Which is the best treatment for displaced intra-articular calcaneal fractures

• Main Authors: Peng Xuxiang, Xiaohua Pan MD, PhD, XiaoMin Wu Mphil
• Format: Article
• Language: English
• Published: SAGE Publishing 2018-09-01
• Series: Foot & Ankle Orthopaedics
• Online Access: https://doi.org/10.1177/2473011418S00520

Category: Trauma Introduction/Purpose: Displaced Intra-Articular Calcaneus Fractures (DIACFs) represent a source of tremendous disability to the patient, economic burden to the society and a treatment challenge to the average orthopaedic surgeon. Open reduction and internal fixation (ORIF), minimally invasive surgery (MIS), external fixator (EF), external fixator combined with limited internal fixation (EFLIF) and non-surgical treatment (NST) are mostly used for the treatment of DIACFs. However, no single approach is universally applicable to all calcaneus fractures. More over, previous studies was still unclear and have offered conflicting recommendations. The purpose of this study is to comprehensively review the literature and ascertain the relative efficacy and safety of ORIF, MIS, EF, EFLIF and NST for patients with DIACFs using a Bayesian network meta-analysis. Methods: We will comprehensively search PubMed, EMBASE, Cochrane Library, Medline, Science Direct, CBM and CNKI from the inception dates to January 01, 2018, to include potentially relevant randomized controlled trials (RCTs) and cohort studies (CSs) that evaluated interventions for treating adults with DIACFs. The quality of included studies was assessed using the Newcastle-Ottawa Scale and the risk of bias according to the Cochrane Handbook. After independent study selection by 2 authors, data were extracted and collected independently. The primary outcome measures were anatomical measures, functional measures, and complications. The data of RCTs and CSs were pooled respectively using the fixed-effect model or random-effect model. Mean differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous data, and relative risks (RRs) with 95% CIs were calculated for dichotomous data. Statistical heterogeneity was assessed with the Q test and I2. Sensitivity analysis was developed to assess the reliability of pooled results. Results: Seventeen trials (5 RCTs and 12 CSs) including 2369 patients were considered in the study. EFLIF had significantly the highest AOFAS Ankle Hindfoot Scale (MD, 9.54 [95% CI, 5.97 to 17.42]) and lower total incidence of complications (RR, 1.65 [95% CI, 1.27 to 2.54]) than ORIF, MIS, EF and NST. Moreover, EFLIF resulted in a lower incidence of additional surgery (RR, 3.47 [95% CI, 2.28 to 6.95]) than ORIF and NST. The rank of anatomical recovery was: EFLIF, ORIF, EF, MIS and NST. The rank of functional recovery was: EFLIF, ORIF, MIS, EF and NST. For reduction in total incidence of complications, the rank was: EFLIF, NST, EF, MIS and ORIF. Conclusion: EFLIF has the highest probability of improving the functional outcome and reducing the total incidence of complications and additional surgery among the five interventions for treating adults with DIACFs.