Bilateral Calcaneal Fractures: Operative Versus Nonoperative Treatment

Abstract

Background: There is poor information in the literature regarding patients who suffer from bilateral calcaneal fractures. The objective of this study was to analyze demographic characteristics and objective clinical features of patients with bilateral calcaneal fractures as well as subjective outcomes following either operative or conservative management. It was a prospective randomized trial. It was performed at four level 1 trauma centers. Methods: Forty-seven patients sustaining bilateral calcaneal fractures were randomized to either operative (open reduction and internal fixation) or conservative treatment groups. Demographic features and fracture patterns were compared between those sustaining unilateral fractures (large calcaneal database) and those sustaining bilateral fractures. Following treatment, comparison of both objective outcome measures (Bohler's angle and subtalar range of motion) and subjective outcomes, as measured by the previously validated visual analogue scale (VAS) and SF-36 scores, was performed. Outcomes were also compared (with existing data from trauma database) for those treated for unilateral calcaneal fracture. Results: No difference in demographic features was found between individuals suffering unilateral and bilateral calcaneal fractures. Among bilaterally injured patients, initial Bohler's angle was slightly, but significantly, more depressed relative to that in the unilateral comparison data ( p < .05). Post-treatment range of motion was significantly better when injury was confined to one side regardless of treatment modality ( p < .01). Surgical intervention did not significantly affect subjective patient outcome as measured by either SF-36 or the VAS. This remained true following stratification by Worker's Compensation Board (WCB) status. However, those who were treated nonoperatively were significantly more likely to require late subtalar arthrodesis ( p < .05). In general, patients whose injury was not associated with a WCB claim demonstrated significantly better subjective outcomes ( p < .01 for SF-36 and VAS). Conclusions: Other than demonstrating a slightly more depressed Bohler's angle, patients sustaining bilateral calcaneal fractures are very similar to those in whom the injury is confined to one side. The evidence presented here does not definitively support primary operative intervention for bilateral calcaneal fractures. Neither objective nor subjective functional outcomes are significantly improved following such intervention. However, careful operative patient selection will minimize complications and lessen the need for late subtalar arthrodesis.