Cost-Effectiveness of Operative Versus Nonoperative Management of Patients With Intra-articular Calcaneal Fractures.

OBJECTIVE: To assess the costs, health gains, and cost-effectiveness of operative versus nonoperative treatment of calcaneal fractures over a 5-year time horizon from both US societal and payer perspectives. METHODS: The societal perspective analysis included both direct medical costs and costs for missed work, whereas the health care payer perspective analysis included only direct medical costs associated with treatment and complications. A decision tree simulation model was developed to estimate the direct medical and indirect costs (2018 US$) and quality-adjusted life-years (QALYs) for treatment of patients sustaining intra-articular calcaneal fractures fixed with an extensile lateral approach. Direct medical costs were obtained from a large US health care system in Utah, Intermountain Healthcare, and indirect costs from the literature. Utility and probability parameters were also derived from the literature. Parameter uncertainty was explored using both one-way and probabilistic sensitivity analysis. RESULTS: From a US societal perspective, operative treatment costs less ($35,110 vs. $39,870) and yielded more QALYs (3.89 vs. 3.51) over 5 years compared with nonoperative treatment. At a willingness-to-pay threshold of $50,000 per QALY, operative fixation had an 89% probability of being cost-effective. From a health care payer perspective, operative management remained cost-effective as the incremental cost-effectiveness ratio is below the willingness-to-pay threshold of $50,000/QALY. CONCLUSION: From both US societal and health care payer perspectives, operative treatment of displaced intra-articular calcaneal fractures utilizing an extensile lateral approach is cost-effective at commonly accepted willingness-to-pay thresholds compared with nonoperative treatment over a 5-year time horizon. Patient variability may impact cost-effectiveness and should be explored in future research. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Timing of initiating manual therapy and therapeutic exercises in the management of patients after hindfoot fractures: a randomized controlled trial.

STUDY DESIGN: Randomized clinical trial. BACKGROUND: Patients with fractures to the talus and calcaneus report decreased functional outcomes and develop long-term functional limitations. Although physical therapy is typically not initiated until six weeks after fixation, there's little research on the optimal time to initiate a formal physical therapy program. OBJECTIVES: To assess whether initiating physical therapy including range of motion (ROM) and manual therapy two weeks post-operatively (EARLY) vs. six weeks post-operatively (LATE) in patients with fixation for hindfoot fractures results in different clinical outcomes. METHODS: Fifty consecutive participants undergoing operative fixation of a hindfoot fracture were randomized to either EARLY or LATE physical therapy. Outcomes, including the American Orthopedic Foot and Ankle Society Hindfoot Scale (AOFAS), the Lower Extremity Functional Scale (LEFS), active ROM, swelling, and pain, were collected at three and six months and analyzed using linear mixed-modeling to examine change over time. Adverse events were tracked for 12 months after surgery. RESULTS: The EARLY group demonstrated significantly larger improvements for the AOFAS (p = .01) and the LEFS (p = .01) compared to the LATE group. Pairwise comparison of the LEFS favors the EARLY group at 6 months [7.5 (95%CI -.01 to 15.0), p = .05]. There were no differences between the groups with regard to ROM, pain, and swelling. The LATE group incurred increased adverse events in this study. CONCLUSION: Initiating early physical therapy may improve long-term outcomes and mitigate complications in patients after hindfoot fractures. LEVEL OF EVIDENCE: Therapy, level 2b.

Plantar Pressure and Gait Symmetry in Individuals with Fractures versus Tendon Injuries to the Hindfoot.

BACKGROUND: The intent of this study was to determine whether differences in function, walking characteristics, and plantar pressures exist in individuals after operative fixation of an intra-articular calcaneal fracture (HFX) compared with individuals with operative repair of an Achilles tendon rupture (ATR). METHODS: Twenty patients (ten with HFXs and ten with ATRs) were recruited approximately 3.5 months after operative intervention. All of the participants completed the Lower Extremity Functional Scale and had their foot posture assessed using the Foot Posture Index. Walking velocity was assessed using a pressure mat system, and plantar pressures were measured using an in-shoe sensor. In addition to between-group comparisons, the involved foot was compared with the uninvolved foot for each participant. RESULTS: There were no differences in age, height, weight, or number of days since surgery between the two groups. The HFX group had lower Lower Extremity Functional Scale scores, slower walking velocities, and different forefoot loading patterns compared with the ATR group. The involved limb of both groups was less pronated. CONCLUSIONS: The results indicate that individuals with an HFX spend more time on their involved limb and walk slower than those with an ATR. Plantar pressures in the HFX group were higher in the lateral forefoot and lower in the medial forefoot and in the ATR group were symmetrically lower in the forefoot.

Biomechanics and pathophysiology of flat foot.

When the foot works properly it is an amazing, adaptive, powerful aid during walking, running, jumping, and in locomotion up or down hill and over uneven ground. Dysfunction of the foot can often arise from the foot losing its normal structural support, thus altering is shape. An imbalance in the forces that tend to flatten the arch and those that support the arch can lead to loss of the medial longitudinal arch. An increase in the arch-flattening effects of the triceps surae or an increase in the weight of the body will tend to flatten the arch. Weakness of the muscular, ligamentous, or bony arch supporting structures will lead to collapse of the arch. The main factors that contribute to an acquired flat foot deformity are excessive tension in the triceps surae, obesity, PTT dysfunction, or ligamentous laxity in the spring ligament, plantar fascia, or other supporting plantar ligaments. Too little support for the arch or too much arch flattening effect will lead to collapse of the arch. Acquired flat foot most often arises from a combination of too much force flattening the arch in the face of too little support for the arch. Treatment of the adult acquired flat foot is often difficult. The clinician should remember the biomechanics of the normal arch and respond with a treatment that strengthens the supporting structures of the arch or weakens the arch-flattening effects on the arch. After osteotomies or certain hindfoot fusions, the role of the supporting muscles of the arch, in particular the PTT, play less of a role in supporting the arch. Rebalancing the forces that act on the arch can improve function and lessen the chance for further or subsequent development of deformity.

Rotational stability of a modified step-cut for use in intercalary allografts.

BACKGROUND: Intercalary allografts are used for the reconstruction of major skeletal defects. Step-cuts help to provide rotational stability when intramedullary fixation is used. A modified step-cut is proposed to reduce rotation at the interface. This study compares the rotational stability of conventional and modified step-cuts. METHODS: In Phase I, seven pairs of human cadaveric femora were divided into a conventional step-cut group (left femora) and a modified step-cut group (right femora). All femora were cut transversely at the mid-diaphysis. In the conventional group, a 1-cm step-cut was created in the exact midsagittal plane in both the proximal and distal segments. In the modified group, a 1-cm step-cut was created in the parasagittal plane, leaving 2 mm of additional bone on both the proximal and the distal fragment. Phase II was identical except that in the modified step-cut group only 1 mm of additional bone was left. Smooth femoral nails were then placed after standard reaming. Specimens were tested by fixing the proximal segment and applying +/-2 N-m (17.7 in-lb) of torque to the distal segments with ten oscillation cycles. Maximum rotation was measured. The data were analyzed with the paired Student t test. RESULTS: The average rotation in Phase I was 23.3 degrees for the conventional step-cut group and 3.0 degrees for the 2-mm modified step-cut group; the difference was significant (p < 0.001). Four femora sustained an incomplete fracture during nail insertion. The average rotation in Phase II was 20.6 degrees for the conventional step-cut group and 0.5 degrees for the 1-mm modified step-cut group without any fractures; the difference was significant (p < 0.001). CONCLUSIONS: Step-cut modification that leaves more bone in the sagittal plane provides rigid fixation and significantly more stability than the conventional step-cut technique.