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Lateral wall osteotomy with biodegradable implant may improve calcaneal fractures outcomes
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Patients with displaced intra-articular calcaneal fractures experienced improved radiological parameters and functional outcomes after lateral wall osteotomy combined with an embedded biodegradable implant, according to results published in Journal of Orthopaedic Surgery and Research.
From May 2013 to December 2015, researchers performed lateral wall osteotomy combined with an embedded biodegradable implant (FreedomPlate, Inion) in 17 patients with 19 calcaneal fractures. Researchers obtained radiographic images, CT scans and MRIs of the operative limb to assess fracture healing and biodegradable implant degradation as well as American Orthopaedic Foot and Ankle Society ankle/hindfoot score to assess functional results at the last follow-up. Researchers also used preoperative and last follow-up radiographic images to analyze Böhler’s and Gissane’s angles, width and height of the injured calcaneus.
At the last follow-up, results showed significant improvement in all radiological parameters, with an increase of 15.58° in Böhler’s angle, 8.38° in Gissane’s angle and 7.65 mm in calcaneal height. Researchers also found a decrease in calcaneal width of 2.51 mm. Patients had a mean AOFAS score of approximately 84.37 at the last follow-up, according to results, with excellent, good and fair rates identified in nine feet, six feet and four feet, respectively. After a mean follow-up of approximately 34.69 months, researchers noted no nonunions, delayed unions or malunions, and one superficial infection occurred 6 days post-surgery.
According to the researchers, lateral wall osteotomy combined with an embedded biodegradable implant is advantageous in its primary wound-healing tendencies, complete visualization of fractured fragments, posterolateral subtalar joint facet and calcaneocuboid joint facet, no requirement for secondary operation for implant removal and less stress-shielding of the calcaneus.
“Its main disadvantage is that it has less fixation strength of biodegradable implants leading to delayed weight-bearing rehabilitation, which may result in poor clinical outcomes,” the authors wrote. – by Casey Tingle
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Stefan Rammelt, MD, PhD
Yang and colleagues present a clinical study of 17 patients with 19 calcaneal fractures treated with a calcaneal wall osteotomy and a biodegradable implant that is placed beneath the calcaneal wall before it is sutured back. The do not provide details on the technique and intraoperative control of the joint reduction. The only functional outcome score is the American Orthopaedic Foot & Ankle Society score, which is neither validated nor reliable.
The technique has to be viewed with great caution. The authors add another fracture to an acutely fractured calcaneus, which further increases instability and is fixed later with just a suture. Moreover, the lateral wall is blown out as a shell-like fragment (bulge) in most displaced calcaneal fractures. Given the shape of the free-form degradable plate the authors used, it remains completely unclear how the subtalar joint reduction is held in place.
The authors recommend that their technique should be limited to Sanders type II and III fractures and that it avoids periosteal stripping when using an extensile lateral approach. However, for the majority of these fracture types, less invasive approaches and percutaneous fixation techniques have evolved over the recent years and have been applied successfully. The authors report improvement of Böhler’s and Gissane’s angles. However, the only radiographic images provided show an almost non-displaced fracture that would be treated with minimally-invasive techniques in most surgeons’ hands.
University Hospital Carl Gustav Carus
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