The answer to this question is that no heel fracture necessitates bone grafting when doing internal fixation.
Sanders said
In 1993, Sanders et al [1] published a landmark in the history of surgical treatment of calcaneal fractures in CORR with their CT-based classification of calcaneal fractures. More recently, Sanders et al [2] concluded that neither bone grafting nor locking plates were necessary in 120 heel fractures with a long-term follow-up of 10-20 years.
CT typing of heel fractures published by Sanders et al. in CORR in 1993.
Bone grafting has two main purposes: structural grafting for mechanical support, such as in the fibula, and granular grafting for filling and inducing osteogenesis.
Sanders mentioned that the heel bone consists of a large cortical shell encasing cancellous bone, and that displaced intra-articular fractures of the heel bone can be quickly reconstructed by cancellous bone with trabecular structure if the cortical shell can be relatively reset.Palmer et al [3] were the first to report on bone grafting in 1948 due to the lack of suitable internal fixation devices to maintain the articular surface fracture in place at that time. With the continuous development of internal fixation devices such as posterolateral plates and screws, the support maintenance of reduction by means of a bone graft became unnecessary. Its long-term clinical studies have confirmed this view.
Clinical controlled study concludes that bone grafting is unnecessary
Longino et al [4] and others conducted a prospective controlled study of 40 displaced intra-articular fractures of the heel with at least 2 years of follow-up and found no significant difference between bone grafting and no bone grafting in terms of imaging or functional outcomes.Gusic et al [5] conducted a controlled study of 143 displaced intra-articular fractures of the heel with similar results.
Singh et al [6] from the Mayo Clinic conducted a retrospective study of 202 patients and although bone grafting was superior in terms of Bohler’s angle and time to full weight bearing, there was no significant difference in functional outcomes and complications.
Bone grafting as a risk factor for trauma complications
Professor Pan Zhijun and his team at Zhejiang Medical Second Hospital had conducted a systematic evaluation and meta-analysis in 2015 [7], which included all the literature that could be retrieved from electronic databases as of 2014, including 1651 fractures in 1559 patients, and concluded that bone grafting, diabetes mellitus, not placing a drain, and severe fractures significantly increase the risk of postoperative traumatic complications.
In conclusion, bone grafting is not necessary during internal fixation of heel fractures and does not contribute to function or final outcome, but rather increases the risk of traumatic complications.
1.Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993;(290):87-95.
2.Sanders R, Vaupel ZM, Erdogan M, et al. 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(10):551-63.
3.Palmer I. The mechanism and treatment of fractures of the calcaneus. J Bone Joint Surg Am. 1948;30A:2–8.
4.Longino D, Buckley RE. Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful? J Orthop Trauma. 2001;15(4):280-6.
5.Gusic N, Fedel I, Darabos N, et al. Operative treatment of intraarticular calcaneal fractures: Anatomical and functional outcome of three different operative techniques. Injury. 2015;46 Suppl 6:S130-3.
6.Singh AK, Vinay K. Surgical treatment of displaced intra-articular calcaneal fractures: is bone grafting necessary? J Orthop Traumatol. 2013;14(4):299-305.
7. Zhang W, Chen E, Xue D, et al. Risk factors for wound complications of closed calcaneal fractures after surgery: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2015;23:18.
Post time: Dec-07-2023
