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Commentary and Perspective   |    
Commentary on an article by Trevor Gaskill, MD, et al.: “Comparison of Surgical Outcomes of Intra-Articular Calcaneal Fractures by Age”
Pierce E. Scranton, Jr., MD1
1 Orthopedics International, Kirkland, Washington
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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.

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Dec 15;92(18):e40 1-1. doi: 10.2106/JBJS.J.01304
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This well-constructed study examines the treatment outcome of open reduction and internal fixation in calcaneal fractures as related to patient age. It is a study that will be repeated time and again, across the spectrum of orthopaedic procedures, as improvements are made in surgical devices and technique and as our perceptions change with regard to the age at which a patient might be considered to be an "older" patient. Given the previous literature1,2, which indicated that patients who were older than fifty years of age and had calcaneal fractures were not candidates for open reduction and internal fixation, this study nicely takes a retrospective look at outcomes in older and younger patient groups and comes up with well-reasoned conclusions.
The study presents 158 fractures that were followed for an average of nearly nine years; all were treated with use of open reduction and internal fixation, which was performed by skilled orthopaedic surgeons with foot and ankle expertise. Group-I patients were younger than fifty years of age, and Group-II patients were fifty years of age or older. The authors give a detailed analysis of outcomes with use of the calcaneal fracture scoring system, the Foot Function Index, and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scoring systems. A surprising result is that outcomes in the older (Group-II) population are better than or at least as good as those in the younger (Group-I) population. The authors carefully correlate mitigating factors, such as the higher prevalence of labor and industry patients and motor-vehicle accidents in the younger (Group-I) population. They offer the opinion that these intra-population differences might relate to the poorer results in the Group-I patients. They confirm the thesis that it is reasonable to treat displaced intra-articular calcaneal fractures in older patients with use of open reduction and internal fixation and expect a satisfactory outcome, provided that the patients have no prohibitive comorbidities.
The Discussion raises further questions regarding the evolution of treatment modalities. It is clear that, during the course of this retrospective study, a change occurred in our understanding of calcaneal fracture patterns and with regard to treatment techniques, surgical exposure, and instrumentation. Any meaningful medium to long-term follow-up study will always have this limitation. However, the goal of orthopaedic treatment has always been to objectively review and then improve on treatment. Since 1931, we have seen a progression of improvement in calcaneal fracture treatment: Bohler clamps, prolonged non-weight-bearing, and prolonged casting; after that, Essex-Lopresti Steinmann pin reductions and large flap lateral dissections; and now, more elegant fixation plates with minimal or percutaneous exposure. The results of this paper let us know that an arbitrary age, in and of itself, is not a contraindication for surgical reduction and fixation of calcaneal fractures.
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.[PubMed]
 
Paley  D;  Hall  H. Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors. J Bone Joint Surg Am.  1993;75:342-54. [PubMed]
 

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References

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.[PubMed]
 
Paley  D;  Hall  H. Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors. J Bone Joint Surg Am.  1993;75:342-54. [PubMed]
 
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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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