Systematic problems include the impossibility of true blinding with respect to treatment allocation, the great variety of fracture patterns and associated soft-tissue damage, the different patient characteristics such as associated injuries, comorbidities, compliance, and functional demand, the dependence on the surgeon's experience and performance. 5 This fact shows the dilemma of many orthopedic RCT's that are hard to overcome despite enormous efforts and resources that go into these studies. 2, 3, 4 Only 1 small trial showed significantly better outcomes with ORIF. Several prospective-randomized controlled trials (RCT's) have failed to show a significant overall superiority of either treatment at first sight, but have provided the readers with important information when having a closer look at the subgroups of their patient cohorts. 1 The question if operative or nonoperative treatment is better for these injuries is still not answered satisfactorily when applying the principles of evidence-based medicine, but maybe it is not the right question to ask from the beginning. The treatment of displaced, intraarticular calcaneal fractures (DIACF's) continues to generate controversy in the orthopedic community. Introduction: Are We Asking the Right Questions? The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. ![]() There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. ![]() To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. ![]() If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. Surgical treatment of these injuries is challenging and have a considerable learning curve. The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial.
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