Journal of Orthopaedic Surgery 2016;24(3):411-6

Review Article: Operative versus non-

operative treatment for displaced intra-
articular calcaneal fracture: a meta-analysis of
randomised controlled trials
Sanjay Meena,1 Shreesh Kumar Gangary,2 Pankaj Sharma3
Department of Orthopaedics, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
1
2
Department of Orthopaedics, Max Smart Super Speciality Hospital, Saket, New Delhi, India
3
Department of Orthopaedics, Pushpawati Singhania Research Institute, Sheikh Sarai phase 2, New Delhi, India

to high-energy trauma (falls from height or road

ABSTRACT
We reviewed 8 randomised controlled trials that
compared operative and non-operative treatment for
displaced intra-articular calcaneal fractures. Patients
with operative treatment were more likely to resume
pre-injury work (relative risk [RR]=0.60, p=0.04),
had fewer problems when wearing shoes (RR=0.42,
p=0.0004), and had a higher physical component
summary score of SF-36 (difference in means=6.75,
p<0.0001) but a higher complication rate (RR=1.74,
p=0.0005).
Key words: ankle fractures; calcaneus; meta-analysis as
topic; surgical procedures, operative
traffic accidents).3 With conservative treatment
alone, the calcaneus can heal but remain deformed.
This leads to incongruity of the subtalar joint and
loss of alignment of the leg through the ankle to the
heel.4 Walking on the incongruous joint may give
rise to osteoarthritis of the subtalar joint and pain.5
Anatomic restoration is not necessarily associated
with good outcome in terms of function and quality
of life. Open reduction and internal fixation (ORIF)
can result in wound healing problems in 16 to 25% or
as many as 43% of patients.6,7 The optimal treatment
remains controversial.8,9 We reviewed 8 randomised
controlled trials that compared operative and non-
operative treatment for displaced intra-articular
calcaneal fractures.

INTRODUCTION
Calcaneal fractures account for about 2% of all
fractures, and 75% of them are intra-articular.1,2 Most
such fractures occur in young adult men secondary
METHODS
In September 2014, the PubMed, EMBASE, and
Cochrane databases were searched using key words:
displaced intra-articular calcaneal fracture, displaced
intra-articular fracture of calcaneus, conservative,

Address correspondence and reprint requests to: Dr Sanjay Meena, Department of Orthopaedics, Lady Hardinge Medical College,
Shaheed Bhagat Singh Road, Diz Area, Connaught Place, New Delhi-110001, India. Email: sanjaymeena@hotmail.com
412 S Meena et al. Journal of Orthopaedic Surgery

operative, non-operative, surgery, non-surgery, and
randomized controlled trials. Associated references of
the retrieved articles were also searched for potential
studies. Randomised controlled trials that compared
operative and non-operative treatment for displaced
intra-articular calcaneal fractures were included.
Studies that lacked primary results or data for meta-
analysis were excluded.
Data (study setting, study type, number of cases
in each group, etc.) were extracted by 2 reviewers.
Any conflict of opinion was resolved by discussion,
and a third reviewer was consulted if necessary.
The quality of the randomised controlled trials
was assessed using the modified Jadad score.10 It is
an 8-item scale to assess randomisation, blinding,
withdrawals and dropouts, inclusion and exclusion
criteria, adverse effects, and statistical analysis. The
score ranges from 0 (lowest quality) to 8 (highest
quality). Randomised controlled trials with a score
of 3 are defined as high quality. Critical appraisal
was conducted by one reviewer and verified by the
other. Subgroup analysis for different fracture types
was not performed because few studies reported the
fracture type.
Primary outcome variables were failure to resume
pre-injury work and residual pain. Secondary outcome
variables were problems in wearing shoes, American
Orthopaedic Foot and Ankle Society (AOFAS) score,
complications, reoperation, and Short Form 36 Health
Survey (SF-36) score. The pooled relative risk (RR)
with a 95% confidence interval (CI) was calculated for
dichotomous variables, and difference in mean with
a 95% CI was calculated for continuous variables.
Heterogeneity was assessed by use of I2. An I2 >50%
was the cut-off for homogeneity of data. When there
was no statistical evidence of heterogeneity, a fixed
effect model was used; otherwise, a random effect
model was used. To validate the credibility of this
meta-analysis, a sensitivity analysis was performed
by sequential omission of individual studies.
Publication bias (by visually observing asymmetry of
the funnel plot for each variable) was not assessed,
because <10 studies were included and it would be
underpowered. All p values were 2-sided and a p
value of <0.05 was considered statistically significant.
RESULTS
Of 308 studies identified, 286 were excluded and 22
were reviewed. Of these, 9 were non-randomised, 3
were irrelevant, 2 were cadaveric, and the remaining
8 were randomised controlled trials (Table).6,9,1116
According to the modified Jadad scoring system, the
study quality was good to excellent in 6 and poor in 2.
In 4 studies that reported the percentage of patients
who failed to resume pre-injury work, patients with
operative treatment were more likely to resume pre-
injury work (RR=0.60, 95% CI=0.370.98, p=0.04, Fig.
1). In 3 studies that reported residual pain, patients
with operative treatment were estimated to have
less residual pain although the difference was not
significant (RR=0.73, 95% CI=0.40-1.36, p=0.33, Fig.
2). In 3 studies that reported the AOFAS score, there

Table
Comparison of the 8 included studies
Study Jadad No. of Operative vs. non-operative treatment Conclusion
score males:
No. of Mean age Follow-up
females
patients (years) (years)
OFarrell et al.,13 1993 2 20:4 12 vs. 12 33.0 vs. 38.0 1.3 vs. 1.2 Surgery improved functional results
Parmar et al.15 1993 2 48:8 25 vs. 31 48.3 vs. 48.8 2.1 vs. 1.8 No significant difference in functional
outcome
Thordarson and 5.5 21:5 15 vs. 11 35.0 vs. 36.0 1.4 vs. 1.2 Surgery improved walking ability
Krieger,12 1996
Buckley et al.6 2002 6.5 381:43 206 vs. 218 41.0 vs. 39.0 3.0 vs. 3.0 No significant difference in functional
outcome
Ibrahim et al.14 2007 4 21:5 15 vs. 11 61.0 vs. 58.0 15.2 vs. 14.8 No significant difference
Nouraei and Moosa,16 4 - 31 vs. 30 46.0 vs. 52.0 3.0 vs. 3.0 Surgically treated patient more likely to
2011 resume pre-injury work
Griffin et al.9 2014 6 127:24 73 vs. 78 44.8 vs. 48.2 2 vs. 2 No significant difference; complication
higher after surgery
Agren et al.11 2013 7 59:23 42 vs. 40 49 vs. 48 10 vs. 10 Operative management not superior in
short term but beneficial in long term
Vol. 24 No. 3, December 2016 Operative versus non-operative treatment for displaced intra-articular calcaneal fracture 413

was not much heterogeneity (I2=36%, p=0.21) and
the fixed effect model was used to pool the results.
Patients with operative and non-operative treatment
were comparable (difference in means=1.16, 95%
CI=-3.515.84, p=0.63, Fig. 3). In 4 studies that
reported problems associated with wearing shoes,
patients with operative treatment were more likely
to have fewer problems (RR=0.42, 95% CI=0.260.68,
p=0.0004, Fig. 4). In 2 studies that reported the SF-
36 score, patients with operative treatment were
more likely to have a higher physical component
summary score (difference in means=6.75, 95%
CI=3.529.97, p<0.0001, Fig. 5), but both groups
were comparable in terms of the mental component
summary score (difference in means = -0.69, 95%
CI= -3.77 to -2.38, p=0.66, Fig. 6). In 3 studies that
reported the reoperation rate, patients with non-
operative treatment were estimated to have a higher
reoperation rate but not significantly (RR=1.32,
95% CI=0.208.67, p=0.77, Fig. 7). In 4 studies that
reported complications, patients with operative
treatment were more likely to have complications
(83/319 vs. 51/338, RR=1.74, 95% CI=1.282.37,
p=0.0005, Fig. 8).

Study or subgroup Operative Non-operative Weight Risk ratio M-H, Risk ratio M-H,
fixed, 95% CI fixed, 95% CI
Events Total Events Total
Griffin et al. 2014 7 45 4 36 14.6% 1.40 (0.44, 4.41)
OFarrell et al. 1993 4 12 9 12 29.6% 0.44 (0.19, 1.05)
Parmar et al. 1993 5 25 10 31 29.3% 0.62 (0.24, 1.58)
Thordarson and Krieger 1996 3 15 7 11 26.5% 0.31 (0.10, 0.95)

Total (95% CI) 97 90 100% 0.60 (0.37, 0.98)

Total events 19 30
Heterogeneity: Chi2=3.88, df=3 (p=0.28); I2=23% 0.01 0.1 1 10 100
Test for overall effect: Z=2.05 (p=0.04) Favours operative Favours non-operative

Figure 1 Forest plot for return to pre-injury work

Study or subgroup Operative Non-operative Weight Risk ratio M-H, Risk ratio M-H,
random, 95% CI random, 95% CI
Events Total Events Total
Nouraei and Moosa 2011 9 31 22 30 30.5% 0.40 (0.22, 0.72)
Parmar et al. 1993 11 25 14 31 30.5% 0.97 (0.54, 1.75)
Thordarson and Krieger 1996 13 15 10 11 39.0% 0.95 (0.73, 1.25)

Total (95% CI) 71 72 100% 0.73 (0.40, 1.36)

Total events 33 46
Heterogeneity: Tau2=0.24, Chi2=10.10, df=2 (p=0.006); I2=80% 0.01 0.1 1 10 100
Test for overall effect: Z=0.98 (p=0.33) Favours operative Favours non-operative

Figure 2 Forest plot for residual pain.

Study or subgroup Operative Non-operative Weight Mean difference Mean difference IV,
IV, fixed, 95% CI fixed, 95% CI
Mean SD Total Mean SD Total
Agren et al. 2013 81 21.2 42 77.2 15.5 40 34.0% 3.80 (-4.21, 11.81)
Griffin et al. 2014 79.2 16.2 54 76.8 19.7 60 50.2% 2.40 (-4.20, 9.00)
Ibrahim et al. 2007 70 16.1 15 78.5 14.4 11 15.7% -8.50 (-20.28, 3.28)

Total (95% CI) 111 111 100% 1.16 (-3.51, 5.84)

Heterogeneity: Chi2=3.14, df=2 (p=0.21); I2=36% -50 -25 0 25 50
Test for overall effect: Z=0.49 (p=0.63) Favours operative Favours non-operative

Figure 3 Forest plot for the American Orthopaedic Foot and Ankle Society score.
414 S Meena et al. Journal of Orthopaedic Surgery

Study or subgroup Operative Non-operative Weight Risk ratio M-H, Risk ratio M-H,
fixed, 95% CI fixed, 95% CI
Events Total Events Total
Nouraei and Moosa 2011 4 31 15 30 38.7% 0.26 (0.10, 0.69)
OFarrell et al. 1993 3 12 8 12 20.3% 0.38 (0.13, 1.08)
Parmar et al. 1993 7 25 9 31 20.4% 0.96 (0.42, 2.22)
Thordarson and Krieger 1996 2 15 7 11 20.5% 0.21 (0.05, 0.82)

Total (95% CI) 83 84 100% 0.42 (0.26, 0.68)

Total events 16 39
Heterogeneity: Chi2=5.80, df=3 (p=0.12); I2=48% 0.01 0.1 1 10 100
Test for overall effect: Z=3.52 (p=0.0004) Favours operative Favours non-operative

Figure 4 Forest plot for problem in wearing shoes.

Study or subgroup Operative Non-operative Weight Mean difference Mean difference IV,
IV, fixed, 95% CI fixed, 95% CI
Mean SD Total Mean SD Total
Agren et al. 2013 47.6 9.8 42 40.8 11.9 40 46.4% 6.80 (2.07, 11.53)
Griffin et al. 2014 43.7 11.1 54 37 13.1 62 53.6% 6.70 (2.30, 11.10)

Total (95% CI) 96 102 100% 6.75 (3.52, 9.97)

Heterogeneity: Chi2=0.00, df=1 (p=0.98); I2=0%
-50 -25 0 25 50
Test for overall effect: Z=4.10 (p<0.0001) Favours operative Favours non-operative
Figure 5 Forest plot for physical component summary score of Short Form-36.

Study or subgroup Operative Non-operative Weight Mean difference Mean difference IV,
IV, fixed, 95% CI fixed, 95% CI
Mean SD Total Mean SD Total
Griffin et al. 2014 53.4 11.4 54 53.6 12.3 62 50.7% -0.20 (-4.51, 4.11)
Agren et al. 2013 49.8 9.9 42 51 10.3 40 49.3% -1.20 (-5.58, 3.18)

Total (95% CI) 96 102 100% -0.69 (-3.77, 2.38)

Heterogeneity: Chi2=0.10, df=1 (p=0.75); I2=0% -50 -25 0 25 50
Test for overall effect: Z=0.44 (p=0.66) Favours operative Favours non-operative

Figure 6 Forest plot for mental component summary score of Short Form-36.

Study or subgroup Operative Non-operative Weight Risk ratio M-H, Risk ratio M-H,
random, 95% CI random, 95% CI
Events Total Events Total
Agren et al. 2013 15 42 4 40 33.4% 3.57 (1.30, 9.85)
Buckley et al. 2002 9 206 37 218 35.1% 0.26 (0.13, 0.52)
Griffin et al. 2014 8 73 3 78 31.5% 2.85 (0.79, 10.33)

Total (95% CI) 321 336 100% 1.32 (0.20, 8.67)

Total events 32 44
Heterogeneity: Tau2=2.50, Chi2=22.11, df=2 (p<0.0001); I2=91% 0.001 0.1 1 10 1000
Test for overall effect: Z=0.29 (p=0.77) Favours operative Favours non-operative

Figure 7 Forest plot for reoperation rate.

Vol. 24 No. 3, December 2016 Operative versus non-operative treatment for displaced intra-articular calcaneal fracture 415
Study or subgroup Operative Non-operative Weight
Events Total Events Total
Buckley et al. 2002 57 206 42 218
Griffin et al. 2014 17 73 3 78
Parmar et al. 1993 8 25 6 31
Thordarson and Krieger 1996 1 15 0 11
Total (95% CI) 319 338
Total events 83 51
Heterogeneity: Chi2=5.44, df=3 (p=0.14); I2=45%
Test for overall effect: Z=3.50 (p=0.0005)
Figure 8 Forest plot for complication rate.
DISCUSSION
In our meta-analysis, operative treatment for
displaced intra-articular calcaneal fractures achieved
better functional outcome but resulted in increased
complications, compared with non-operative
treatment. Patients with operative treatment were
more likely to resume their pre-injury work. Those
involved in light-to-moderate work may achieve
better recovery after operative treatment, but patients
engaged in heavy work are unlikely to recover well
regardless of treatment type.6 Patients with operative
treatment have a significantly shorter absence from
work.17 They also have better functional outcome
and less pain when the Bohler angle is restored and
anatomic reduction achieved.6 Nonetheless, anatomic
restoration of the angle is not associated with the
clinical outcome.14
Patients with operative treatment have fewer
problems in wearing shoes (probably owing to
restoration of the calcaneal width) and less pain
(although not significantly). They have a significantly
longer pain-free walking distance (4 vs. 1 km) and a
larger range of subtalar movement.13
According to the Cochrane review, it remains
unclear whether the potential advantages of
operative treatment outweigh the risks. Compared
with patients with non-operative treatment, patients
with operative treatment have a better physical
component summary score but comparable mental
component summary score and AOFAS score.18,19
Nonetheless, patients with operative treatment
have a higher rate of complications, up to 54%.20
Operative treatment may not be appropriate for
patients with comorbidities such as peripheral
vascular disease, diabetes mellitus, smoking habit,
fracture blisters, delayed presentation, and severe
associated injuries.21
Risk ratio M-H, Risk ratio M-H,
fixed, 95% CI fixed, 95% CI
82.2% 1.44 (1.01, 2.04)
5.8% 6.05 (1.85, 19.81)
10.8% 1.65 (0.66, 4.14)
1.2% 2.25 (0.10, 50.54)
100% 1.74 (1.28, 2.37)
0.01 0.1 1 10 100
Favours operative Favours non-operative
Percutaneous screw insertion for displaced
intra-articular calcaneal fractures achieves excellent
outcome.22,23 Percutaneous distractional reduction
and fixation is a safe technique and achieves good
outcome and an acceptable complication rate.24 It
achieves comparable outcome compared with open
reduction and internal fixation through a lateral
extensile approach, with significantly fewer wound-
related complications.25 The percutaneous approach
can avoid soft-tissue complications,26 and is an
alternative for moderately displaced type-II fractures.
It provides adequate control during anatomic joint
reduction with either subtalar arthroscopy or high-
resolution fluoroscopy.27
Patients with non-operative treatment have a
higher reoperation rate but not significantly. The most
frequent revision surgery is subtalar arthrodesis.
Operative treatment to restore the anatomy of the
calcaneus renders the subsequent surgery less
challenging.
One limitation of this review was the lack of a
standardised outcome assessment system. This may
have led to loss of data for meta-analysis and reduced
the reliability of the conclusions. Other limitations
were the small sample size and varying follow-up
periods.
CONCLUSION
Operative treatment for displaced intra-articular
calcaneal fractures results in a higher rate of return
to pre-injury work but a higher rate of complications.
DISCLOSURE
No conflicts of interest were declared by the authors.
416 S Meena et al. Journal of Orthopaedic Surgery

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