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The Relationship Between the Outcome of Operatively Treated Calcaneal Fractures and Institutional Fracture LoadA Systematic Review of the Literature
Martijn Poeze, MD, PhD1; Jan P.A.M. Verbruggen, MD, PhD1; Peter R.G. Brink, MD, PhD1
1 Section of Traumatology, Department of Surgery, University Hospital Maastricht, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands. E-mail address for M. Poeze: m.poeze@ah.unimaas.nl
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Section of Traumatology, Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 May 01;90(5):1013-1021. doi: 10.2106/JBJS.G.00604
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Abstract

Background: It has been assumed that outcome after open reduction and internal fixation of displaced intra-articular calcaneal fractures may be affected by the presence of institutional trauma care and the institution's fracture volume. The purpose of this systematic review was to investigate whether a relationship exists between institutional fracture load and the rates of serious infection and subtalar arthrodesis following the treatment of these fractures.

Methods: With use of a systematic method, all studies published between 2000 and 2006 describing adult patients undergoing open reduction and internal fixation of a displaced intra-articular fracture of the calcaneus were included. Patients with open fractures and patients undergoing percutaneous procedures were excluded. Institutional fracture load was calculated by dividing the number of calcaneal fractures that were treated operatively by the number of months that were included in the reported studies. A serious deep infection was defined as an infection requiring surgical débridement and hardware removal, reconstruction with a flap, and/or the presence of osteomyelitis. Traumatic subtalar arthritis was considered to be severe when subtalar arthrodesis was required. Numerous confounding factors were also analyzed, and a systematic methodological quality assessment was performed.

Results: Of a total of 236 studies, twenty-one were included in the analysis. The total number of fractures included was 1656. The median institutional fracture load was 0.8 fracture per month (95% confidence interval, 0.2 to 4.6 fractures per month). The median infection rate in the studies combined was 5.1% (95% confidence interval, 0.0% to 19.9%). The infection rate increased exponentially with a decreasing fracture load (r2 = -0.5; p = 0.03). The median rate of subtalar arthrodesis was 2.5% (95% confidence interval, 0.0% to 15.4%). A significant inverse correlation was present between the fracture volume and the subtalar arthrodesis rate (r2 = -0.7; p = 0.008). These factors were unrelated to the methodological quality. Multivariate analysis identified fracture volume as an independent determinant of the infection rate.

Conclusions: A significant relationship between the deep infection rate, traumatic subtalar arthritis, and the fracture load may indicate a need for specialized institutional trauma care to improve outcomes associated with the operative treatment of calcaneal fractures.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Adam Starr, M.D.
    Posted on May 12, 2008
    Risk Factors for Infection following Operatively Treated Calcaneus Fractures
    University of Texas Southwestern Medical Center, Dallas TX 75390

    To The Editor:

    I read with interest the recent article, “The Relationship Between the Outcome of Operatively Treated Calcaneal Fractures and Institutional Fracture Load, A Systematic Review of the Literature”(1).

    I would agree with the authors' conclusion. It seems reasonable that centers that routinely perform open reduction and internal fixation of calcaneus fractures would have a lower rate of infection.

    However, some of their results surprised me. They reported, “There was no correlation between the infection rate and the above-mentioned confounding factors [the percentage of patients with joint depression-type fractures as compared with tongue-type fractures, the percentage of patients with a Sanders type-IV fracture, the percentage of patients with a bilateral fracture, the percentage of patients with diabetes or who smoked, the number of surgeons performing the procedures, the mean time to surgery, the mean duration of surgery, the mean postoperative Bohler angle, or the mean duration of follow-up]…”(2).

    While I do not care for patients who sustain calcaneus fractures, it seems to me that most papers reporting complications after calcaneus fracture repair have noted that diabetes and smoking are risks factors for infection. I would also suspect that duration of surgery is related to infection risk.

    Do the authors believe that a diabetic smoker whose fracture repair takes 8 hours has no greater infection risk than a non-diabetic non-smoker whose surgery is completed in an hour?

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Reference:

    1. Poeze M, Verbruggen JPAM, Brink PRG. 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. 2008;90:1013-1021.

    2. Poeze M, Verbruggen JPAM, Brink PRG. 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. 2008;90:1018.

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