This Canadian multicenter RCT (1991–1997) randomized 424 patients with 471 displaced intra-articular calcaneal fractures to ORIF via extended lateral approach versus nonoperative care. The primary question: does surgery produce better SF-36 and VAS outcomes at two years? The headline answer depends entirely on who you're treating.
The decision to operate on a displaced intra-articular calcaneal fracture cannot rest on the CT alone. This trial shows that patient factors matter more than fracture pattern in predicting who benefits from surgery.
When you see a non-WC patient who is young (under 29), female, has a light workload, or presents with a Böhler angle above zero, surgery is the better choice — these groups had significantly higher satisfaction scores with ORIF.
When you see a patient over 50, male, with a heavy labor job, a WC claim, or bilateral injuries, nonoperative management is reasonable and spares them a 16% wound complication risk. The 5.5× higher arthrodesis rate in the nonoperative group is the strongest argument for operating in borderline cases. Failing nonoperative care means a salvage fusion, not a second chance at ORIF.
One nuance worth knowing: reduction quality only predicted outcomes after WC patients were excluded. In WC patients, even anatomic reduction did not improve scores. Psychosocial factors dominate over surgical quality in that population.
This Canadian multicenter RCT (1991–1997) randomized 424 patients with 471 displaced intra-articular calcaneal fractures to ORIF via extended lateral approach versus nonoperative care. The primary question: does surgery produce better SF-36 and VAS outcomes at two years? The headline answer depends entirely on who you're treating.
The decision to operate on a displaced intra-articular calcaneal fracture cannot rest on the CT alone. This trial shows that patient factors matter more than fracture pattern in predicting who benefits from surgery.
When you see a non-WC patient who is young (under 29), female, has a light workload, or presents with a Böhler angle above zero, surgery is the better choice — these groups had significantly higher satisfaction scores with ORIF.
When you see a patient over 50, male, with a heavy labor job, a WC claim, or bilateral injuries, nonoperative management is reasonable and spares them a 16% wound complication risk. The 5.5× higher arthrodesis rate in the nonoperative group is the strongest argument for operating in borderline cases. Failing nonoperative care means a salvage fusion, not a second chance at ORIF.
One nuance worth knowing: reduction quality only predicted outcomes after WC patients were excluded. In WC patients, even anatomic reduction did not improve scores. Psychosocial factors dominate over surgical quality in that population.