SLR - September 2012 - Jennifer Miller
References: Zhang, Jingwei, Ebraheim, Nabil, Lause, Gregory E., Xiao, Baiping and Rongming Xu. J Trauma. 2011; XX:00-000
Scientific Literature Review
Reviewed by: Jennifer Miller, DPM
Residency Program: St. John Hospital and Medical Center, Detroit, MI
Podiatric Relevance:
Open reduction internal fixation of intra-articular calcaneal fractures with metallic plates and screws represents the standard and accepted treatment course. Use of this fixation option may necessitate later removal of internal fixation secondary to peroneal tendon irritation and risk for infection. In such high energy injuries, any method to reduce postoperative complications and further surgical procedures may improve the chances for positive clinical outcomes. Bioabsorbable screw fixation may pre-empt later hardware removal and may provide equal clinical and radiographic outcomes as compared to metallic plates and screws.
Methods:
Ninety-seven closed, unilateral intra-articular calcaneal fractures were randomized and prospectively divided into two surgical fixation approaches for this fracture type. These approaches consisted of open reduction internal fixation with either Synthes plates and screws or with 3.5mm poly-L-lactide bioabsorbable screws from February of 2007 to March of 2009. All open fractures, cases with multiple foot injuries, or bilateral involvement were excluded from this study. All fractures were classified by the Sander’s classification. American Orthopaedic Foot and Ankle-Hindfoot Scale (AOFAS), Foot Function Index (FFI), and Calcaneal Fracture Scoring System (CFSS) scores were obtained at one year post-operatively. All patient scores were blinded. Radiographically, pre- and postoperative measurement of Gissane’s and Bohler’s angles were measured by one senior author whom was blinded. Angular measurements were repeated at one year follow-up.
Results:
The metallic fixation group consisted of a total of 52 fractures of which 38 were male and fourteen were female. The bioabsorbable fixation group contained 47 fractures of which 35 were male and twelve were female. Average age for both groups was 41 years. Average time to operative fixation was 9.2 days and average follow-up was 23 months. Postoperative AOFAS, FFI, and CFSS scores for the metallic fixation group were 71.6, 21.4, and 73.5 respectively. Scores for fractures fixated with bioabsorbable screw fixation were 72.3, 22.7, and 75.1 respectively. Mean Bohler’s angle improved from 3.5 to 32.6 degrees postoperatively in the metallic fixation group while in the bioabsorbable group the mean measurement improved from 4.2 to 35.1 degrees. Fracture union was achieved in all groups at three to four months. A complication rate of 21 percent associated with metallic fixation was demonstrated by six cases of poor wound healing, one case of deep infection requiring irrigation and debridement, and four cases of peroneal tendon irritation. Fractures fixated with bioabsorbable screws demonstrated one case of superficial infection not requiring surgical intervention yielding a complication rate of 2 percent.
Conclusions:
The study concluded that use of absorbable screws is a viable option in treating acute closed intra-articular calcaneal fractures and may yield lower risks for soft tissue envelope complications. Use of metallic fixation in this study showed a rate of 6.6 percent of later internal fixative removal. This compared favorably to no instances reported for fractures fixated with bioabsorbable screws.