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Back to Journal »Treatment and Clinical Risk Management» Volume 14

Author Bulut T, Gursoy M, Ozturk T, Ozcan C, Sener M

Published on September 11, 2018, Volume 2018: 14 pages, 1665-1670 pages

DOI https://doi.org/10.2147/TCRM.S146530

Single anonymous peer review

Editor who approved for publication: Professor Garry Walsh

Tugrul Bulut, 1 Merve Gursoy, 2 Tahir Ozturk, 1 Cem Ozcan, 1 Muhittin Sener, 1 Orthopedics and Traumatology, Ataturk Training and Research Hospital, Katipu Celebi University, Izmir, Izmir, Turkey; 2 Department of Radiology, Ataturk Training and Research Hospital, Izmir Katipu Celebi University, Izmir, Turkey Purpose: The purpose of this study is to determine whether tricortical iliac autograft is Sanders 3-4 Type calcaneal fracture fixation provides the added benefit of a locking plate. Materials and methods: The study included 29 calcaneal fractures (Sanders Type 3/4=15/14). All fractures were fixed with an extended lateral approach locking plate. Bone grafts were used in 16 cases (group A; Sanders 3/4=7/9) and 13 cases (group B; Sanders 3/4=8/5) were not used for calcaneal fractures. As a graft material, only tri-cortical iliac crest bone autograft was used. All operations are performed by the same surgeon. All fractures use the same locking plate. The height and angle of the calcaneus of the two groups of Bohler and Gissane were measured in the early postoperative and final control X-rays. Clinical evaluation was performed using the American Orthopedic Foot and Ankle Joint Association's Hindfoot Ankle Scale. Results: In terms of clinical results, there was no difference between the groups. Radiologically, there was no difference in the degree of change of Bohler's angle, Gissane's angle, and calcaneal height among the groups. Conclusion: Bone grafts do not affect the clinical and radiological results of Sanders type 3-4 calcaneal fractures with locking plate fixation, and they have no additional benefits for stabilization. We believe that the use of a locking plate is sufficient, and bone grafting is not required. Keywords: calcaneal fracture, Sanders type 3-4, locking plate, autologous bone graft

Calcaneus fracture is the most common tarsal fracture. Approximately 75% of calcaneal fractures are intra-articular fractures. 1,2 Displaced intra-articular fractures of the calcaneus occur due to talar impingement. These are usually high-energy injuries. 3,4 The talar impact resulted in collapse and fragmentation of the back of the calcaneus, which can be clearly seen on a computed tomography (CT) scan. Sanders et al.5 classified calcaneal fractures based on the number of fractures of the posterior articular surface of the calcaneus. This classification is of prognostic importance. 6 The prognosis of Sanders type 3 and 4 fractures is worse than other types.

Calcaneus fractures have long been considered to have various complications and poor functional outcomes. Compared with other orthopedic injuries and other health problems (such as myocardial infarction and organ transplantation), displaced intra-articular fractures of the calcaneus are currently not functioning as expected. 7 Sanders type 3 and type 4 fractures are especially an important cause of labor loss and socioeconomic problems.

Surgery is usually recommended for displaced intra-articular fractures of the calcaneus. 8,9 One of the main goals of surgical treatment is the anatomical reduction of the posterior articular surface. The spongy bone defect occurs after the collapse of the posterior articular surface is reduced. Grafting is a method often used to form defects. In the literature, there are different views on the subject of the necessity and effectiveness of the use of these grafts. 9-12

The purpose of this study was to investigate whether the tricortical iliac crest bone autograft made an additional contribution to the stability of Sanders type 3 and 4 fractures fixed with locking plates. The clinical and radiological results of the tricortical iliac crest bone autograft were also evaluated.

This retrospective study was approved by the Institutional Review Board of our hospital (Izmir Katip Celebi University Non-interventional Clinical Studies Institutional Review Board; IRB: 177). Due to the retrospective nature of the study, the informed consent of patients and providers is not required. The patient’s consent is not required to view the medical records, because all data is de-identified. All methods were performed in accordance with approved guidelines.

In this study, Sanders type 3 and type 4 displaced intra-articular calcaneal fractures were fixed with a locking plate and a lengthened lateral approach between 2013 and 2016. The age is <18 years or the follow-up period is <6 months. This retrospective study included 29 fractures in 27 patients, including 4 women and 23 men, with an average age of 41.48±11.33 (range, 22-59) years, Sanders type 3 (n=15) and type 4 ( n=14) Fracture (posterior articular surface step> 2 mm, calcaneal height decreased, and Bohler angle decreased). Two patients were determined to have bilateral calcaneal fractures.

All fractures were operated by the same surgeon, and all cases used the same type of locking plate (Lowprofile Calcaneus Interlocking Plate, TST, Istanbul, Turkey) (Figure 1). Sixteen calcaneal fractures (Sanders Type 3/4=7/9) used grafts, and 13 fractures (Sanders Type 3/4=8/5) did not use grafts. As a graft material, only tri-cortical iliac crest bone autograft was used. In any case, no donor site complications were observed. Fractures with grafts are called group A, and those without grafts are called group B.

Figure 1 (A) Preoperative X-ray of a patient with Sanders type 4 calcaneal fracture, (B and C) Preoperative coronal and sagittal CT images of the same patient, (D) Early postoperative X-ray of the patient. Abbreviation: CT, computer tomography.

All patients were followed up in accordance with the standard postoperative follow-up plan for calcaneal fracture surgery established by our clinic. Based on this, all patients were fixed with a short-leg brace for 2 weeks postoperatively. After removing the brace, start active and passive ankle exercises. Partial weight-bearing activities begin in week 6, and full weight-bearing is allowed in week 12.

No necrosis was observed in the skin flaps of any patients. One case (1/29=3.5%) had a superficial infection, which was completely cured after oral antibiotic treatment. One case (1/29=3.5%) developed a deep infection, and antibiotic treatment did not improve. The steel plate was taken out at the 10th month after the operation. Since the fracture was healed, no additional fixation was performed after the plate was removed. The two patients who developed infection belonged to the graft-used group (2/16=12.5%).

In all patients, the Bohler angle, Gissane critical angle, and calcaneal height were measured during the early postoperative X-rays (day 0 or day 1 after surgery) and the final follow-up examination (at the earliest 3 months after the start of the full examination) . Weight-bearing, ≥6 months). By comparing these two values, record any changes (if any) in the angle and height values ​​since the beginning of the full load. By comparing the loss of the final measurement values ​​between the two groups, it is determined whether the use of tricortical iliac crest bone autograft has any additional contribution to the stability of Sanders type 3 and type 4 calcaneal fractures. Lock the board.

The American Orthopaedic Foot and Ankle Society (AOFAS) Posterior Ankle Scale was used for clinical evaluation during the final follow-up examination. In this 100-point AOFAS scoring system, ≥90 is considered excellent, 80-89 is good, 70-79 is fair, and ≤69 is bad. 13,14

All radiological measurements are performed by independent radiologists, and all clinical evaluations are performed by independent orthopedic experts.

Use IBM SPSS Statistics version 24.0 software (IBM Corporation, Armonk, NY, USA) for data analysis. According to the group, the age distribution used Mann-Whitney U test, the infection rate and gender distribution used Fisher's Exact test, the affected side (right/left) and Sanders fracture type were analyzed by Pearson χ2, and the clinical results were based on the AOFAS score by χ2 trend analysis. Mann-Whitney U analysis was used to compare the early and late radiological measurement results, AOFAS score and postoperative follow-up time of each group. A value of p<0.05 is considered statistically significant.

It was observed that there were no statistically significant differences in age, gender, lateral (right/left) and Sanders fracture type (p>0.05) (Table 1-3) in each group.

Table 1 Age distribution of each group Note: Mann-Whitney U analysis. Group A, fractures with grafts; group B, fractures without grafts.

Table 2 Gender distribution of each group Note: Fisher's exact test. Group A, fractures with grafts; group B, fractures without grafts.

Table 3 Distribution of AOFAS side, Sanders type and clinical results among groups Note: *Pearson χ2, **χ2 trend analysis, ***Fisher's exact test. Group A, fractures with grafts; group B, fractures without grafts. Abbreviation: AOFAS, American Orthopaedic Foot and Ankle Association.

The postoperative follow-up time was 12.25±4.58 months in group A and 11.38±5.47 months in group B. There was no significant difference between the groups (p>0.05) (Table 4).

Table 4 Bohler's and Gissane's angle distribution, height, AOFAS score and inter-group follow-up time Note: Mann-Whitney U analysis. Group A, fractures with grafts; group B, fractures without grafts. Bold text indicates statistical significance​​​ Abbreviation: AOFAS, American Orthopaedic Foot and Ankle Association.

According to the AOFAS score, 62.5% (10/16) of the transplantation group and 69.3% (9/13) of the non-transplantation group achieved excellent and good results. The average AOFAS score in group A was 83.63±10.26, and group B was 87.54±10.6. There was no significant difference between the groups (p>0.05) (Table 3 and Table 4).

No difference was found in the early and late Bohler angle and calcaneal height values ​​between the two groups (p>0.05). The early and late Gissane angle values ​​of group A were lower than those of group B (p<0.05) (Table 4).

Observing the changes in the Bohler angle, Gissane angle and calcaneal height at the last follow-up, the average loss of Bohler angle was 1.54°±1.48° (range, 0°–6.5°) in group A and 1.38°±1.02° (range , 0°–4.1°) in group B, the average Giza internal angle change in group A was 1.86°±1.4° (range, 0°–6.8°) and 1.79 in group B°±0.85° (range, 1.2° -4.2°), the average loss of calcaneal height in group A was 0.98±0.92 (range, 0.03-3.6) mm, 0.81±0.63 (range, group B was 2.2) mm. At the last follow-up examination, there was no statistically significant difference between the groups in the amount of change in the angle and height values ​​(p>0.05) (Table 4).

In group A, 2 cases (2/16=12.5%) were infected, and there was no infection in group B, and the difference was not statistically significant (p>0.05).

Regarding the treatment of displaced intra-articular calcaneal fractures, there is no complete consensus in the literature. 11,15-17 are still looking for new treatments that may be alternatives. 18,19 Open reduction and internal fixation (ORIF) is currently accepted by many authors as the main treatment for displaced intra-articular calcaneal fractures. 8,20 Although there is controversy as to which technique should be used for ORIF, the basic goal of all methods is the anatomical reduction of the posterior articular surface and the articular surface. Anatomical restoration of the height, width and length of the calcaneus. In the literature, the advantages and effectiveness of locking steel plates are very clear. 21-23 However, the necessity and effectiveness of transplantation is still a controversial issue. 9-12

In addition to the role of bone grafting to fill defects, it also has the role of providing mechanical support and promoting bone healing. Therefore, while some authors argue for the necessity of frequent use of grafts, others argue that use is always necessary. 24-27 In some recent studies, it has been reported that the graft has no positive effect on function and radiological results. 8, 12, 28

Duymus et al9 investigated the need for allogeneic cancellous bone grafts during calcaneal fracture surgery, and Singh and Viney10 reported the need for autologous iliac cancellous bone grafts. In these two studies, the clinical and radiological results of Sanders 2-4 displaced intra-articular calcaneal fractures with and without grafts were compared. In any one study, the functional results between the groups were not determined, but the transplantation obtained more satisfactory radiological results. Therefore, Duymus et al. 9 report that bone grafts can be recommended, and Singh and Viney 10 report that large cavities formed after transplant reduction should be considered in the treatment plan. Longino and Buckley12 studied the effect of autologous bone supplementation on quality reduction. In this study, Sanders type 2 and Sanders type 3 and 4 displaced intra-articular fractures of the calcaneus were evaluated. According to reports, bone graft supplements could not determine objective radiological or functional benefits. 12 In contrast to these recent studies, Leung et al.24, 25 pointed out that ORIF with bone grafts is the preferred method of treatment of calcaneal fractures. Although grafts were strongly recommended in earlier studies, in recent studies, the effectiveness and necessity of grafts in calcaneal fractures have become controversial. We believe that due to the current wider use of perioperative imaging methods, established surgical principles, and advanced implantation techniques, this opposite view may arise. Further research is needed on calcaneal fractures with more homogeneous populations. Sanders type 2 and type 4 fractures should not be included in the same cohort. The ideal assessment method is to compare each type of fracture within the group.

In the current study, only Sanders type 3 and type 4 displaced intra-articular calcaneal fractures were evaluated. By using tri-cortical iliac crest bone autograft to provide mechanical support, it is investigated whether there is any additional contribution to stability. In terms of clinical results, no differences were found between the two groups. Radiologically, there was no significant difference in the degree of change of Bohler's angle, Gissane's angle, and calcaneal height between the groups. These results indicate that grafting does not provide additional stability. Although there was no difference in the Bohler angle and calcaneal height in the morning and evening in each group, only the Gissane angle in the morning and evening in group A was lower than that in group B. We believe that this finding is in line with our hypothesis but indicates the quality of fracture reduction, so it will not affect our research conclusions. If these grafts make an additional contribution to the level that affects clinical and radiological results, the loss of Bohler angle and height in the non-graft group after full weight bearing should be at a higher significant level. However, the results of this study showed that there was no difference between patients with and without grafts in terms of the loss rate of the final measurement. This can be explained by the fact that the tricortical iliac crest bone autograft has no additional contribution to the stability and protection of Sanders type 3 and type 4 calcaneal fractures fixed with a locking plate. Therefore, it can be considered that after proper reset, the use of the locking plate for fixing is sufficient.

Studies in the literature indicate that grafts are associated with higher infection rates. 29-31 Benirschke and Kramer32 announced that it was 1.8%, and Sanders et al.5 announced that the deep infection rate after ORIF was 2%. Duymus et al.9 reported that the surface infection rate after ORIF was 12.5%. In our study, 1 case (1/29=3.5%) had a superficial infection, and 1 case (1/29=3.5%) had a deep infection. The two cases of infection were in the transplantation group (2/16=12.5%). Although there was no statistically significant difference, the infection rate was higher in the transplantation group. If we have a larger sample size, this difference may become obvious. The process of autologous bone collection may increase the operation time for calcaneal fractures, so this situation may increase the infection rate.

The advantage of this study is that all operations are performed by the same surgeon, all fractures use the same type of locking plate, only tri-cortical iliac autografts are used, and the clinical and radiological results are evaluated by independent observers. However, the disadvantage of this study is that it was conducted in a cohort that can be considered extremely homogeneous. It is retrospective, so there is no specific randomization method to decide whether to proceed with bone transplantation. The number of patients is very large. And the follow-up time is relatively short. We believe that further research is needed to have a wider and homogeneous series (only Sanders Type 3, only Sanders Type 4).

Since there is no additional positive contribution to the clinical and radiological results, an autologous iliac bone graft should not be considered necessary during calcaneal fracture surgery. It is sufficient to fix it with a locking plate. After considering the potential complications, we believe that autotransplantation is not necessary.

The authors report no conflicts of interest in this work.

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