this study was a controlled clinical trial aiming to compare the outcomes of open reduction and rigid internal fixation of displaced calcaneal fractures with that of non operative treatment .
the research proposal of this study was approved by research department of isfahan university of medical sciences .
from december 1998 until january 2009 , 72 patients with displaced intra - articular calcaneal fractures admitted in kashani university hospital and were randomly allocated to surgical and non surgical groups .
first group underwent open reduction and internal fixation with reconstruction plate and screws fixation and the other group were treated with closed reduction and cast immobilization.13 data were collected by clinical observation and a questionnaire six months following surgery .
some reasons that patients were not selected for surgery were as follows : patient disagreement with surgery , open fractures ( not suitable for open reduction internal fixation ) , combined injuries ( head trauma , cardiovascular disorders , severe osteoporosis ... ) also were not suitable for surgery179 and severe comminution .
post - operative exam after two weeks , one month , three months , six months and one year was recorded .
roentgenography was obtained and physical examination including pain scoring , swelling , limitation of activities , shoe wearing difficulties , range of motion and osteoarthritis in ankle and subtalar joints as well as patient satisfaction were also scored and recorded .
functional scoring based on kerr 's meta - analysis and pain scoring was used.1121 data were analyzed by spss 18 software .
seventy two patients with mean age 49 years ( 21 - 84 years old ) were included .
eleven patients were excluded from the study ( unable to follow up after hospital discharge ) .
eventually , 61 cases of calcaneal fractures enrolled and were also followed - up for averagely 3 years .
patients in operation group sub - classified in two categories : first group comprised of 17 cases with essex - lopresti technique ( under fluoroscopy - x - ray control , closed reduction , internally fixed with pin fixation , and cast immobilization).22 second group consisted of 14 cases with open reduction with lateral calcaneal approach and fixation with reconstruction plate ( figure 4 ) .
ambulation with crutch walking and non - weight bearing continued for 6 - 10 weeks after surgery .
lateral calcaneal approach with exostosectomy thirty cases had non - surgical treatment , with splinting , ice pack , elevation the limb , then short leg cast and ambulation with crutch walking and non weight bearing . in non - surgery
group ambulation with crutches started 3 days after casting and cast was removed after 6 weeks and physical therapy , home exercises and partial weight bearing was recommended .
the findings regarding the comparison between two groups for different variables are shown in table 1 .
fracture classification ( sander s ) in post operation examinations , range of motion of ankle in both groups were good ( more than 50% of r.o.m ) but in subtalar joints decreased range of motion in non - operative group compared to operative group was obtained ( odds ratio : 6.75 , p = 0.002 ) .
last x - ray examinations showed that traumatic osteoarthritis ( degenerative joint disease ) in non - operative group was a major problem ( 26% compared to 9% in operative group ) .
shoe fitting difficulties was also a major problem ( 50% in non - operative compared with 12% in operative group).18 pain in walking was 63% in conservative group compared to 29% in operative group ( odds ratio : 6.72 , p = 0.001).2122 swelling in ankle and foot , reflex sympathetic dystrophy including focal osteoporosis and or spotty osteoporosis in non operative group was twice more than operative group ( 6 cases versus 3 cases ; odds ratio : 6.80 , p = 0.001 ) ( table 2 ) .
our findings showed that open reduction and internal fixation of displaced calcaneal fractures in absence of open fracture , severe osteoporosis , or comminution and poor general condition may be the preferred method of treatment .
although surgical treatment of calcaneal fractures has recently received attention owing to good results and less morbidities,13911 most of orthopaedic surgeons prefer to treat them conservatively , probably because of many complications including post operative infections , wound dehiscence , malreductions and long term osteoarthritis .
most of calcaneal fractures are intra - articular and displaced . on the other hand , many of these fractures have ecchymosis , swelling , and blister which increase risk of open reduction and internal fixations ( fracture- blister).14 thornes et al.15 showed that surgically treated calcaneal fractures have better prognosis compared with those conservatively treated .
burdeaux 's work also showed that shoe fitting and weight bearing difficulties were less in those underwent operation.16 pain in daily living activities were dramatically less in patients with open reduction and internal fixation , and range of motion in ankle and subtalar joints were desirable.1720
open reduction and internal fixation of displaced calcaneal fractures in absence of open fracture , severe osteoporosis , or comminution , poor general condition may be the preferred method of treatment .
young and middle aged patients with calcaneal fracture who are in sander 's type ii and iii with mild comminution due to minor trauma , without soft tissue injuries may be the best candidates for open reduction and internal fixation .
mhn and fmm participated in the design study , conduct the study and prepared the manuscript .
 background : the aim of this study was to compare outcomes of open reduction and rigid internal fixation of displaced calcaneal fractures with that of non operative treatment.methods:seventy two consecutive patients with displaced intra - articular calcaneal fractures were selected regarding inclusive and exclusive criteria and then were randomly allocated to surgical and non surgical groups . 
 first group underwent open reduction and internal fixation with reconstruction plate and screws fixation and the other group were treated with closed reduction and cast immobilization . 
 data were collected by clinical observation and a check list . 
 data was analyzed by chi - square and student 's t-test.results:the results showed significant difference between outcomes of surgical treatment and nonsurgical method ( p = 0.001 ) . 
 there were some differences between two methods in terms of decreasing pain [ odd ratio ( or ) : 6.72 , p = 0.001 ] , swelling ( or : 6.80 , p = 0.001 ) , increased range of motion of the joints ( p = 0.001 ) , decreased late osteoarthritis ( or : 2.33 , p = 0.22 ) in favor of surgical group.conclusions:open reduction and internal fixation of displaced calcaneal fractures in absence of open fracture , severe osteoporosis , or comminution , poor general condition may be the preferred method of treatment . 
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Authors Contributions