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Published on: November 8, 2024
Nonoperative Treatment of Intra-articular Calcaneus Fractures Is Associated With Lower Rates of Certain Long-term
Ava M McKane1, N Reid Kiritsis1, Karl V Mohr1
1Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Background:
Management of displaced intra-articular calcaneus fractures remains controversial. While operative techniques are well-described, few large-scale studies have compared long-term outcomes between operative vs nonoperative treatment. Conservative management may limit soft-tissue complications, while operative treatment may improve alignment and potentially reduce the risk of posttraumatic arthritis.
Methods:
The TriNetX Research Network, including 140 million patient records, was used to identify patients with displaced intra-articular calcaneus fractures using ICD-10 codes S92.061, S92.062, S92.063 over a 20-year period. Patients were stratified into operative (CPT: 28415, 28420, 28406) and nonoperative (CPT: 28400, 28405) cohorts. Patients with polytrauma or incomplete records were excluded. Propensity score matching adjusted for demographics and comorbidities, yielding 1260 patients per group. Primary outcomes included any adverse event within 90 days and posttraumatic osteoarthritis, nonunion, malunion, and conversion to subtalar fusion at 2 and 5 years. Statistical analyses included t test, χ2, and odds ratios with 95% CIs (P < .05).
Results:
Baseline demographics and comorbidities were balanced between groups. At 90 days, operative treatment was associated with significantly higher rates of overall adverse events (8.5% vs 3.6%, OR 2.51, P < .001) and lower emergency department utilization (11.5% vs 21.6%, OR 0.47, P < .001). At 5 years, operative patients experienced higher rates of posttraumatic osteoarthritis (6.1% vs 3.8%, OR 1.64, P = .008) and implant-related complications (3.6% vs 1.3%, OR 2.71, P < .001). Nonunion, malunion, and subtalar fusion rates were similar at all time points.
Conclusion:
Operative treatment was associated with higher rates of certain complications. Findings should be interpreted cautiously given limitations, including coding variations, lack of surgical specifics, and inability to stratify by fracture severity. The observed associations do not establish causality, as fracture severity is a critical determinant of outcomes and treatment selection, although the findings are important for informing future studies. Prospective studies incorporating fracture classification, cost-analysis, and patient-reported outcomes are needed.
Level Of Evidence:
Level III, retrospective analysis.
