Richard Buckley

Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management.

Objective To report on all complications experienced by patients with displaced intra-articular calcaneal fractures (DIACFs) following nonoperative management or open reduction internal fixation (ORIF). Design Prospective, randomized, multicenter study. Setting Four level I trauma centers. Patients The patient population consisted of consecutive patients, age 17 to 65 at the time of injury, presenting to 1 of the centers with DIACFs between April 1991 and December 1998. Interventions Patients were randomized to the nonoperative treatment group or to operative reduction using a lateral approach to the calcaneus. Main Outcome Measurements Follow-up for patients was at 2 weeks, 6 weeks, 3 months, 12 months, 24 months, and once greater than 24 months following injury. At each follow-up interval, patients were assessed for the development of major and minor complications. After a minimum of 2-year follow-up, patients were asked to fill out a validated visual analogue scale questionnaire (VAS) and a general health review (SF-36). Results There were 226 DIACFs (206 patients) in the ORIF group with 57 of 226 (25%) fractures (57 of 206 patients [28%]) having at least 1 major complication. Of 233 fractures (218 patients) nonoperatively managed, 42 (18%) (42 of 218 patients [19%]) developed at least 1 major complication (indirectly resulting in surgery). Conclusion Complications occur regardless of the management strategy chosen for DIACFs and despite management by experienced surgeons. Complications are a cause of significant morbidity for patients. Outcome scores in this study tend to support ORIF for calcaneal fractures. However, ORIF patients are more likely to develop complications. Certain patient populations (WCB and Sanders type IV) developed a high incidence of complications regardless of the management strategy chosen.

Bohler's angle: correlation with outcome in displaced intra-articular calcaneal fractures.

OBJECTIVES Bohlers tuber joint angle is commonly assessed when evaluating calcaneal fractures. A severe heel fracture will result in a significant decrease or loss of this angle. The purpose of this study was to evaluate the correlation between Bohlers angle and functional outcome in displaced intra-articular calcaneal fractures. DESIGN Prospective cohort study. SETTING Level I trauma center. METHODS Ninety-five fractures in eighty-eight patients were analyzed for clinical outcome as measured by previously validated visual analogue scale (VAS) and SF-36 Health Survey scores. Radiographic results were measurements of Bohlers angle on plain x-rays. Angles were measured twice by two observers working independently. RESULTS This prospective randomized cohort study indicates that patients initially presenting with a severely depressed Bohlers angle have a poor two-year outcome regardless of treatment. As well, fractures of lesser initial displacement, as measured by Bohlers angle, had higher functional scores on both VAS and SF-36 scoring scales. CONCLUSION In this study, Bohlers angle had significant prognostic value in terms of predicting morbidity. Fractures with a markedly diminished Bohlers angle demonstrated a much poorer two-year outcome regardless of treatment. It would seem that the initial Bohlers angle was highly prognostic, regardless of treatment modality.

Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion.

Objective The goal of the current study was to analyze the prospective clinical outcome of patients who failed closed or open treatment of a displaced intra-articular calcaneal fracture. This cohort of patients required a secondary subtalar fusion by distraction bone-block arthrodesis. Design Review of prospective, randomized trial database. Setting Four level I trauma centers. Patients Between April 1, 1991 and December 31, 1997, 424 patients with 471 displaced intra-articular calcaneal fractures were involved in a large, multicenter, randomized trial. Forty-four patients who required subtalar fusion following initial treatment of a displaced intra-articular calcaneal fracture were compared to the population of patients who did not require subtalar fusion. The variables compared between the two groups included Böhler angles, two computed tomography classification systems, and clinical scores including SF-36, visual analogue score, and oral analogue score. Intervention Subtalar distraction bone-block arthrodesis with tricortical bone graft was used in all 45 feet. Main Outcome Measurements The following were examined: x-ray fracture classification, specifically Böhler angles and Essex-Lopresti classification; computed tomography classification, specifically Sanders and Crosby; clinical scores, specifically validated visual analogue score, general health survey scores, oral analogue score, and other factors (i.e., patient demographics including age, sex, profession, smoking history, and Workers Compensation Board involvement. Results Initial treatment of the 44 patients in our study was nonoperative in 37 (84%) patients and operative (open reduction and internal fixation) in 7 (16%) (1 patient had bilateral heel fractures). Patients requiring fusion differed demographically from those patients not requiring fusion. Mean age was 39 years in both the fusion and nonfusion group. The fusion group had 97% males, whereas the nonfusion group had 89% males. Sixty-four percent of the fusion patients were Workers Compensation Board claims, whereas 35% of the nonfusion group were Workers Compensation Board claims. Of those that required fusion, 77% were heavy laborers. On average, the fusion group had a Böhler angle 15° less than the nonfusion group. Forty-six percent of the fusion patients were Sanders-type IV initial fractures. Logistic regression analysis revealed that the primary predictors of requiring fusion were Workers Compensation Board status (odds ratio = 3.03, 95% confidence interval = 1.41–6.57), Sanders-type IV (odds ratio = 5.48, 95% confidence interval = 1.57–19.18), Böhler angle <0° (odds ratio = 10.64–95% confidence interval = 1.33–85.17), and nonoperative initial treatment (odds ratio = 5.86–95% confidence interval = 2.33–14.67). Conclusion These data suggest that the amount of initial injury involved with the calcaneal fracture is the primary prognostic determinant of long-term patient outcome. Böhler angle on presentation of <0° was 10 times more likely to require a secondary subtalar fusion than a Böhler angle on presentation of >15°. Sanders-type IV calcaneal fractures were 5.5 times more likely to be fused than a simple Sanders type II fracture. Workers Compensation Board patients were three times more likely to be fused than non-Workers Compensation Board patients. Nonoperative care was six times more likely to lead to a late fusion as compared to open reduction and internal fixation treatment. Late fusion provided relief from pain and improved function as evidenced by an improvement in visual analogue score postsurgery. This study demonstrates that there is a distinct patient group with a displaced intra-articular calcaneal fracture who are at high risk of subtalar fusion. These include male Workers Compensation Board patients who participate in heavy labor work with a fracture pattern with Böhler angle less than 0°. If their initial treatment was nonoperative, the likelihood of requiring late subtalar fusion was significantly increased. Initial open reduction and internal fixation of patients with displaced intra-articular calcaneal fracture minimized the likelihood that subtalar fusion would be required.

The use of calcium phosphate bone cement in fracture treatment: a meta-analysis of randomized trials

BACKGROUND Available options to fill fracture voids include autogenous bone, allograft bone, and synthetic bone materials. The objective of this meta-analysis was to determine whether the use of calcium phosphate bone cement improves clinical and radiographic outcomes and reduces fracture complications as compared with conventional treatment (with or without autogenous bone graft) for the treatment of fractures of the appendicular skeleton in adult patients. METHODS Multiple databases, online registers of randomized controlled trials, and the proceedings of the meetings of major national orthopaedic associations were searched. Published and unpublished randomized controlled trials were included, and data on methodological quality, population, intervention, and outcomes were abstracted in duplicate. Data were pooled across studies, and relative risks for categorical outcomes and weighted mean differences for continuous outcomes, weighted according to study sample size, were calculated. Heterogeneity across studies was determined, and sensitivity analyses were conducted. RESULTS We identified eleven published and three unpublished randomized controlled trials. Of the fourteen studies, six involved distal radial fractures, two involved femoral neck fractures, two involved intertrochanteric femoral fractures, two involved tibial plateau fractures, one involved calcaneal fractures, and one involved multiple types of metaphyseal fractures. All of the studies evaluated the use of calcium phosphate cement for the treatment of metaphyseal fractures occurring primarily through trabecular, cancellous bone. Autogenous bone graft was used in the control group in three studies, and no graft material was used in the remaining studies. Patients managed with calcium phosphate had a significantly lower prevalence of loss of fracture reduction in comparison with patients managed with autograft (relative risk reduction, 68%; 95% confidence interval, 29% to 86%) and had less pain at the fracture site in comparison with controls managed with no graft (relative risk reduction, 56%; 95% confidence interval, 14% to 77%). We were unable to compare pain at the bone-graft donor site between the studies because of methodological reasons. Three studies independently demonstrated improved functional outcomes when the use of calcium phosphate was compared with the use of no grafting material. CONCLUSIONS The use of calcium phosphate bone cement for the treatment of fractures in adult patients is associated with a lower prevalence of pain at the fracture site in comparison with the rate in controls (patients managed with no graft material). Loss of fracture reduction is also decreased in comparison with that in patients managed with autogenous bone graft.

An economic evaluation of operative compared with nonoperative management of displaced intra-articular calcaneal fractures.

BACKGROUND The choice of therapy for a displaced intra-articular calcaneal fracture has long been a source of uncertainty in orthopaedic surgery, both in terms of the impact of the therapy on clinical outcomes and on health-care and non-health-care costs. We performed an economic evaluation, based on the results of a randomized clinical trial, to evaluate the economic implications of operative compared with nonoperative management of this fracture. METHODS An economic evaluation was performed, with use of a four-year time horizon, to determine the effect on costs and health benefits of operative compared with nonoperative management for a group of patients with displaced intra-articular fractures of the calcaneus. The complication rate, arthrodesis rate, survival data, and health-outcome data were estimated prospectively from a recent randomized clinical trial. Direct health-care costs and indirect costs (the cost of time lost from work) were estimated retrospectively from the center treating the majority of the patients. RESULTS Operative management resulted in a lower rate of subtalar arthrodesis and a shorter time off from work compared with nonoperative treatment. When indirect costs, such as the time lost from work, were included in the analysis, operative management was less costly (an average savings of Can

Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful?

19,000 per patient) and more effective, thus making it the preferred strategy. The result was most sensitive to the estimates of the costs of time lost from work. When these costs were excluded, operative treatment remained more effective, but with an increased average cost of Can

Functional outcome (SF-36) of patients with displaced calcaneal fractures compared to SF-36 normative data.

2800 per patient. CONCLUSIONS Calcaneal fractures have been recognized as having relatively poor clinical outcomes and a major socioeconomic impact with regard to time lost from work and recreation. Our analysis suggests that operative management of displaced intra-articular fractures is economically attractive. However, further exploration of the impact and valuation of time lost from work and patient outcomes is required.

A Prospective Randomized Controlled Trial of a Bioresorbable Calcium Phosphate Paste (α-BSM) in Treatment of Displaced Intra-Articular Calcaneal Fractures

Objective To determine whether autologous bone graft supplementation with open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures (DIACFs) is beneficial in achieving and maintaining restoration of calcaneal height and anatomic reduction of the posterior facet. Design Prospective historical cohort. Setting Level I trauma center, university hospital. Patients and Intervention Twenty DIACFs in twenty patients who received ORIF with bone graft supplementation were individually prospectively matched to twenty DIACFs in twenty patients who received only ORIF. Matching criteria for these pairs of patients included age, sex, occupational workload, Essex-Lopresti and Sanders classification, preoperative Böhlers angle, and fixation in the joint. Main Outcome Measurements Postoperative computed tomography assessed quality of anatomic reduction. Postoperative and three-month follow-up radiographs assessed Böhlers angle. A validated visual analog scale and Short Form-36 assessed functional outcome at a minimum of two years after surgery. Results Twenty-one fractures were (Orthopaedic Trauma Association) 73-C2 (Sanders Type III); fifteen fractures were 73-C1 (Sanders Type II); and four fractures were 73-C3 (Sanders Type IV). In the individually matched pairs of patients, the mean preoperative Böhlers angle was 2 degrees (standard deviation [SD] 14 degrees) for the bone graft group and 1 degree (SD 12 degrees) for the non–bone graft group. Preoperative Böhlers angle differed between individually matched pairs an average of 4 degrees (range 0 to 10 degrees). Böhlers angle increased with surgery a mean of 26 degrees (SD14 degrees) in the bone graft group and 27 degrees (SD 10 degrees) in the non–bone graft group. In the first three months after surgery, a mean decrease in Böhlers angle of 7 degrees (SD 4 degrees) in the bone graft group and 6 degrees (SD 7 degrees) in the non–bone graft group occurred. Statistical analysis of the individually matched pairs found no significant difference between the bone graft and non–bone graft patients regarding the change in Böhlers angle obtained with surgery (p = 0.98) and the change in Böhlers angle in the three months after surgery (p = 0.94). Quality of reduction was similar between groups, with eight matched pairs obtaining an equal reduction, six achieving a better reduction with bone graft, and six achieving a poorer reduction with bone graft. No differences in functional outcome were detected. Conclusions We found no objective radiographic or functional benefit to the use of bone graft supplementation in the operative treatment of DIACFs.

Bilateral Calcaneal Fractures: Operative Versus Nonoperative Treatment:

Background: The purpose of this study was to demonstrate the general health status after treatment of displaced intraarticular calcaneal fractures compared to normative data, other orthopaedic procedures, and other medical conditions. Methods: Three hundred and twelve patients between 25 and 64 years of age were treated for displaced intraarticular calcaneal fractures at a Level I trauma center. Followup ranged from 2 to 8 years. The Short Form 36 Health Status Survey (SF-36) was used for outcome measurement. Results: The scores in eight SF-36 categories in patients with displaced intraarticular calcaneal fractures differed by more than five points from the population norms. This suggests that there is clinical and social relevance to this injury. Outcomes in patients with displaced intraarticular calcaneal fractures were not as good across most SF-36 categories as were outcomes of patients with other orthopaedic conditions. Outcomes in patients with intraarticular calcaneal fractures also were worse across most categories than outcomes in patients who had organ transplants or myocardial infarctions. Conclusion: By comparing treatment for displaced intraarticular calcaneal fractures with treatment for orthopaedic problems or other disease processes, we concluded that intraarticular calcaneal fractures are serious life-changing events.

Displaced intra-articular calcaneal fractures.

BACKGROUND Displaced intra-articular calcaneal fractures are devastating injuries and pose a therapeutic challenge. The purpose of this study was to determine whether open reduction internal fixation (ORIF) plus an injectable bioresorbable calcium phosphate paste (alpha-BSM [bone substitute material]) is superior to ORIF alone in the treatment of calcaneal bone voids encountered after operative treatment of displaced intra-articular calcaneal fractures. METHODS We prospectively randomized 47 patients with 52 closed displaced intra-articular fractures necessitating operative fixation to receive ORIF alone (n = 28) or ORIF plus alpha-BSM (n = 24). The maintenance of Böhlers angle was evaluated at follow-up visits for more than 1 year. Secondary outcome measures included the SF-36 and lower extremity measure every 6 months, and the Oral Analog Scale (OAS) score at 2 years. RESULTS There was no difference between the groups in the degree of collapse of Böhlers angle at 6 weeks and 3 months when compared with initial postoperative values. However, at 6 months, the mean collapse of the alpha-BSM and ORIF group was 5.6 degree (SD, 4.5 degree) and ORIF alone was 9.1 degree (SD, 5.8 degree), which was statistically significant (p = 0.03). Final radiographic evaluation after 1 year revealed a Böhlers angle loss of 6.2 degree (SD 5.9 degree) and 10.4 degree (SD 7.1 degree) in alpha-BSM and ORIF and ORIF alone groups, respectively, (p = 0.05). There was no difference between the two groups in regards to secondary outcome measures of general health, limb specific function, and pain past 2 years. CONCLUSION These results support the use of an injectable, in situ hardening calcium phosphate paste to fill the bone void after a displaced intra-articular calcaneal fracture. There was no impact on general health, limb specific function, and pain past 2 years and no associated complications with alpha-BSM use, supporting it safety as an augment to ORIF.