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Scientific Articles   |    
Comparison of Surgical Outcomes of Intra-Articular Calcaneal Fractures by Age
Trevor Gaskill, MD1; Karl Schweitzer, MD1; James Nunley, MD1
1 Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710. E-mail address for C. Gaskill: gaski011@mc.duke.edu
View Disclosures and Other Information
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.

A commentary by Pierce E. Scranton Jr., MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.
Investigation performed at the Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Dec 15;92(18):2884-2889. doi: 10.2106/JBJS.J.00089
A commentary by Pierce E. Scranton, Jr., MD, is available here
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Abstract

Background: 

Internal fixation is an accepted treatment for displaced fractures of the calcaneus. Operative intervention in older patients, however, is traditionally discouraged in the literature. The purpose of this study was to compare the outcomes of internal fixation of intra-articular fractures of the calcaneus on the basis of patient age.

Methods: 

One hundred and seventy-five patients (191 fractures) who underwent internal fixation between 1992 and 2007 for a displaced, intra-articular calcaneal fracture were identified. The American Society of Anesthesiologists score, the fracture pattern, and the mechanism of injury were recorded. Each patient was contacted to complete a follow-up survey from which clinical outcome scores were calculated. One hundred and forty-six patients with 158 fractures were available for follow-up and were divided into two groups for comparison. Group I consisted of 108 fractures in patients who were less than fifty years old. Group II was composed of fractures in fifty patients who were fifty years of age or older.

Results: 

The mean duration of follow-up was 8.98 years. The average patient age was thirty-six years for Group I and fifty-eight years for Group II. The average adjusted American Orthopaedic Foot & Ankle Society score was 64 for Group I and 75 for Group II. The mean calcaneal fracture scoring system score was 66 for Group I, and 76 for Group II. Similarly, the average Foot Function Index was 24 and 15 for Groups I and II, respectively. Each clinical outcome measure suggests significantly better outcomes for Group II as compared with Group I (all p < 0.05). Overall, the complication rates were similar between groups. Conversion to subtalar fusion was 15% for Group I and 8% for Group II.

Conclusions: 

In this series, outcomes of older patients are at least equivalent to those of younger patients undergoing internal fixation for an intra-articular calcaneal fracture. Operative intervention appears to be a reasonable option for displaced calcaneal fractures in older patients. Physiologic age should be considered when evaluating older patients, and individualized treatment plans remain critical because patients with low physical demands or who have medical complications may be better candidates for nonoperative treatment. Prospective studies are needed in this area.

Level of Evidence: 

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

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    References

    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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    Trevor R Gaskill, MD
    Posted on March 19, 2011
    Dr. Gaskill and colleagues respond to Dr. Wang and colleagues
    Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina

    We would like to thank Dr. Wang for his interest and comments on our article regarding the operative management of calcaneus fractures in older patients (2010;92:2884-9). We are glad that Dr. Wang enjoyed the work and we are pleased that several valuable questions have been raised so that we could expand upon the published manuscript. Poor bone quality is a concern when considering operative fixation of any fracture. It is apparent that osteopenic bone may contribute to calcaneus fractures occurring with lower energy mechanisms and can make internal fixation more tenuous. Furthermore, bone voids resulting from compression mechanisms can also contribute to surgical difficulties as Dr. Wang indicates. We have anecdotally found the bulk of the locking plate to be concerning with respect to wound healing and none were used in the series of patients reported. CT scans are routinely obtained to ensure adequate bone stock for stable fixation prior to surgical intervention. This combined with strict postsurgical non-weight bearing restrictions are, we believe, critical to good surgical outcomes. Furthermore, we have not found bone grafting to be necessary in most cases.

    The malunion that occurred in group II was the result of fracture fixation failure. Immediate postoperative images show fracture fragments were acceptably reduced, however, subsequent images show loss of fixation. Review of clinical documentation also indicates that the patient began ambulating prematurely, which may have contributed to this patient’s loss of reduction. Ultimately the fracture healed, albeit in a less favorable position.

    This complication highlights two very important aspects of calcaneus fracture fixation. As we discuss in the manuscript, operative fixation is not appropriate for all patients and it is critical that management strategies be individualized to the patient and fracture characteristics. If, as you suggest, bone is osteopenic enough that stable fixation is not possible or, as in this case, the patient is likely to be non-compliant with postsurgical restrictions, they become less optimal candidates for surgical intervention and may be better managed nonoperatively. The purpose, however, of the manuscript is to illustrate that age is not a good predictor of outcome and that in appropriately selected patients, outcomes in an older age group can be equivalent to outcomes already established as beneficial in younger groups.

    Finally, in reference to the HOST criteria (1), objective tools that help appropriately select patients for operative or nonoperative intervention are always useful. To our knowledge these criteria have not been reported in calcaneus fractures, let alone an over 50 year old population of calcaneus fractures so its current utility is likely limited, but should be explored and validated if possible. We are always concerned, however, with strictly algorithmic approaches to medicine. Because of the complexity of medical decisions algorithms are simply unable to account for all possible clinical scenarios and therefore, use generalities to guide management. While these generalities can be very helpful in educating patients regarding expected outcomes from particular treatments, it is critical that they be tempered with good clinical judgment and patient desires.

    We would again like to thank Dr. Wang for his comments and interest in this article. We hope these responses will be helpful in the future care of calcaneus fracture patients.

    References

    1. Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Rel Res. 2005;433:205-11.

    Xin Wang
    Posted on March 19, 2011
    Evaluation and Treatment of Calcaneal Fractures in Older Patients
    Orthopaedic Surgeon, Department of Orthopaedic Surgery, Tongji Hospital, Shanghai, China

    To the Editor:

    We are interested in the article which is entitled "Comparison of Surgical Outcomes of Intra-Articular Calcaneal Fractures by Age" by Gaskill et al. (2010;92:2884-9). It is well known that open reduction and internal fixation has been widely recommended for intra-articular calcaneal fractures. But much literature has suggested that the patients who are older than 50 years should be considered a relative contraindication because of highly unpredictable complications (1). Throughout the article, outcomes of older patients are at least equivalent to those of younger patients undergoing internal fixation for an intra-articular calcaneal fracture. Operative intervention appears to be a reasonable option for displaced calcaneal fractures in older patients, which can increease our confidence for operative treatment for calcaneal fractures in older patients.

    Calcaneal fractures in older patients are often from low energy injury because of osteoporosis. The characteristics of calcaneal fractures in older patients are often different from younger patients. The joint-depression type fractures are more common, and the tongue-type fractures are relatively rare. The width and height of the calcaneus changes more obviously than the length of it. The extent of bone defects is larger than in younger patients after being reduced. The internal fixation is easily loosened and becomes ineffective because of the osteoporosis. The authors reported that one patient had a malunion in group II (older patients), and there was no malunion in group I. We want to know the reason for this malunion: unsatisfactory reduction or internal fixation failure? Had you selected the locking plate to treat severe calcaneal fractures in older patients? What are the indications and advantages of locking plate? Do you think that a bone graft is necessary in older patients to prevent reduced fractures from collapsing again?

    Another line of questions relates to the physiologic age. The authors inferred that physiologic age, rather than chronological age, should be considered when evaluating older patients. How to evaluate objectively? There was no objective method to predict the older patients who would benefit or be harmed from calcaneal fracture surgery. No literature reported the older patient's preinjury medical state (including age) with respect to the subsequent risk of postoperative complication of calcaneal fractures. Could you share some experiences and help us to select appropriate patients for operative treatment?

    In our opinion, it is very important to choose suitable patients to operate. We propose that the Host classification should be applicable to patients with calcaneal fractures as a objective method of identifying increased risk because of comorbid medical illness. Patients can been divided into Class A, B, or C based on 14 immune system compromising factors by the Host classification (2). There have been several relevant reports related to the Host classification that can predict the incidence of operative complications(3), but no previous reports on the calcaneal fractures. If patients in class C would be at a markedly increased risk of complication , they may be better candidates for nonoperative treatment. The prospective and retrospective studies should be performed further because of inadequate theoretical basis.

    References

    1. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84:1733-44.

    2. McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M. Periprosthetic total hip infection: outcomes using a staging system. Clin Orthop Relat Res. 2002;403:8-15.

    3. Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Rel Res. 2005;433:205-11.

    Trevor R. Gaskill, MD
    Posted on March 19, 2011
    Dr. Gaskill and colleagues respond to Dr. Gomez Rice and colleagues
    Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina

    We would like to thank Dr. Gomez Rice for his interest and comments on our article regarding the operative management of calcaneus fractures in older patients (2010;92:2884-9). Several important questions were raised by Dr. Gomez Rice and we are thankful to have the opportunity to provide some clarification and expand upon the published manuscript. Distal lower extremity fractures are known to be associated with significant soft tissue injury and early intervention in the face of poor soft tissue health can lead to devastating wound complications. Therefore, it is common to delay surgery until soft tissue health is such that it can withstand a second insult caused by the surgical procedure. The referenced article by Koski et al. suggests that delay in surgical intervention was associated with a higher prevalence of wound complications, however they also report that operative time and fracture severity were similarly correlated (1). Because the authors did not control for operative time or fracture severity it is unclear what true effect surgical delay has on wound complications. Moreover, other authors have found no correlation between longer surgical delay and increased wound complications (2).

    Data regarding the delay to definitive fixation was not collected in this series. It is our practice, however, to delay surgery until soft tissues are clinically appropriate for surgical intervention to the extent bony malunion does not occur. Higher severity fractures typically require a longer delay prior to surgery to allow soft tissue healing in our experience. Therefore, inadequate surgical delay would be more likely to adversely affect wound complications than longer delays. Considering major complication rates were similar between groups we feel the lack of this data does not significantly undermine the conclusions of this study.

    It is intuitive that familiarity with calcaneal fractures and their treatment contributes to surgical outcomes. As you indicate, the majority of these fractures were treated by the senior author and his involvement represented 72% and 78% of groups I and II respectively. The remainder of each group was treated by experienced, fellowship trained, foot and ankle or trauma surgeons that are familiar with operative treatment of calcaneus fractures. The referenced article by Poeze et al. indicates a relationship exists between calcaneus fracture complications and institutional fracture load (3). In this article they indicate a mean fracture load for these trauma centers was 0.8 fractures per month (95% CI 0.2 to 4.6 fractures per month). During the present study period, 1.27 displaced intraarticular calcaneus fractures were treated per month, well above the mean institutional average in this manuscript. Therefore, while we agree surgeon and institutional experience do influence the outcome of surgically treated calcaneus fractures, we believe these factors are minimized in this study.

    Additionally, we would argue that the “skewed” prevalence of motor vehicle injuries should be expected in any analysis stratified by age. Considering osteopenia is more common in older populations it is intuitive to believe that calcaneus fractures may occur more easily with lower energy mechanisms such as a fall. By contrast, higher energy mechanisms are likely necessary to result in similar fractures considering more robust bone structure in younger patients. Therefore, we believe differences between groups are expected characteristics based on age stratification and likely do not represent sampling bias. In support of this, the reported prevalence of a fall as a mechanism of calcaneus fracture in an elderly population is similar (71% versus 70%) to that reported by Herscovici et al. (4).

    Under these auspices, it may be true that higher energy injuries predispose patients to a higher risk of wound complications. In our opinion, however, this represents unique characteristics of the age-stratified groups and may partially explain the equivalent reported outcomes in the older population of the present series.

    In conclusion we would like to thank Dr. Gomez Rice for his interest in the article and his comments. We hope these responses help clarify the questions raised, however we feel the queries raised do not ultimately change the conclusions of the original manuscript.

    References

    1. Koski A, Kuokkanen H, Tukiainen E. Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scand J Surg. 2005;94:243-5.

    2. Court-Brown CM, Schmidt M, Schutte BG. Factors affecting infection after calcaneal fracture fixation. Injury. 2009;40:1313-5.

    3. Poeze M, Verbruggen JP, Brink PR. 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;90:1013-21.

    4. Herscovici et al. Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am (2005) vol. 87 (6) pp. 1260-43.

    Alejandro Gomez Rice
    Posted on March 19, 2011
    Differences Between Groups
    Orthopaedic Surgeon, Hospital Universitario de Getafe, Getafe, Spain

    To the Editor:

    We read with great interest the recent article by Gaskill et al. entitled, "Comparison of Surgical Outcomes of Intra-Articular Calcaneal Fractures by Age" (2010;92:2884-9). As the author correctly points out, it is commonly assumed without firm evidence that patients older than fifty should be treated nonoperatively. This study seems to imply that we should not hold to this view. On the contrary, according to this article, it would seem that older patients have better reported outcomes, mainly because of their lower physical demands. However, several limitations of this study should be acknowledged:

    1. Although there is some mixed evidence (1), some recent studies suggest that surgical delay may be correlated with an increased risk of infection (2,3). This study provides no data indicating that surgical delay was comparable in both groups.

    2. Surgical experience (4) and fracture load (5) have been proven to be key factors in surgical outcomes. Although most of the patients were operated on by the senior author (JN), this article does not provide information about the percentage of patients operated by the senior surgeon in each group.

    3. The predominant injury mechanism was a fall in both groups but the percentage of fractures caused by motor-injuries (higher energy injuries) was much higher in Group I. It is well known that the severity and the extent of soft tissue disruption are proportional to the amount of force and energy involved in producing the injury (6).Thus, it seems reasonable to believe that patients in group I (younger patients) were at higher risk of developing soft tissue complications. We believe that the importance of this study remains unclear and cannot be evaluated without adequately correcting for differences between groups.

    References

    1. Al-Mudhaffar M, Prasad CV, Mofidi A. Wound complications following operative fixation of calcaneal fractures. Injury. 2000;31:461-4.

    2. Koski A, Kuokkanen E, Tukiainen E. Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scand J Surg. 2005;94:243-5.

    3. Tennent TD, Calder PR, Salisbury RD, Allen PW, Eastwood DM. The operative management oí displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol. Injury. 2001;32:491-6.

    4. Court-Brown CM, Schmidt M, Schutte BG. Factors affecting infection after calcaneal fracture fixation. Injury. 2009;40:1313-5.

    5. Poeze M, Verbruggen JP, Brink PR. 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;90:1013-21.

    6. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82:225-50.

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