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Outcome of calcaneal fractures treated operatively and non-operatively. The effect of litigation on outcomes.
Thornes BS, Collins AL, Timlin M, Corrigan J.
Department of Orthopaedic Surgery, Waterford Regional Hospital, Ireland.
Ir J Med Sci. 2002 Jul-Sep;171(3):155-7
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BACKGROUND: The optimum management of calcaneal fractures is controversial. These injuries are frequently associated with compensation litigation, which effects the outcome.
AIMS: To assess the outcome of operatively and conservatively managed intra-articular calcaneal fractures and to examine the effect of compensation litigation on outcome.
METHODS: This was a retrospective study of calcaneal fractures from a single regional trauma unit, with management decided by the admitting consultant surgeon's preference. Fifty-four patients (33 operative, 21 conservative) with an average follow-up of 40 months (range 14-78 months) were reviewed. Sixteen patients (30%) were pursuing a compensation case resulting from the injury.
RESULTS: Despite similar fractures, medical co-morbidity and trauma energy, significantly worse outcome scores were seen in litigants (p < 0.0001). Footwear fitting problems were greater in litigants. Time off work was more than twice that of non-litigants (14.5 vs 6 months, p < 0.01). Results were similar between the operative and non-operative groups in terms of functional score, footwear problems and time off work.
CONCLUSIONS: Litigation was the major determinant of outcome following calcaneal fracture repair; highlighting the unreliability of subjective evaluation in determining outcome in the face of litigation. No subset of patients appeared to significantly benefit from internal fixation of their fracture.
Re: Effect of litigation on calcaneal fracture outcomes
The Effect of Compensation on General Health in Patients Sustaining Fractures in Motor Vehicle Trauma.
Harris IA, Young JM, Jalaludin BB, Solomon MJ. J Orthop Trauma. 2008 Apr;22(4):216-220.
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OBJECTIVES:: The receipt or pursuit of compensation after injury has been associated with poor outcomes. This study aims to determine the association between compensation-related factors and general health in patients with fractures sustained in motor vehicle trauma.
DESIGN:: Prospective survey. SETTING:: Metropolitan trauma centers. PATIENTS/PARTICIPANTS:: The study population was patients aged 18 years and older, presenting acutely with at least one fracture involving the long bones, pelvis, patella, talus, or calcaneus, resulting from motor vehicle trauma, and presenting acutely to 1 of 15 hospitals. INTERVENTION:: Patients were surveyed on admission to determine general factors, injury factors, and socioeconomic factors. Employment status at follow-up, compensation-related factors, and the main outcome variables were measured by survey at 6 months after injury. Multiple regression was used to determine significant predictors of outcome. MAIN OUTCOME MEASUREMENT:: Physical and mental health summaries of the SF-36 General Health Survey.
RESULTS:: Of the 306 patients recruited to the study, five were excluded, and completed questionnaires were available for 232 (75.8%). Claiming compensation was strongly associated with poor physical and mental health on univariate analysis, but it was not significant on multivariate analysis. The use of a lawyer in relation to the injury was the most significant variable associated with poor physical and mental health, after adjusting for other factors.
CONCLUSIONS:: Lawyer involvement, rather than pursuit of compensation, is associated with poor general health after fractures sustained in motor vehicle injuries. Although this may represent a direct effect, further research is recommended to determine the cause for this association.
Re: Effect of litigation on calcaneal fracture outcomes
Long-Term Results of Calcaneal Fracture Treatment by Open Reduction and Internal Fixation Using a Calcaneal Locking Compression Plate from an Extended Lateral Approach.
[Article in Czech]
Zeman P, Zeman J, Matějka J, Koudela K. Acta Chir Orthop Traumatol Cech. 2008;75(6):457-464.
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PURPOSE OF THE STUDY To report on the surgical treatment of intra-articular calcaneal fractures by open reduction and internal fixation with a calcaneal locking compression plate (LCP) from an extended lateral approach, and to retrospectively analyze the mid-term results in a group of patients treated by this technique.
MATERIAL In the period from August 2005 till March 2007, a total of 49 patients with 61 calcaneal fractures were treated. Of these, 11 (18 %) were treated conservatively. Reduction combined with Kirschner-wire fixation was used in four fractrues (6.6 %). Open reduction with internal calcaneal LCP fixation (ORIF- calcaneal LCP) from an extended lateral approach was carried out to treat 46 fractures (75.4 %) in 38 patients. The group evaluated here comprised 29 patients with 33 calcaneal fractures treated by ORIF-calcaneal LCP at a follow-up longer than 6 months. The fractures were classified on the basis of computer tomography (CT) findings as Sanders types I to IV. The group had two woman (6.9 %) and 27 men (93.1 %) with an average age of 34.2 years (range, 19-55 years). In 11 fractures (33.3 %), the primary treatment included filling a central cancellous bone defect area. Calcium phosphate bone substitute material (resorbable ChronOS) was used in nine cases (27.3 %), a self-solidifying hydroxyapatite implant was injected in two (6.1 %) cases (X3 Wright and Norian SRS, respectively), and a bone allograft was implanted in one case (3 %).
METHODS Indicated for surgery were patients with an intra-articular calcaneal fracture, Sanders type II or type III, with articular surface displacement by more than 1 mm. Contraindications included age over sixty years, poor cooperation, smoking habits, peripheral vascular disease or skin infection. Surgery was performed only after oedema had resolved. The aim of our treatment was to achieve anatomical reconstruction of all articular surfaces, to restore the height, length, width and axis of the heel bone, to carry out primary stable osteosynthesis, and to enable the patient to begin rehabilitation with early mobilization. A passive rehabilitation usually started on the first post-operative day, and full weight-bearing of the extremity was allowed not earlier than 3 months post-operatively. Regular check-ups were at 6 weeks, 3, 6 and 12 months and then every year. The mid-term results were evaluated by the system of Rowe et al., scoring rest pain, possibility of return to preinjury jobs, use of walking aids, restriction of physical activity and limping.
RESULTS The most frequent cause of injury was a fall or jump from height; this was recorded in 27 patients (93.1 %). An open fracture was diagnosed on two occasions (6.9 %). Bilateral calcaneal fractrues were found in six patients (20.7 %); four (13.8 %) were treated by bilateral ORIF-calcaneal LPC and two (6.9 %) underwent closed reduction on one and Kirschnerwire transfixation on the other extremity. A combined injury to the musculoskeletal system was diagnosed in 11 patients (38 %), in whom four (13.8 %) had a tibial pylon fracture of the contralateral limb and four (13.8 %) had a thoracolumbar spine fracture. The surgical procedure was performed on average within 11.7 days of injury, and the average hospital stay was 18.2 days (range, 6 to 18 days). Early post-operative complications were recorded in six patients (20.7 %). Wound dehiscence was found in two (6.9 %), necrosis of wound edges in two (6.9 %), and early superficial infection responding to antibiotic therapy also in two patients (6.9 %). Deep infection, non-union or post-operative compartment syndrome were not recorded. Excellent Rowe scores were achieved in 10 patients (34.5 %), good in 15 (51.7 %) and satisfactory in two (6.9 %). Only two patients (6.9 %) reported poor outcome.
DISCUSSION The methods of classification and treatment of calcaneal fractures continue to be a frequently discussed topic. The technique of ORIF-calcaneal LCP from an extended lateral approach has recently been preferred for patients with displaced Sanders type II or III calcaneal fractrues. In agreement with other literature references, this approach allowed us to observe the fracture, to reduce both the subtalar and calcaneocuboid articulations, to stabilize the fracture by internal fixation and to begin early rehabilitation. Because of the risk of early complications, the timing of surgery and a thorough consideration of indications and contraindications are of principal importance.We agree with other authors that filling calcaneal bone defects is not necessary. Pre- and post-operative CT scans are necessary. In accordance with literature data, fractures developing compartment syndrome are indicated for urgent fasciotomy and ORIF-calcaneal LCP should be postponed. In patients with multiple trauma and also in those with open calcaneal fractures, a temporary stabilization with an external fixator medially is performed first, and then converted to a second-stage, ORIF-LCP procedure.
CONCLUSIONS The surgical treatment of displaced intra-articular fractures that involves open reduction from an extended lateral approach and internal fixation with a calcaneal LCP shows very good preliminary results. A CT examination is required for the diagnosis and classification of fractures and a correct indication for surgery. Good timing is of principal importance. An urgent surgical intervention is necessary in open fractures or in those in which soft tissues are squashed by bone fragments. In the other fractures, surgery is carried out after oedema subsidence. Foot compartment syndrome is a serious complication of calcaneal fractures and urgent fasciotomy is the only adequate therapy. Full weight-bearing of the operated extremity depends on the rate of bone healing; it is usually allowed at 3 months after surgery.
Effect of litigation on calcaneal fracture outcomes
Re: Effect of litigation on calcaneal fracture outcomes
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