Key messages
• In people who have broken their heel bone, surgery may improve how people use their foot and ankle up to two years after their injury compared to non-surgical treatments.
• Surgery may also reduce the number of people experiencing pain up to two years after injury, and may slightly improve their quality of life.
• The evidence came from only a few small studies that were not always well conducted, meaning that we have little confidence in the findings.
• More well-conducted studies are needed to increase our confidence in the evidence. Future studies should use tools to measure outcomes that are designed specifically for heel bone fractures. They could also test newer surgical approaches that are not included in this review. Sometimes called 'minimally invasive', these newer methods limit the number of cuts or incisions the surgeon is required to make. This could lead to fewer postoperative complications and better long-term outcome for the patient than the other types of surgery included in this review.
Broken heel bones
The calcaneus is a bone in the heel of the foot that helps to support the foot in normal walking. A broken heel bone typically occurs after a fall from a height or a high-impact event such as a car crash, and is more common in young adults. It is a painful injury, and people may not be able to weight-bear (put all their weight on the injured leg) for many weeks after injury. This is likely to limit physical activity and may lead to delays in the person returning to normal activities (such as work).
Treatments for a broken heel bone include:
• surgery using metal plates, screws, or wires to hold the broken pieces of bone together whilst they heal;
• non-surgical treatment in which people will be asked to rest, keep their leg raised, and sometimes use ice to manage any swelling from the injury. People may also wear a plaster cast, a removable cast or splint, or a tight bandage.
For both treatments, it is likely that people will be asked not to weight-bear for at least six weeks.
What did we want to find out?
We wanted to find out whether surgery or non-surgical treatment works best for broken heel bones.
We wanted to know whether these treatments improved function (e.g. how well the person can use their ankle and foot), pain, quality of life, and ability to return to their normal activities (such as work). We were particularly interested in the longer-term impact on people's lives up to about two years after injury. We were also interested in function in the first three months of injury.
We also wanted to find out if the treatments affected the number of complications and what the side effects were of surgical treatment.
What did we do?
We searched for studies that looked at surgery compared with non-surgical treatment in people who were at least 14 years of age. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 12 studies that involved 1097 people with broken heel bones. The average age of study participants was 28 to 52 years, and 86% of participants were men, which is fairly typical for broken heel bones.
We found that compared to non-surgical treatments, surgery may improve function within the first two years, although we were unsure if this improvement was big enough to make an important difference to people. No studies reported function in the first three months after injury.
Surgery may also reduce the number of people with pain and may result in a small but meaningful improvement to people's quality of life up to two years after injury. There may be little or no difference between treatments in the number of people able to return to their normal activities.
In one small study, a single person treated with surgery needed to have an amputation (removing the leg from the knee downwards), with no amputations in the group that had non-surgical treatment; no other studies reported this outcome. There may be no difference between treatment options in the number of people who needed further surgery to fuse the joint around the heel bone.
For those treated with surgery, 14% had a wound infection that could be treated with antibiotics.
What are the limitations of the evidence?
We have little confidence in the evidence because people in the studies were aware of which treatment they received, which could have introduced bias. Also, in some studies people were not randomly placed into the different treatment groups, meaning that differences between groups could be due to differences between people rather than treatments. Furthermore, most studies involved only small numbers of people.
How up-to-date is the evidence?
This is an update of a previous review. The evidence is current to November 2022.
Our confidence in the evidence is limited. Although pooled evidence indicated that surgical treatment may lead to improved functional outcome but with an increased risk of unplanned second operations, we judged the evidence to be of low certainty as it was often derived from few participants in studies that were not sufficiently robust in design. We found no evidence of a difference between treatment options in the number of people who needed late reconstruction surgery for subtalar arthritis, although the estimate included the possibility of important harms and benefits. Large, well-conducted studies that attempt to minimise detection bias and that measure functional outcomes using calcaneal-specific measurement tools would increase the confidence in these findings. Given that minimally invasive surgical procedures are already becoming more prevalent in practice, research is urgently needed to determine whether these newer surgical techniques offer better outcomes with regard to function, pain, quality of life, and postoperative complications for intra-articular displaced calcaneal fractures.
Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures. These fractures are mostly caused by a fall from a height, and are common in younger adults. Treatment can be surgical or non-surgical; however, there is clinical uncertainty over optimal management. This is an update of a Cochrane Review first published in 2013.
To assess the effects (benefits and harms) of surgical versus conservative treatment of displaced intra-articular calcaneal fractures.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, Embase, and clinical trials registers in November 2022.
We included randomised controlled trials (RCTs) and quasi-RCTs comparing surgical versus non-surgical management of displaced intra-articular calcaneal fractures in skeletally mature adults (older than 14 years of age). For surgical treatment, we included closed manipulation with percutaneous wire fixation, open reduction with internal fixation (ORIF) with or without bone graft, or primary arthrodesis. For non-surgical treatment, we included ice, elevation and rest, or plaster cast or splint immobilisation.
We used standard Cochrane methodological procedures. We collected data for the following outcomes: function in the short term (within three months of injury) or long term (more than three months after injury), chronic pain, health-related quality of life (HRQoL) and ability to return to normal activities, as well as complications which may or may not have led to an unplanned return to theatre.
We included 10 RCTs and two quasi-RCTs with 1097 participants. Sample sizes in studies ranged from 29 to 424 participants. Most participants were male (86%), and the mean age in studies ranged from 28 to 52 years. In the surgical groups, participants were mostly managed with ORIF with plates, screws, or wires; one study used only minimally invasive techniques. Participants in the non-surgical groups were managed with a plaster cast, removable splint or a bandage, or with rest, elevation, and sometimes ice.
Risk of performance bias was unavoidably high in all studies as it was not possible to blind participants and personnel to treatment; in addition, some studies were at high or unclear risk of other types of bias (including high risk of selection bias for quasi-RCTs, high risk of attrition bias, and unclear risk of selective reporting bias). We downgraded the certainty of all the evidence for serious risk of bias. We also downgraded the certainty of the evidence for imprecision for all outcomes (except for complications requiring return to theatre for subtalar arthrodesis) because the evidence was derived from few participants. We downgraded the evidence for subtalar arthrodesis for inconsistency because the pooled data included high levels of statistical heterogeneity.
We found that surgical management may improve function at six to 24 months after injury when measured using the American Orthopaedic Foot and Ankle Society (AOFAS) score (mean difference (MD) 6.58, 95% confidence interval (CI) 1.04 to 12.12; 5 studies, 319 participants; low-certainty evidence). We are not aware of a published minimal clinically important difference (MCID) for the AOFAS score for this type of fracture. Previously published MCIDs for other foot conditions range from 2.0 to 7.9. No studies reported short-term function within three months of injury. Surgical management may reduce the number of people with chronic pain up to 24 months after injury (risk ratio (RR) 0.56, 95% CI 0.37 to 0.84; 4 studies, 175 participants; low-certainty evidence); this equates to 295 per 1000 fewer people with pain after surgical management (95% CI 107 to 422 per 1000). Surgical management may also lead to improved physical HRQoL (MD 6.49, 95% CI 2.49 to 10.48; 2 studies, 192 participants; low-certainty evidence). This outcome was measured using the physical component score of the 36-Item Short Form Health Survey. We used a change in effect of 5% to indicate a clinically important difference for this scoring system and thus judged that the difference in HRQoL between people treated surgically or non-surgically includes both clinically relevant and not relevant changes for those treated surgically. There may be little or no difference in the number of people who returned to work within 24 months (RR 1.26, 95% CI 0.94 to 1.68; 5 studies, 250 participants; low-certainty evidence) or who require secondary surgery for subtalar arthrodesis (RR 0.38, 95% CI 0.09 to 1.53; 3 studies, 657 participants; low-certainty evidence). For other complications requiring return to theatre in people treated surgically, we found low-certainty evidence for amputation (2.4%; 1 study, 42 participants), implant removal (3.4%; 3 studies, 321 participants), deep infection (5.3%; 1 study, 206 participants), and wound debridement (2.7%; 1 study, 73 participants). We found low-certainty evidence that 14% of participants who were treated surgically (7 studies, 847 participants) had superficial site infection.