Open reduction and augmentation of internal fixation with an injectable skeletal cement for the treatment of complex calcaneal fractures.
OBJECTIVE
To describe the surgical handling, potential complications, and remodeling of an injectable, osteoconductive calcium phosphate cement (Norian SRS) for joint depression-type calcaneal fractures in humans, and to illustrate the clinical efficacy of this cement with special reference to early postoperative full weight bearing.


METHODS
Prospective cohort study.


METHODS
Level I trauma centers in Bochum and Leipzig, Germany.


METHODS
Thirty-six joint depression type calcaneal fractures in thirty-two patients were augmented with the calcium phosphate cement after standard open reduction with internal fixation. Postoperative full weight bearing was allowed progressively earlier, and as the study progressed, the last patients were bearing full weight as early as three weeks postoperatively. Biopsies for histologic analysis were performed at time of hardware removal after one year (seven biopsies) or in case of infection at time of debridement (five biopsies).


METHODS
Clinical outcome was evaluated according to a calcaneal scoring system. Data were compared and statistically analyzed between patients with postoperative full weight bearing after eight to twelve weeks and three to six weeks, respectively. Histologic findings are described.


RESULTS
Cement injection averaged ten cubic centimeters and could easily be performed under fluoroscopic control. Progressively earlier full weight-bearing was achieved without loss of reduction. There was no statistical difference in clinical outcome scores in patients with full weight bearing before or after six weeks postoperatively. The infection rate was 11 percent, possibly related to the skin incisions. The biopsies from clinically satisfactory cases showed nearly complete bone apposition, areas of vascular penetration, and reversal lines illustrating progressive cycles of resorption and new bone formation. Biopsy specimens from infected cases showed bone and cement surrounded by either fibrous tissue or acute inflammation without extensive bone apposition.


CONCLUSIONS
Calcium phosphate cement augmentation of standard open reduction with internal fixation in joint-depression type calcaneal fractures allows postoperative full weight bearing as early as three weeks postoperatively. The injectable bone cement can easily be handled surgically under fluoroscopic control and has proved to be remodelable.
Chirurgische Klinik u. Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität, Bochum, Germany.
T A
TA
Schildhauer
T W
TW
Bauer
C
C
Josten
G
G
Muhr
D000328:Adult; D000368:Aged; D001843:Bone Cements; D002111:Calcaneus / Q000000981:diagnostic imaging / Q000293:injuries* / Q000473:pathology / Q000601:surgery; D002130:Calcium Phosphates / Q000008:administration & dosage*; D004434:Early Ambulation; D005260:Female; D005500:Follow-Up Studies; D018409:Foot Injuries / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing / Q000187:drug effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000473:pathology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D001843:Bone Cements; D002130:Calcium Phosphates; C485828:alpha-tricalcium phosphate; C485830:tetracalcium phosphate; C485838:calcium phosphate, monobasic, anhydrous; C020243:calcium phosphate; C485829:calcium phosphate, dibasic, anhydrous