Dept. of Orthopaedic Surgery, Massachusetts General Hospital, MA, USA.
Foot Ankle Int. 2011 Mar;32(3):262-71. doi: 10.3113/FAI.2011.0262.
There appears to be a general lack of consensus in treating calcaneus fractures. Many different patient-based variables such as smoking, diabetes, or occupation, may influence treatment decisions possibly more so than the nature of the injury itself. Indications for operative versus nonoperative treatment are often unclear. The goals of this study were to determine if lack of consensus exists, determine which factors most influence orthopaedic surgeons in choosing operative versus nonoperative treatment and determine if there are differences in treatment based on fellowship training and exposure to these injuries.
Practicing orthopaedic surgeons of various backgrounds and training were administered an electronic survey. The survey consisted of clinical vignettes and questions regarding fellowship training, demographics and exposure to calcaneus fractures. Orthopaedic surgeons were asked to weigh the importance of patient-based variables in determining operative versus nonoperative treatment.
For patients with an uncomplicated medical history, there was a general consensus on treatment as guided by the Sanders classification. For those with a complex medical history, there was less consensus on management despite fracture pattern. Foot & ankle fellowship-trained surgeons (F&AT) ranked calcaneal deformity as more important than trauma fellowship-trained surgeons (NFT), and ranked peripheral vascular disease (PVD)/diabetes mellitus (DM) more important than did both trauma fellowship-trained surgeons (TFT) and NFT surgeons. There was no significant difference in choosing operative versus nonoperative treatment for surgeons treating more calcaneus fractures (more than four per month) versus those who treated fewer (less than one a month).
There was general agreement among surgeons regarding the most important variables for determining management of calcaneus fractures. How this information is utilized varies according to practitioner and leads to varying consensus. There was generalized consensus regarding management in cases of anatomic deformity at either end of the spectrum of severity and non-complex medical histories. When additional confounders were added, the agreement between surgeons declined.
治疗跟骨骨折似乎普遍缺乏共识。许多不同的患者相关变量，如吸烟、糖尿病或职业，可能比损伤本身更能影响治疗决策。手术与非手术治疗的适应证往往不明确。本研究的目的是确定是否存在共识缺失，确定哪些因素最能影响骨科医生选择手术与非手术治疗，并确定是否根据 fellowship 培训和对这些损伤的接触程度存在治疗差异。
对不同背景和培训的骨科医生进行了电子调查。该调查包括临床病例和关于 fellowship 培训、人口统计学和接触跟骨骨折的问题。要求骨科医生权衡患者相关变量在确定手术与非手术治疗中的重要性。
对于无复杂病史的患者，根据 Sanders 分类，治疗方法存在普遍共识。对于有复杂病史的患者，尽管骨折模式不同，但管理方法的共识较少。足踝 fellowship培训医生（F&AT）将跟骨畸形的重要性排在创伤 fellowship培训医生（NFT）之前，将外周血管疾病（PVD）/糖尿病（DM）的重要性排在 NFT 医生之前。治疗更多跟骨骨折（每月超过 4 例）的外科医生与治疗较少跟骨骨折（每月不到 1 例）的外科医生相比，选择手术与非手术治疗的差异没有统计学意义。
外科医生在确定跟骨骨折管理的最重要变量方面存在普遍共识。如何利用这些信息因从业者而异，导致共识存在差异。在严重程度谱的两端和非复杂病史的情况下，对于解剖畸形的管理存在普遍共识。当增加其他混杂因素时，外科医生之间的一致性下降。
