Open Reduction and Internal Fixation Compared With ORIF and Primary Subtalar Arthrodesis for Treatment of Sanders Type IV Calcaneal Fractures: A Randomized Multicenter Trial

Objectives: To compare long-term health outcome of Sanders type IV calcaneal fractures treated with open reduction and internal fixation (ORIF) versus ORIF plus primary subtalar arthrodesis (PSTA). Design: Randomized prospective multicenter trial. Setting: Four Level 1 trauma hospitals in Canada. Patients: Thirty-one patients with 31 Sanders IV displaced intra-articular calcaneal fractures. Intervention: Seventeen patients were treated with a standard protocol involving a lateral approach for ORIF. Fourteen patients were treated with a standard protocol involving a lateral approach with ORIF + PSTA. Main Outcome Measurements: Health outcomes were assessed with 4 validated instruments: (1) the Short Form 36 version 2 (SF-36), (2) the Musculoskeletal Functional Assessment Survey, (3) the American Orthopaedic Foot and Ankle Society's Ankle-Hindfoot Scale, and (4) the Visual Analogue Scale. Results: From 2004 to 2011, 26 patients (26 displaced intraarticular calcaneal fractures) were followed for a minimum of 2 years (81% follow-up). No statistical difference was found between the results for ORIF compared with ORIF + PSTA: the mean SF-36 physical component scores were, respectively, 30.2 (SD = 11.4) and 37.8 (SD = 10.4) (P = 0.10); the mean Musculoskeletal Functional Assessment Survey scores were 44.2 (SD = 25.6) and 37.9 (SD = 21.5) (P = 0.50); the mean Ankle-Hindfoot Scale scores were 62.5 (SD = 19.6) and 65.8 (SD = 19.2), (P = 0.68); and the mean Visual Analogue Scale scores were 36.8 (SD = 34.7) and 36.0 (SD = 30.7) (P = 0.82). Conclusions: We were unable to demonstrate a significant difference between treating Sanders type IV fractures with either ORIF or ORIF + PSTA. It remains the choice of the surgeon and patient to take into account patient specific factors to determine treatment. However, ORIF + PSTA may be advantageous for both patients with Sanders type IV fractures and the health care system as patients heal quickly. Furthermore, ORIF + PSTA may prevent the need for late secondary subtalar fusion adding to increased costs and lost time from work.