Surgery or non-surgical treatment for broken heel bones

Fractures or breaks of the heel bone mostly involve a joint within the heel. These injuries can be difficult to treat and manage. This injury typically occurs in young adults after a fall from a height. Heel fractures are painful and cause significant disability because they prevent weight-bearing for many weeks after injury. These fractures restrict physical activity, delay return to work and usual activities, and can have other consequences, such as being unable to wear the same shoes as before injury.

Treatment of heel fractures can be broadly divided into surgical or non-surgical (conservative) management. Surgery involves a procedure where a plate and screws are inserted into the heel to stabilise the broken bones. This is usually followed by a period of non-weight bearing of six to eight weeks. Non-surgical treatment initially involves leg elevation, ice and plaster cast splints and then gradual introduction of non-weight bearing mobilisation for six to eight weeks. Currently, there is no consensus over which is the best management strategy for patients.

This review included four studies (602 participants) that have looked at the results of surgery compared with non-surgical treatment for people who have had a heel fracture. The strongest evidence comes from one large multi-centre Canadian trial that recruited 424 participants. The remaining studies were small. All four studies had weaknesses in their design, conduct and reporting.

Based mainly on the results from the largest study, the review found no strong evidence of differences between surgical and non-surgical treatment in functional ability, including walking, and quality of life, at three years after treatment. From two small studies, there is some evidence that participants having surgery were more likely to return to work more quickly. However, those having surgery were more likely to have a major complication such as surgical site infection after treatment. Conversely, those having surgery were less likely to have joint fusion surgery because they had developed arthritis later on.

The review concluded that there was currently insufficient evidence to say whether surgical or non-surgical treatment of heel fractures is best. Further good quality research is recommended.

Authors' conclusions: 

The bulk of the evidence in this review derives from one large multi-centre but inadequately reported trial conducted over 15 years ago. This found no significant differences between surgical or conservative treatment in functional ability and health related quality of life at three years after displaced intra-articular calcaneal fracture. Though it reported a greater risk of major complications after surgery, subtalar arthrodeses for the development of subtalar arthritis was significantly greater after conservative treatment.

Overall, there is insufficient high quality evidence relating to current practice to establish whether surgical or conservative treatment is better for adults with displaced intra-articular calcaneal fracture. Evidence from adequately powered randomised, multi-centre controlled trials, assessing patient-centred and clinically relevant outcomes is required. However, it would be prudent to reassess this need after an update of the review that incorporates new evidence from a currently ongoing multi-centre trial.

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Background: 

Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures. These fractures are mostly caused by a fall from a height, and are common in younger adults. Treatment can be surgical or non-surgical; however, there is clinical uncertainty over optimal management.

Objectives: 

To assess the effects of surgical compared with conservative treatment of displaced intra-articular calcaneal fractures in adults.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to July 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 3), MEDLINE (1948 to July 2011), EMBASE (1980 to 2011 Week 27), the WHO International Clinical Trials Registry Platform, Current Controlled Trials, and Orthopaedic Trauma Association annual meeting archives (1996 to 2011). Reference lists of retrieved articles were checked. No language restrictions were applied.

Selection criteria: 

Randomised and quasi-randomised controlled clinical studies comparing surgical versus conservative management for displaced intra-articular calcaneal fractures.

Data collection and analysis: 

Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. Primary outcomes were function (e.g. walking ability) and chronic pain. Risk ratios were calculated for dichotomous outcomes and mean differences for continuous outcomes. Missing standard deviations were calculated from P values.

Main results: 

Four trials were included (602 participants). Three trials were small single-centre trials, and the fourth a large multi-centre trial including 424 participants. All trials had methodological flaws, usually failure to conceal allocation and incomplete follow-up data, which put them at high risk of bias. Follow-up ranged from 1 to 15 years after treatment.

Data for functional outcomes, including walking ability, from three trials could not be pooled. The strongest evidence was from the multi-centre trial. This showed no statistically or clinically significant differences between the surgical and conservatively treated groups at three years follow-up in the ''validated disease-specific" score (0 to 100: perfect result; 424 participants; mean difference (MD) 4.30, 95% confidence interval (CI) -1.11 to 9.71; P = 0.12). There was no significant difference between the two groups in the risk of chronic pain at follow-up (19/40 versus 24/42; risk ratio (RR) 0.79, 95% CI 0.53 to 1.18; 2 trials). The multi-centre trial found no statistically or clinically significant difference between the two groups in health-related quality of life at three years follow-up (SF-36 (0 to 100: best outcome): MD 4.00, 95% CI -1.16 to 9.16; P = 0.13).

Two small trials provided some limited evidence of a tendency for a higher return to previous employment after surgery (27/34 versus 15/27; RR 1.45, 95% CI 0.75 to 2.81; I² = 55%; 2 trials). One small trial found no difference between the two groups in the ability to wear normal shoes, whereas another small trial found that surgery resulted in more people who were able to wear all shoes comfortably. There was a higher rate of major complications, such as surgical site infection, after surgery compared with conservative treatment (57/206 versus 42/218; RR 1.44, 95% CI 1.01 to 2.04; 1 trial). Conversely, significantly fewer surgical participants had subtalar arthrodeses due to the development of subtalar arthritis (7/206 versus 37/218; RR 0.20, 95% CI 0.09 to 0.44; 1 trial). There were no significant differences between the two groups in range of movement outcomes or radiological measurements (e.g. Bohler's angle).

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