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. 2023 Nov 7;2023(11):CD008628. doi: 10.1002/14651858.CD008628.pub3

Summary of findings 1. Surgical versus non‐surgical management for displaced intra‐articular calcaneal fractures.

Surgical versus non‐surgical management for displaced intra‐articular calcaneal fractures
Population: people aged over 14 years with displaced intra‐articular calcaneal fractures
Setting: treated in hospital
Intervention: surgical management (ORIF, or closed reduction and percutaneous fixation)
Comparison: non‐surgical management (rest, elevation, ice; below‐knee plaster casts, removable splints)
Outcomes Anticipated absolute effects* (95% CI) Relative effect
(95% CI) Number of participants
(studies) Certainty of the evidence
(GRADE) Comments
Risk with non‐surgical treatment Risk with surgery
Function in the short term ‐ ‐ ‐ ‐ ‐ No studies reported function in the first 3 months after injury.
Function in the long term
Measured using AOFAS score (0 to 100, higher scores indicate improved function)
Follow‐up: 6 to 24 months		 Mean scores in the non‐surgical groups ranged from 55 to 76.8. MD 6.58 higher
(1.04 higher to 12.12 higher) ‐ 319
(5 studies) ⊕⊕⊝⊝
Lowa 		The MCID for AOFAS in this fracture type is not established. MCIDs for other foot conditions range from 2.0 to 7.9.
Chronic pain
Measured as number of people experiencing pain
Follow‐up: 6 to 24 months		 Study population RR 0.56
(0.37 to 0.84) 175
(4 studies) ⊕⊕⊝⊝
Lowa 		295 fewer people (95% CI 107 to 422 fewer) had chronic pain up to 24 months after surgery.
670 per 1000b 375 per 1000
(248 to 563)
Health‐related quality of life (physical)
Measured using SF‐36 (PCS) (score 0 to 100, higher scores indicate better physical HRQoL)
Follow‐up: 12 to 24 months		 Mean scores in the non‐surgical group ranged from 37 to 42.5. MD 6.49 higher
(2.49 higher to 10.48 higher) ‐ 192
(2 studies) ⊕⊕⊝⊝
Lowa 		Based on a 5% threshold (or 5 points on a 100‐point SF‐36 scale), this difference includes the possibility of a clinically important difference.
Return to work
Follow‐up: 12 to 24 months		 Study population RR 1.26
(0.94 to 1.68) 250
(5 studies) ⊕⊕⊝⊝
Lowa 		 
603 per 1000b 760 per 1000
(567 to 1000)
Complications requiring unplanned return to theatre
Subtalar arthrodesis
Follow‐up: 2 to 12 years		 Study population RR 0.38
(0.09 to 1.53)		 657
(3 studies)		 ⊕⊕⊝⊝
Lowc 		Other complications requiring unplanned return to theatre:

  • 1/42 (2.4%) participants in surgical groups and 0/40 participants in non‐surgical groups required amputation.

  • 11/321 (3.4%) participants in surgical groups required implant removal.

  • 11/206 (5.3%) participants in surgical groups had deep infection.

  • 2/73 (2.7%) participants in surgical groups required wound debridement in theatre.
131 per 1000b 50 per 1000
(12 to 200)
Complications not requiring unplanned return to theatre
Superficial infection (affecting only participants who had surgical treatment)
Follow‐up: postoperative period		 Study population See comment 847
(7 studies)		 ⊕⊕⊝⊝
Lowa 		59/419 (14%) participants in the surgical groups had superficial infection.
Other complications not requiring unplanned return to theatre:
4/45 (9%) participants in surgical groups had wound dehiscence.
‐ 140 per 1000
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
AOFAS: American Orthopaedic Foot and Ankle Society; CI: confidence interval; HRQoL: health‐related quality of life; MCID: minimum clinically important difference; MD: mean difference; ORIF: open reduction and internal fixation; RR: risk ratio; SMD: standardised mean difference; SF‐36 (PCS): 36‐Item Short Form Health Survey (physical component score)
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level owing to serious risk of bias in the included studies and one level owing to imprecision because the analysis included few participants.
bDerived from the pooled estimate of the non‐surgical treatment group.
cDowngraded one level owing to serious risk of bias in the included studies and one level for inconsistency due to unexplained substantial levels of statistical heterogeneity in the pooled effect.