Open reduction and internal fixation (ORIF) versus ORIF and primary subtalar arthrodesis for complex displaced intraarticular calcaneus fractures

Abstract

Objectives: To determine the optimal patient-oriented treatment between open reduction and internal fixation (ORIF) with or without primary subtalar arthrodesis (PSTA) for patients with displaced intraarticular calcaneus fractures (DIACFs, OTA 82-C3 and C4). Design: Expected value decision analysis. Setting: Academic military treatment facility Participants: One hundred randomly selected volunteers. Intervention: Hypothetical clinical scenario involving ORIF versus ORIF with PSTA. Main outcome measurements: Decision analysis was used to elucidate the superior treatment option based on expected patient values, composed of: the product of the average outcome probabilities established by previously published studies and the average ascribed patient utility values for each outcome probability. One-way sensitivity analysis was performed to quantify the amount of change required for the inferior treatment to equal or surpass the superior option. Results: Expected values for ORIF and ORIF with PSTA were 8.96 and 18.06, respectively, favoring ORIF with PSTA. One-way sensitivity analysis was performed by artificially decreasing the rate of secondary fusion following isolated ORIF thus increasing its overall expected value. Adjusting the rate of secondary fusion to 0%, the expected value of ORIF with PSTA nearly doubled that of ORIF (18.06 vs 9.45). Similarly, when adjusting the moderate and severe complication rates following ORIF with PSTA to 100%, the expected value of ORIF with PSTA still exceeded that of ORIF (15.45 vs 8.96, and 13.52 vs 8.96, respectively). Conclusion: Expected value decision analysis favors ORIF with PSTA as the optimal treatment for complex DIACF.

Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures

“…14,28,41 More recent studies have produced promising results with ORIF and primary STA (PSTA) of comminuted DIACFs in the acute or subacute setting. 9,10,14,18,28 There are not, however, extensive studies on this scenario in the worker's compensation population.…”

“…Previous studies of ORIF+PTSA primarily included Sanders IV fractures with few Sanders II and III fractures. 9,18,28,40 Biopsychosocial factors and the economic impact of trauma should be considered in the shared decision making with patients. 37,38 The purpose of this study is to examine the radiographic and clinical outcomes in DIACFs after ORIF+PSTA using a screws-only construct via a sinus tarsi approach.…”

“…3,6,8,26,45 Studies suggest that the amount of comminution and posterior facet depression contribute to patient outcomes with a normal Bohler angle being associated with better outcomes in both operative and nonoperative treatment. 14,18,41 Although operative treatment in certain conditions and populations can lead to better outcomes, these benefits are only evident once the worker’s compensation population is excluded from analyses because of very poor outcomes in the worker’s compensation group. 11 This demonstrates that there are biopsychosocial components that contribute to the outcome.…”

“…Previous studies of ORIF+PTSA primarily included Sanders IV fractures with few Sanders II and III fractures. 9,18,28,40 Biopsychosocial factors and the economic impact of trauma should be considered in the shared decision making with patients. 37,38…”