractures. J Res Med Sci 16:1014–1019, 2011. 17. Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int 17:2–9, 1996. 18. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 17:241–249, 2003. 19. Sharma V, Dogra A. Sanders type II calcaneum fracturesdsurgical or conservative treatment? A prospective randomized trial. J Clin Orthop Trauma 2:35–38, 2011. 20. Bahari Kashani M, Kachooei AR, Ebrahimi H, Peivandi MT, Amelfarzad S, Bekhradianpoor N, et al. Comparative study of peroneal tenosynovitis as the complication of intraarticular calcaneal fracture in surgically and non-surgically treated patients. Iran Red Crescent Med J 15(10):e11378, 2013. 21. Dooley P, Buckley R, Tough S, McCormack B, Pate G, Leighton R, Petrie D, Galpin B. Bilateral calcaneal fractures: operative versus nonoperative treatment. Foot Ankle Int 25:47–52, 2004. 22. Ibrahim T, Rowsell M, Rennie W, Brown AR, Taylor GJ, Gregg PJ. Displaced intraarticular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury 38:848–855, 2007. 23. O’Farrell DA, O’Byrne JM, McCabe JP, Stephens MM. Fractures of the os calcis: improved results with internal fixation. Injury 24:263–265, 1993.
24. Chrintz H, Sonne-Holm S. Clinical results after conservative versus operative treatment of dislocated intraarticular fractures of calcaneus [abstract]. Acta Orthop Scand 64(Suppl 251):63–64, 1993. 25. Rodriguez-Merchan EC, Galindo E. Intra-articular displaced fractures of the calcaneus. Operative vs non-operative treatment. Int Orthop 23:63–65, 1999. 26. Jarvholm U, Korner L, Thoren O, Wiklund LM. Fractures of the calcaneus. A comparison of open and closed treatment. Acta Orthop Scand 55:652–656, 1984. 27. Leung KS, Yuen KM, Chan WS. Operative treatment of displaced intra-articular fractures of the calcaneum. Medium-term results. J Bone Joint Surg Br 75:196–201, 1993. 28. Xia S, Shi D, Wang Z, Wang X, Lu Y, Wang H, et al. Operative versus nonoperative managements for displaced intraarticular fractures of calcaneus. Chin J Orthop Trauma 12:1089–1091, 2010. 29. Erdmann MW, Richardson J, Templeton J. Os calcis fractures: a randomized trial comparing conservative treatment with impulse compression of the foot. Injury 23:305–307, 1992. 30. Thordarson DB, Greene N, Shepherd L, Perlman M. Facilitating edema resolution with a foot pump after calcaneus fracture. J Orthop Trauma 13:43–46, 1999. 31. Barla J, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R, Canadian Orthopaedic Trauma Society. Displaced intraarticular calcaneal fractures: longterm outcome in women. Foot Ankle Int 25:853–856, 2004. 32. O’Brien J, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Personal gait satisfaction after displaced intraarticular calcaneal fractures: a 2–8 year followup. Foot Ankle Int 25:657–665, 2004. 33. Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma 6:216–222, 1992. 34. Poeze M, Verbruggen JP, Brink PR. The relationship between the outcome of operatively treated calcaneal fractures and institutional fracture load. A systematic review of the literature. J Bone Joint Surg Am 90:1013–1021, 2008. 35. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res (290):87–95, 1993. 36. Schepers T, Den Hartog D, Vogels LM, Van Lieshout EM. Extended lateral approach for intra-articular calcaneal fractures: an inverse relationship between surgeon experience and wound complications. J Foot Ankle Surg 52:167–171, 2013. 37. Backes M, Schep NW, Luitse JS, Goslings JC, Schepers T. The effect of postoperative wound infections on functional outcome following intra-articular calcaneal fractures. Arch Orthop Trauma Surg 135:1045–1052, 2015. 38. De Boer AS, Van Lieshout EM, Den Hartog D, Weerts B, Verhofstad MH, Schepers T. Functional outcome and patient satisfaction after displaced intra-articular calcaneal fractures: a comparison among open, percutaneous, and nonoperative treatment. J Foot Ankle Surg 54:298–305, 2015. 39. Basile A. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures in elderly patients. J Foot Ankle Surg 49:25–32, 2010. 40. Gilani SF, Amin MS. Operative treatment of displaced intra-articular fractures of Calcaneum: Is it worthwhile? J Pak Med Assoc 64(12 Suppl 2):S161–S166, 2014. 41. Chen L, Zhang G, Hong J, Lu X, Yuan W. Comparison of percutaneous screw fixation and calcium sulfate cement grafting versus open treatment of displaced intraarticular calcaneal fractures. Foot Ankle Int 32:979–985, 2011. 42. 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 34:773–780, 2013. 43. Sampath Kumar V, Marimuthu K, Subramani S, Sharma V, Bera J, Kotwal P. Prospective randomized trial comparing open reduction and internal fixation with minimally invasive reduction and percutaneous fixation in managing displaced intra-articular calcaneal fractures. Int Orthop 38:2505–2512, 2014. 44. Xia S, Lu Y, Wang H, Wu Z, Wang Z. Open reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fracturesda randomized controlled trial. Int J Surg 12:475–480, 2014. 45. Yeo JH, Cho HJ, Lee KB. Comparison of two surgical approaches for displaced intraarticular calcaneal fractures: sinus tarsi versus extensile lateral approach. BMC Musculoskelet Disord 16:63, 2015. 46. Buckley R, Leighton R, Sanders D, Poon J, Coles CP, Stephen D, Paolucci EO. Open reduction and internal fixation compared with ORIF and primary subtalar arthrodesis for treatment of Sanders type IV calcaneal fractures: a randomized multicenter trial. J Orthop Trauma 28:577–583, 2014. 47. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal fractures: long-term (10–20 years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma 28:551–563, 2014. 48. Radnay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? J Bone Joint Surg Am 91:541–546, 2009. 49. Schepers T. The subtalar distraction bone block arthrodesis following the late complications of calcaneal fractures: a systematic review. Foot (Edinb) 23:39–44, 2013. 50. Schepers T. The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop 35:697–703, 2011. 51. Schepers T. Towards uniformity in communication and a tailor-made treatment for displaced intra-articular calcaneal fractures. Int Orthop 38:663–665, 2014.
Calcaneal Fractures: Looking Beyond the Meta-Analyses In this issue of The Journal of Foot & Ankle SurgeryÒ, Luo et al present the results of an updated meta-analysis on displaced intra-articular calcaneal fractures (1). They conclude, “The small sample size and the great heterogeneity of included studies make it difficult to draw conclusions in some combined results.” Over the years, more meta-analyses have been published than randomized trials (Table). And most have concluded that there is still insufficient evidence to promote one therapy over another. There is substantial variation in included studies. Some metaanalyses include non- or quasi-randomized trials, whereas others include multiple studies on the same patients (subgroup analysis on the 2002 Buckley study [13,18,21]), or same patients longer follow-up (12,22). One might question if the final answer will ever emerge, considering the best treatment of displaced intra-articular calcaneal fractures, as the number of randomized trials appears sufficient. Upon closer look however, almost all randomized trials have flaws to some extent. Flaws included, for example, inclusion of patients with less severe fractures (14,15) or with fewer than 2 surgically treated patients per year per surgeon (14,15). In these studies, the postoperative step-off was more than 2 mm in 22% to 40% of cases (14,15), which is a predictor of poorer outcome (13) and might underline the need for centralization in this complex injury (34–36). One thing all randomized trials included in this meta-analysis have in common is that they compare the so-called gold standard extended lateral approach (ELA) with a nonoperative regimen. The largest drawback of the ELA is the number of wound complications. In the 3 largest studies, the percentage of wound complications was 19% to 23% (13–15). In a recent retrospective series, it was shown that wound complications had a (clinically) significant negative effect on outcome, even after a median follow-up of almost 6 years (37). In addition to these randomized trials and frequently updated meta-analyses there have been several recent non-randomized comparative trials, often showing more favorable outcome with surgery (20,23,25,38–40). Of course, these studies have methodologic drawbacks, including selection bias. Recently, several studies comparing the extended lateral approach with a less invasive technique have been published (41–45). A large difference in postoperative wound infections is
seen, without compromising reduction, and some showed a significant difference in functional outcome favoring the less invasive procedure. Besides less invasive procedures, a technique re-emerging from the past is the primary arthrodesis. Following anatomic restoration of the calcaneus the subtalar joint is debrided and an arthrodesis is performed. One randomized trial compared ELA to the primary fusion in Sanders type 4 calcaneal fractures (46). Even though patients showed no difference in outcome, patients with a primary arthrodesis tend to heal more quickly than those with a joint reconstruction, and there was less need for secondary procedures (e.g., subtalar arthrodesis), which might be as high as 47% to 72% in Sanders type 3 and 4 fractures (35,47). One of the conclusions of the currently published meta-analysis is the significant lower subtalar fusion rate in the operatively treated patient. The outcome of these patients is frequently not reported, and it is not included in the final analysis on outcome (13). Radnay et al showed an improved outcome if the secondary arthrodesis was performed following initial operative management, compared with nonoperatively treated patients (48). In addition, a secondary in situ fusion in a previously anatomically restored calcaneus is a far less complicated procedure than a bone block distraction arthrodesis, which is often performed with the use of a tricortical bone-block from the iliac crest (49). Albeit circumstantial evidence, a less complicated salvage procedure in case of persistent complaints, with a possibly favorable outcome following initial operative treatment, might be a reason to opt for primary operative management. With so-called new techniques dethroning the current standard of ELA, one can argue that we are still in need of yet another meta-analysis comparing ELA with nonoperative treatment. With the use of a sinus tarsi approach, the rate of wound complications is about 5%, with most complications being superficial (50,51). In addition, a lower complication rate is found with experience (34,36). And the experience with less invasive procedures is increasing rapidly. By restoring the anatomy of the calcaneus, at a far lower complication risk as before, one can prevent a more complex reconstruction if needed in the future. When more studies comparing the ELA and the less invasive procedures (i.e., the sinus tarsi approach) show favorable results considering wound complications, adequate reduction and
Table Overview of existing meta-analysis on displaced intra-articular calcaneal fractures Meta-Analysis
Included Studies
Total No. of Patients
Main Conclusion
Luo, 2016 (1)
12–17,22
824
Liu, 2015 (2) Zhang, 2016 (3)
13–15,18 13–17,19,20
966 908
Dhillon, 2014 (4) Bruce, 2013 (5) Jiang, 2012 (6) Gougoulias, 2009 (7) Bondi, 2007 (8)
12,13,15–18,21–23 12,13,17,24 12,13,16,17,22,23,25–28 12,13,17,22,23,29,30 12,13,17,18,23,29,31,32
703 602 891 611 557
Bajammal, 2005 (9) Randle, 2000 (10)
12,13,17,23 12,17,23,26,27,33
534 242
Bridgman, 2000 (11)
12,17,23,29
134
Less subtalar fusions after ORIF More complications after ORIF Insufficient evidence Surgery offers protection against early subtalar arthrodesis in displaced intraarticular calcaneal fractures When the surgery is performed correctly, better shoe wear and improved gait patterns can be expected. This appears to be based on surgical experience, in order to obtain an acceptable reduction Insufficient evidence There is insufficient high quality evidence Surgery is probably the optimal choice in DIACF treatment Still a need for a carefully designed large-scale study comparing ORIF and nonoperative management It is not possible at the moment to provide a definitive conclusion regarding the better results of operative management There is insufficient evidence to determine with certainty whether operative treatment is superior Trend for return to same work in ORIF Nonoperative trend to more pain Some evidence of benefit of operative treatment. Unclear whether advantages outweigh the risks
DIACF, displaced intra-articular calcaneal fracture; ORIF, open reduction internal fixation. 1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.05.009
898
T. Schepers / The Journal of Foot & Ankle Surgery 55 (2016) 897–898
outcome, we might have to declare a new gold standard in the treatment of displaced intra-articular calcaneal fractures, which will most likely be the conclusion of the next meta-analysis on displaced intra-articular calcaneal fractures. Tim Schepers, MD, PhD Trauma Unit, Department of Surgery Academic Medical Center Amsterdam, The Netherlands E-mail address: [email protected] References 1. Luo X, Li Q, He S, He S. Operative versus nonoperative treatment for displaced intra-articular calcaneal fractures: a meta-analysis of randomized controlled trials. J Foot Ankle Surg 55:816–823, 2016. 2. Liu Y, Li Z, Li H, Zhang Y, Wang P. Protective effect of surgery against early subtalar arthrodesis in displaced intra-articular calcaneal fractures: a meta-analysis. Medicine (Baltimore) 94(45):e1984–0, 2015. 3. Zhang W, Lin F, Chen E, Xue D, Pan Z. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a meta-analysis of randomized controlled trials. J Orthop Trauma 30(3):e75–81, 2016. 4. Dhillon MS, Gahlot N. Are results of surgical treatment for calcaneal fractures better than non-operative treatment? Journal of Foot and Ankle Surgery (AsiaPacific) 1(1):17–23, 2014. 5. Bruce J, Sutherland A. Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database Syst Rev 1:CD008628, 2013. 6. Jiang N, Lin QR, Diao XC, Wu L, Yu B. Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. Int Orthop 36:1615–1622, 2012. 7. Gougoulias N, Khanna A, McBride DJ, Maffulli N. Management of calcaneal fractures: systematic review of randomized trials. Br Med Bull 92:153–167, 2009. 8. Bondì R, Padua R, Bondì L, Battaglia A, Romanini E, Campi A. Treatment of calcaneal fractures: the available evidence. Journal of Orthopaedics and Traumatology 8(1):36–41, 2007. 9. Bajammal S, Tornetta P 3rd, Sanders D, Bhandari M. Displaced intra-articular calcaneal fractures. J Orthop Trauma 19:360–364, 2005. 10. Randle JA, Kreder HJ, Stephen D, Williams J, Jaglal S, Hu R. Should calcaneal fractures be treated surgically? A meta-analysis. Clin Orthop Relat Res (377):217–227, 2000. 11. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. Interventions for treating calcaneal fractures. Cochrane Database Syst Rev (2):CD001161, 2000. 12. Parmar HV, Triffitt PD, Gregg PJ. Intra-articular fractures of the calcaneum treated operatively or conservatively. A prospective study. J Bone Joint Surg Br 75:932– 937, 1993. 13. 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 trial. J Bone Joint Surg Am 84-A:1733–1744, 2002. 14. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, Lamb SE, UK Heel Fracture Trial Investigators. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ 349:g4483, 2014. 15. Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 95:1351–1357, 2013. 16. Nouraei MH, Moosa FM. Operative compared to non-operative treatment of displaced intra-articular calcaneal fractures. J Res Med Sci 16:1014–1019, 2011. 17. Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int 17:2–9, 1996. 18. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 17:241–249, 2003. 19. Sharma V, Dogra A. Sanders type II calcaneum fracturesdsurgical or conservative treatment? A prospective randomized trial. J Clin Orthop Trauma 2:35–38, 2011. 20. Bahari Kashani M, Kachooei AR, Ebrahimi H, Peivandi MT, Amelfarzad S, Bekhradianpoor N, et al. Comparative study of peroneal tenosynovitis as the complication of intraarticular calcaneal fracture in surgically and non-surgically treated patients. Iran Red Crescent Med J 15(10):e11378, 2013. 21. Dooley P, Buckley R, Tough S, McCormack B, Pate G, Leighton R, Petrie D, Galpin B. Bilateral calcaneal fractures: operative versus nonoperative treatment. Foot Ankle Int 25:47–52, 2004. 22. Ibrahim T, Rowsell M, Rennie W, Brown AR, Taylor GJ, Gregg PJ. Displaced intraarticular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury 38:848–855, 2007. 23. O’Farrell DA, O’Byrne JM, McCabe JP, Stephens MM. Fractures of the os calcis: improved results with internal fixation. Injury 24:263–265, 1993.
24. Chrintz H, Sonne-Holm S. Clinical results after conservative versus operative treatment of dislocated intraarticular fractures of calcaneus [abstract]. Acta Orthop Scand 64(Suppl 251):63–64, 1993. 25. Rodriguez-Merchan EC, Galindo E. Intra-articular displaced fractures of the calcaneus. Operative vs non-operative treatment. Int Orthop 23:63–65, 1999. 26. Jarvholm U, Korner L, Thoren O, Wiklund LM. Fractures of the calcaneus. A comparison of open and closed treatment. Acta Orthop Scand 55:652–656, 1984. 27. Leung KS, Yuen KM, Chan WS. Operative treatment of displaced intra-articular fractures of the calcaneum. Medium-term results. J Bone Joint Surg Br 75:196–201, 1993. 28. Xia S, Shi D, Wang Z, Wang X, Lu Y, Wang H, et al. Operative versus nonoperative managements for displaced intraarticular fractures of calcaneus. Chin J Orthop Trauma 12:1089–1091, 2010. 29. Erdmann MW, Richardson J, Templeton J. Os calcis fractures: a randomized trial comparing conservative treatment with impulse compression of the foot. Injury 23:305–307, 1992. 30. Thordarson DB, Greene N, Shepherd L, Perlman M. Facilitating edema resolution with a foot pump after calcaneus fracture. J Orthop Trauma 13:43–46, 1999. 31. Barla J, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R, Canadian Orthopaedic Trauma Society. Displaced intraarticular calcaneal fractures: longterm outcome in women. Foot Ankle Int 25:853–856, 2004. 32. O’Brien J, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Personal gait satisfaction after displaced intraarticular calcaneal fractures: a 2–8 year followup. Foot Ankle Int 25:657–665, 2004. 33. Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma 6:216–222, 1992. 34. Poeze M, Verbruggen JP, Brink PR. 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