Review
Operative Versus Nonoperative Treatment for Displaced Intra-Articular Calcaneal Fractures: A Meta-Analysis of Randomized Controlled Trials

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Abstract

The purpose of the present study was to perform an updated meta-analysis of the operative versus nonoperative treatment of displaced intra-articular calcaneal fractures in adults. We searched the Cochrane Library, MEDLINE, EMBASE, and Google Scholar for eligible studies. All published randomized controlled trials comparing operative with nonoperative treatment for displaced intra-articular calcaneal fractures were eligible. The meta-analysis was performed using RevMan, version 5.0, software. Seven studies assessing 824 patients were eligible for the meta-analysis. The pooled results indicated no significant differences between the 2 groups with regard to the functional results. The incidence of complications was 25.0% (80 of 319) in the operative group and 16.6% (55 of 330) in the nonoperative group (relative risk 1.53, 95% confidence interval 1.13 to 2.08; p = .006) with a significant difference. The rate of subtalar arthrodesis was significantly lower in the operative group than in the nonoperative group. The current evidence is still insufficient to ascertain whether operative treatment is superior to nonoperative treatment for displaced intra-articular calcaneal fractures. Operative treatment can reduce the risk of late subtalar arthrodesis but is associated with a greater risk of complications. The small sample size and the great heterogeneity of the included studies made it difficult to draw conclusions regarding some of the combined results. Furthermore, more high-quality, randomized controlled trials with long-term follow-up data on this issue are required to provide evidence for surgeons to make an informed decision.

Section snippets

Criteria for Considering Studies for Our Meta-Analysis

All RCTs comparing operative and nonoperative treatment for DIACF were eligible. The participants were limited to adult patients with fresh, closed displaced intra-articular calcaneal fractures. Patients undergoing open reduction with any type of internal fixation method were considered for the present study. To avoid repeated calculations, multiple reports of the same patient population were pooled as 1 study.

Search Methods for Identification of Studies

Two reviewers (She. H., Q.L.) independently searched the Cochrane Central Register of

Description of Studies

The process of study selection is displayed in the flowchart (Fig. 1). A total of 7 studies (8 reports) were included in the present meta-analysis 17, 18, 19, 20, 21, 22, 23, 24. Parmar et al (18) and Ibrahim et al (17) reported the results of the same patients with different follow-up periods. A total of 824 patients were included in the 7 studies: 404 patients in the operative group and 420 in the nonoperative group. The 7 included studies were published between 1993 and 2014, all in English.

Discussion

The controversy over operative treatment for a DIACF remains a topic in published studies because of the greater incidence of postoperative complications, which was reported to be 16% to 28% 9, 12, 25. From the results of the present meta-analysis, we have found that no significant differences exist in the functional results between operative and nonoperative treatment for DIACF. Although operative treatment might reduce the risk of late subtalar arthrodesis, it is associated with a greater

References (35)

  • G. Melcher et al.

    Results of operative treatment for intra-articular fractures of the calcaneus

    J Trauma

    (1991)
  • P. Zeman et al.

    Long-term results of calcaneal fracture treatment by open reduction and internal fixation using a calcaneal locking compression plate from an extended lateral approach

    Acta Chir Orthop Traumatol Cech

    (2008)
  • N. Gougoulias et al.

    Management of calcaneal fractures: systematic review of randomized trials

    Br Med Bull

    (2009)
  • J. Bruce et al.

    Surgical versus conservative interventions for displaced intra-articular calcaneal fractures

    Cochrane Database Syst Rev

    (2013)
  • J.A. Randle et al.

    Should calcaneal fractures be treated surgically? A meta-analysis

    Clin Orthop Relat Res

    (2000)
  • N. Jiang et al.

    Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

    Int Orthop

    (2012)
  • Higgins JPT, Green S (eds). Cochrane Handbook for Systematic Reviews for Intervention, Version 5.0.0 [updated March...
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    Conflict of Interest: None reported.

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