Displaced Intra‑Articular Calcaneal Fractures Treated with Open Reduction and Internal fixation and Bone Void Filling with an Injectable Calcium Sulfate/Hydroxyapatite Bone Graft Substitute: A Series of 18 Patients

Document Type: Original Article

Authors

1 Department of Orthopedic Surgery and Traumatology, Santa Chiara Hospital, Trento, Italy

2 Department of Radiology, Santa Chiara Hospital, Trento, Italy

Abstract

Background: There is an ongoing debate if bone graft substitutes (BGSs) are beneficial in the treatment of displaced intra‑articular calcaneal
fractures (DIACFs). The purpose of this study was to evaluate the effect of an injectable calcium sulfate/hydroxyapatite BGS (CERAMENTTM
iBONE VOID FILLER, BONESUPPORT AB, Lund, Sweden) in internal fixation of calcaneal fractures. Methods: The records of patients
presenting with calcaneal fractures type Sanders III and IV and treated with internal fixation plus BGS were reviewed. Radiographs were
analyzed using different measurements (including Böhler’s angle and calcaneal facet height). The clinical outcome was evaluated using the
American Orthopaedic Foot and Ankle Society (AOFAS) Ankle‑Hindfoot Scale. Results: A total of 20 fractures were available for radiographic
and clinical examination at a minimum follow‑up of 12 months. No decrease in Böhler’s angle was recorded in six fractures, a reduction
of <5° in 6 and of more than 5° in 8 fractures. In all fractures, the BGS was completely resorbed at 12 months on radiographs. The AOFAS
score was on an average 89.8 (range, 68–99) at 1‑year follow‑up and indicated an excellent outcome in 11, a good outcome in 8, and a fair
outcome in 1 fracture. Conclusions: The study results support the use of an injectable, in situ hardening calcium sulfate/hydroxyapatite BGS
in DIACFs. The BGS is easy and safe to use as an augment to open reduction and internal fixation.

Keywords


1. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intra‑articular calcaneal fractures: Aprospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84‑A: 1733‑44.

2. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, et al. Complications following management of displaced intra‑articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241‑9.

3. Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. Fractures of the calcaneus. Orthop Clin North Am 2002;33:263‑85, x.

4. Brauer CA, Manns BJ, Ko M, Donaldson C, Buckley R. An economic evaluation of operative compared with nonoperative management of displaced intra‑articular calcaneal fractures. J Bone Joint Surg Am 2005;87:2741‑9.

5. Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal fractures: Long‑term (10‑20 years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma 2014;28:551‑63.

6. Leung KS, Yuen KM, Chan WS. Operative treatment of displaced intra‑articular fractures of the calcaneum. Medium‑term results. J Bone Joint Surg Br 1993;75:196‑201.

7. Singh AK, Vinay K. Surgical treatment of displaced intra‑articular calcaneal fractures: Is bone grafting necessary? J Orthop Traumatol 2013;14:299‑305.

8. Schildhauer TA, Bauer TW, Josten C, Muhr G. Open reduction and augmentation of internal fixation with an injectable skeletal cement for the treatment of complex calcaneal fractures. J Orthop Trauma 2000;14:309‑17.

9. Huber FX, Hillmeier J, McArthur N, Kock HJ, Meeder PJ. The use of nanocrystalline hydroxyapatite for the reconstruction of calcaneal fractures: Preliminary results. J Foot Ankle Surg 2006;45:322‑8.

10. Johal HS, Buckley RE, Le IL, Leighton RK. A prospective randomized controlled trial of a bioresorbable calcium phosphate paste (alpha‑BSM) in treatment of displaced intra‑articular calcaneal fractures. J Trauma 2009;67:875‑82.

11. Huang PJ, Huang HT, Chen TB, Chen JC, Lin YK, Cheng YM, et al. Open reduction and internal fixation of displaced intra‑articular fractures of the calcaneus. J Trauma 2002;52:946‑50.

12. Eastwood DM, Langkamer VG, Atkins RM. Intra‑articular fractures of the calcaneum. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. J Bone Joint Surg Br 1993;75:189‑95.

13. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine (Phila Pa 1976) 1995;20:1055‑60.

14. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop Relat Res 1997;339:76-81.

15. Kurz LT, Garfin SR, Booth RE Jr. Harvesting autogenous iliac bone grafts. A review of complications and techniques. Spine (Phila Pa 1976) 1989;14:1324‑31.

16. Summers BN, Eisenstein SM. Donor site pain from the ilium. A complication of lumbar spine fusion. J Bone Joint Surg Br 1989;71:677‑80. 17. Thordarson DB, BollingerM. SRS cancellous bone cement augmentation of calcaneal fracture fixation. Foot Ankle Int 2005;26:347‑52. 18. Larsson S, Bauer TW. Use of injectable calcium phosphate cement for fracture fixation: A review. Clin Orthop Relat Res 2002;395: 23-32.

19. Elsner A, Jubel A, Prokop A, Koebke J, Rehm KE, Andermahr J, et al. Augmentation of intraarticular calcaneal fractures with injectable calcium phosphate cement: Densitometry, histology, and functional outcome of 18 patients. J Foot Ankle Surg 2005;44:390‑5.

20. De Long WG Jr., Einhorn TA, Koval K, McKee M, Smith W, Sanders R, et al. Bone grafts and bone graft substitutes in orthopaedic trauma surgery. A critical analysis. J Bone Joint Surg Am 2007;89:649‑58.

21. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87-95.

22. Heier KA, Infante AF, Walling AK, Sanders RW. Open fractures of the calcaneus: Soft‑tissue injury determines outcome. J Bone Joint Surg Am 2003;85‑A: 2276‑82.

23. Bratzler DW, Houck PM; Surgical Infection Prevention Guidelines Writers Workgroup, American Academy of Orthopaedic Surgeons, American Association of Critical Care Nurses, American Association of Nurse Anesthetists, et al. Antimicrobial prophylaxis for surgery: An advisory statement from the national surgical infection prevention project. Clin Infect Dis 2004;38:1706‑15.

24. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop Relat Res 1993;292:128-134.

25. Schepers T, Ginai AZ, Mulder PG, Patka P. Radiographic evaluation of calcaneal fractures: To measure or not to measure. Skeletal Radiol 2007;36:847‑52.

26. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M, et al. Clinical rating systems for the ankle‑hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349‑53.

27. Zwipp H, Tscherne H, Thermann H, Weber T. Osteosynthesis of displaced intraarticular fractures of the calcaneus. Results in 123 cases. Clin Orthop Relat Res 1993;290:76-86.

28. Abramo A, Geijer M, Kopylov P, Tägil M. Osteotomy of distal radius fracture malunion using a fast remodeling bone substitute consisting of calcium sulphate and calcium phosphate. J Biomed Mater Res B Appl Biomater 2010;92:281‑6.

29. Iundusi R, Gasbarra E, D’Arienzo M, Piccioli A, Tarantino U. Augmentation of tibial plateau fractures with an injectable bone substitute: CERAMENT™. Three year follow‑up from a prospective study. BMC Musculoskelet Disord 2015;16:115.

30. Nilsson M, Wang JS, Wielanek L, Tanner KE, Lidgren L. Biodegradation and biocompatability of a calcium sulphate‑hydroxyapatite bone substitute. J Bone Joint Surg Br 2004;86:120‑5.

31. Clare MP, Sanders RW. Calcaneus fractures. Unfallchirurg 2011;114:869‑76.