Surgical Treatment of Displacedintra-Articular Calcaneal Fractures: Is Bone Grafting Necessary?

SLR- January 2014- Pauline Seymour

Singh AK and Vinay K. Surgical Treatment of Displaced Intra-articular Calcaneal Fractures: Is Bone Grafting Necessary? Journal of Orthopaedic Traumatology. 2013;1-7.

 

Scientific Literature Review

Reviewed By: Pauline Seymour, DPM
Residency Program: St. John Hospital and Medical Center
 

Podiatric Relevance: Displacedintra-articular calcaneal fractures account for 60-75 percent of all calcanealfractures and have a high morbidity rate. Approximately 20 percent of these patients are unable to return to work within a year. The need for bone graft in the treatment of these fractures is still controversial. The rationale for surgeons in favor of bone grafting is that it could stimulate fracture healing, lead to early full weight-bearing, may prevent post-traumatic arthritis and increasing mechanical strength and help prevent late collapse. Surgeons that oppose bone grafting state the highly vascular calcaneusheals radiographically in four to eight weeks after surgery without the aid of bone graft, internal fixation can support the articular surface and bone grafting increases infection rate, blood loss, post-operative pain and donor sitemorbidity and complications can also occur with harvesting autograft. The purpose of this study was to compare the outcomes and complications of displaced intra-articular calcaneal fractures treated by open reduction and internal fixation with or without autologousiliac bone graft.

Methods:Three hundred and ninety patients with a displaced intra-articular calcaneal fracture from December 2002 to December 2010 treated with open reduction and internal fixation either with (group A) or without bone graft (group B) were included in the study. The inclusion criteria consisted of unilateral, displaced intra-articular calcaneal fractures [posterior articular facet step-off more than 2 mm, significant shortening, loss of height, and widening of the calcaneus, i.e. decreased Bohler’s and Gissane’s angle, valgus deviation > 10°, varus deviation > 5°] of Sanders type II, III, or IV, age greater than or equal to 18 years and a follow-up period of at least two years. Bilateral calcaneal fractures, open fractures and fracture in patients < 18 years old were excludes from the study. Two hundred and two patients were in group A and one hundred and eighty-eight patients were in group B. One hundred and eighty-one patients had Sanders type II, one hundred and eighty-two patients had Sanders type III and twenty-seven patients had Sanders type IV fractures. The average age for group A was 40.0 years and 41.2 years for group B. Gender, the side fractured and fracture type were similar in both groups. All patients were operated on between seven to 10 days after injury, had either general or spinal anesthesia, were placed in a lateral decubitus position and had an extended lateral approach incision performed. Locking plates and screws were used and the restoration of the calcaneus was the main goal of open reduction. Cancellous autograft was taken from the ipsilateral iliac crest in the group A patients. Standard postoperative protocol was followed. The type of facture that had occurred was assessed with X-ray films. Preoperative CT scans were used to classify the fractures according to the Sanders classification. Immediate post-operative X-rays (taken on the second or third day) were compared with the two-year follow-up visit. Bohler’s angle, the crucial angle and height of the calcaneus were measured and any changes in parameters were documented and analyzed. The overall patient outcome were evaluated by the AOFAS Ankle-Hindfoot Scale and compared in both groups.
 

Results: There was an average follow-up of two years for both groups. The average hospital stay for patients in group A was 20.20 ± 5.2 days and 19.02 ± 4.8 days for patients in group B, resulting in no significant difference between the two groups. There was a significantly lower mean time to full weight-bearing in group A (6.2 ± 1.7 months) than group B (9.8 ± 1.5 months). The subtalar joint reduction was shown to be satisfactory with no significant difference between the two groups on comparing the good reduction rate. Radiographic comparison of immediate-postoperative and at the two-year follow-up showed changes in Bohler’s angle, crucial angle, and the height of the calcaneus. Bohler’s angle was significantly higher in group A at the two-year follow-up. The loss of Bohler’s angle was significantly lower in group A (3.5 ± 1.4°) than in group B (6.2 ± 2.5°) after two years. The crucial angle average change was 3.8 ± 1.8° for group A and 3.6 ± 2.1° for group B. The calcaneal height average change was 2.8 ± 1.4 mm for group A and 2.5 ± 1.2 mm for group B. The results were not statistically significant for either group. The mean AOFAS score was lower in group A (76.4 ± 5.4 points) than in group B (81.6 ± 4.8 points), but no significant difference was found. The outcome of treatment was excellent in 32 percent, good in 39 percent, fair in 24 percent and poor in 4 percent of the patients in group A compared to 33 percent excellent, 43 percent good, 19 percent fair and 4 percent poor for the patients in group B. This difference was not significant. Complications of subtalar arthrosis occurred in 50 patients (27 in group A and 23 in group B with no significant difference). There were 26 patients with superficial wound dehiscence and 25 patients had wound infection. No donor-site wound complications existed. Postoperative subtalar fusion rate was 3.2 percent in group A and 3.4 percent in group B. The infection rate was higher in group A than in group B, although neither was significantly different.

Conclusions: The incorporation of bone graft with open reduction and internal fixation of an intra-articular calcaneal fracture has become increasingly popular, but is still a topic of debate. In a nation-wide survey of the Netherlands, surgeons who operated on the ORIF group revealed that 20 percent used bone graft, 42 percent used grafting when necessary and 38 percent did not use any bone graft. In this study, both groups had similar clinical and radiological improvement. Although, group A had a slightly longer duration of hospital stay, these patients were able to return to full weight-bearing earlier than group B. Group A patients had a lower mean AOFAS score compared to group B. The long-term follow-up of subtalar joint reduction was maintained in both groups. Although, this study is a retrospective investigation and not all of the patient details were available leading to limitations, it provides evidence that treatment of intra-articular calcaneal fractures with bone graft along with internal fixation leads to better restoration of Bohler’s angle and the prevention of late collapse. The patients treated without bone graft showed similar functional outcomes and complication rates as those patients treated with bone grafting.