The morphology of osseous structure in subtalar joint with chronic ankle instability.

BACKGROUND: Osseous structures have been demonstrated as risk factors for chronic ankle instability (CAI). Previously, the researchers only focused on the osseous structures of ankle, but ignored the osseous structures of subtalar joint(STJ). Accordingly, the aim of our study was to investigate the morphological characteristics of STJ osseous structures in CAI. METHODS: 52 patients with CAI and 52 sex- and age- matched control subjects were enrolled from The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. The lateral radiographs of ankle in weight-bearing were used to compare the diversity of the two groups. Specifically, The Length of calcaneus, Calcaneal facet height and Absolute foot height, Böhler's angle, Gissane's angle, Calcaneal inclination angle, Talocalcaneal angle, Tibiotalar angle, Tibiocalcaneal angle, Talar-horizontal angle, talar declination angle, facet inclination angle were gauged in the two groups. RESULTS: The Böhler's angle, Calcaneal inclination, Talocalcaneal angle, Tibiotalar angle, Talar-horizontal angle, Talar declination angle, Facet inclination angle and Absolute foot height of CAI group were significantly higher than normal control group (P < 0.05). There were no significant differences in Gissane's angle, Tibiocalcaneal angle, Length of calcaneus and Calcaneal facet height between patients with CAI and normal controls (P > 0.05). CONCLUSIONS: The osseous structures of STJ in CAI patients are different from normal people in morphology. Therefore, we should pay more attention to the changes of STJ anatomical parameters in the diagnosis and prevention of CAI. LEVEL OF EVIDENCE: Ⅲ.

Percutaneous reduction, cannulated screw fixation and calcium sulfate cement grafting assisted by 3D printing technology in the treatment of calcaneal fractures.

BACKGROUND: Percutaneous reduction, cannulated screw fixation and calcium sulfate cement grafting (PR + CSC) for treatment of displaced and intra-articular calcaneal fractures (DIACFs) is a difficult technique, because the minimally invasive treatment has limited exposure and cannot be used to reduce articular surface under direct vision. The goal of this study was to apply 3D printing technology to preoperative planning and surgery of DIACFs, and to evaluate its effectiveness, feasibility and safety in fracture repair. METHODS: We enrolled 81 patients with DIACFs in the study from August 2015 to August 2017. Patients with DIACFs in our hospital were randomly divided into the 3D printing group (40 cases) and the conventional group (41 cases). The operation duration, blood loss volume and the number of fluoroscopy were compared. Radiological results were evaluated using radiographs and functional results were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score. The complications were also assessed. In addition, we made a questionnaire to verify the usefulness of the 3D printed model for both doctors and patients. RESULTS: The operation duration, blood loss volume and the number of fluoroscopy in 3D printing group were significantly less than that in the conventional group. Besides, 3D printing group achieved significantly better radiological results than conventional group both postoperatively and at the final follow-up except the calcaneal width at the final follow-up. The AOFAS score in the 3D printing group was significantly higher than that in the conventional group. In addition, the questionnaire from doctors and patients exhibited high scores of overall satisfaction of the 3D printed models. As for complications, there was no significant difference among the two groups. CONCLUSION: This study suggested the clinical feasibility of PR + CSC assisted by 3D printing technology in the treatment of DIACFs. LEVEL OF EVIDENCE: II.

Outcomes of management of displaced intra-articular calcaneal fractures.

Despite the advances in operative management, displaced intra-articular calcaneal fractures (DIAFCs) are often associated with long term sequelae, permanent disability, a considerable reduction in quality of life, and a high socio-economic cost. Randomized controlled trials have shown that patient reported outcomes of surgery are no better than those of nonoperative management. Methodological flaws and selection bias may have influenced the results, however, and subgroup analysis showed that some patients could benefit from surgery, whilst patients' preference can be the decisive factor in choosing a management modality. Fractures with significant lateral wall displacement predisposing to impingements often require surgery, and management has to be individualized and tailored to the patient. Surgery does not usually achieve excellent results, though it exposes the patient to potential risks and complications. Wound healing problems and infections affect around 20% of patients when the extensile lateral approach has been used. Sinus tarsi approach and minimally invasive surgery may be viable alternatives, offering similar results with fewer wound complications, but most of the available studies are of low to moderate quality. Late subtalar joint arthrodesis is often required: however, such procedure would be less technically difficult and could result in better foot function should the shape of the calcaneus have been anatomically restored with surgery in the acute phase.

Extensive eggshell-like debridement technique plus antibiotic-loaded calcium sulphate for one-stage treatment of chronic calcaneal osteomyelitis.

BACKGROUND: Management of chronic calcaneal osteomyelitis is challenging. At present, there is still no widely accepted, simple, and effective surgical method to eradicate the infection and prevent osteomyelitis recurrence. The objective of this study was to assess the outcomes of one-stage treatment of chronic calcaneal osteomyelitis with a shape-preserving debridement technique combined with antibiotic-loaded calcium sulphate. METHODS: Between 2012 and 2018, 33 patients (33 limbs) with chronic calcaneal osteomyelitis were treated with a novel debridement technique, named "eggshell-like debridement", plus antibiotic-impregnated calcium sulphate. The infection remission rate, recurrence rate, and amputation rate were analyzed. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to assess postoperative hindfoot function. RESULTS: 26 patients (81.8%) achieved infection remission without recurrence. In the patients with osteomyelitis remission, pain, limitation of movement, sinus tracts, and typical redness and swelling were generally eliminated. Most of the patients could tolerate full weight-bearing without pain. The average AOFAS ankle and hindfoot score was 88 points (range, 67-100 points), implying the foot function was mostly restored. 6 patients (18.2%) had osteomyelitis recurrence but no amputation was required to elimilate the infection. CONCLUSIONS: Eggshell-like debridement combined with antibiotic-loaded calcium sulphate is an effective method for one-stage management of chronic calcaneal osteomyelitis. With the application of this technique, secondary autogenous bone or muscle flap grafts are unnecessary. The surgical procedure can be simplified whlie the hindfoot function is well preserved.

Calcium Sulfate/Calcium Phosphate Bone Void Filler in the Treatment of Bilateral Adolescent Unicameral Calcaneal Bone Cysts: 36-Month Follow-Up.

A 36-month follow-up of the management of bilateral adolescent unicameral bone cysts in a high school gymnast treated with a calcium sulfate/calcium phosphate (CSCP) bone void filler (BVF) is presented. The more developed left calcaneal cyst was managed with a traditional, open approach consisting of allogenic bone graft, CSCP BVF mixed with platelet-rich plasma. The less developed right calcaneal cyst was managed with a less used approach, a percutaneous bone cortex incision with only the CSCP BVF. The rationale for the selection between the open and percutaneous approaches, long-term BVF incorporation, and positive patient outcome allowing a quick return to athletics are presented.

Determination of Pathogens in Postoperative Wound Infection After Surgically Reduced Calcaneal Fractures and Implications for Prophylaxis and Treatment.

High rates of postoperative wound infection (POWI) have been reported after surgery for calcaneal fractures. This is a retrospective cohort study to determine the causative pathogens of these infections and subsequent treatment strategies. In addition, microbacterial growth from superficial wound swabs and deep fluid or tissue cultures were compared. Patients with a unilateral surgically treated calcaneal fracture during a 15-year period were included. Patient, fracture, and surgical characteristics were collected from the electronic medical records. An infection was categorized as deep or superficial using the Centers for Disease Control and Prevention criteria. Secondary outcomes were wound edge necrosis and wound dehiscence. The collection of culture swabs, their results, and treatment strategies were documented. Of 357 patients, 92 (26%) developed a POWI; 55 (60%) deep and 37 (40%) superficial. The most frequent causative pathogens were Enterobacteriaceae and Staphylococcus aureus. Of the 55 patients with deep infection, 31 (56%) were treated with intravenous antibiotics and surgical debridement, 2 (4%) with intravenous antibiotics, and 22 (40%) with implant removal. In 33 of 92 patients (36%) with a POWI, both superficial and deep cultures were obtained, with a microorganism not cultured from the superficial swab 13 (39%) times. In conclusion, we found that one quarter of patients with operative calcaneal fracture treatment developed a POWI, mainly caused by Enterobacteriaceae or S. aureus. Physicians should not rely on the results of superficially obtained cultures for adequate treatment of deep infection. Because the spectrum of sensitivity profiles varies greatly between hospitals and countries, we recommend empiric antibiotic treatment of both gram-positive and gram-negative microorganisms on suspicion of deep infection.

Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: The Silo technique.

BACKGROUND: Chronic osteomyelitis necessities appropriate infected bone and soft tissue excision. The authors describe the Silo surgical technique for the treatment of calcaneal osteomyelitis using a new antibiotic-loaded absorbable calcium sulphate/hydroxyapatite biocomposite. METHODS: The Silo method involves debridement of the dead bone and local delivery of antibiotic in drilled tunnels using the biocomposite. It is combined with multiple sampling and culture-specific systemic antibiotic treatment guided by a multidisciplinary team. Twelve consecutive diabetic patients with heel ulcers and calcaneal osteomyelitis were treated with the above method. All had comorbidities (Cierny-Mader (C-M) Class B hosts). The mean age was 68 years (range 50-85). A retrospective review of radiographs and electronic medical records was conducted. RESULTS: Patients were followed up until clinical cure of the ulcer for a mean of 16 weeks (range 12-18). Infection was eradicated in all 12 patients with a single stage procedure following a bone preserving technique. One patient required a subsequent flap operation and six vacuum-assisted closure (V.A.C.). There was also one case of prolonged wound leakage and no calcaneal fractures. CONCLUSIONS: The Silo technique is an effective method of local delivery of antibiotics and can be effectively implemented into the single-stage treatment of calcaneal osteomyelitis offering increased bone preservation and local delivery of antibiotic, decreasing the need for a major amputation. LEVEL OF EVIDENCE: Level IV- case series.

Comparison of percutaneous cannulated screw fixation and calcium sulfate cement grafting versus minimally invasive sinus tarsi approach and plate fixation for displaced intra-articular calcaneal fractures: a prospective randomized controlled trial.

BACKGROUND: The management of displaced intra-articular calcaneal fractures (DIACFs) remains challenging and controversial. A prospective randomized controlled trial was conducted to compare percutaneous reduction, cannulated screw fixation and calcium sulfate cement (PR+CSC) grafting with minimally invasive sinus tarsi approach and plate fixation (MISTA) for treatment of DIACFs. METHODS: Ultimately, 80 patients with a DIACFs were randomly allocated to receive either PR+CSC (N = 42) or MISTA (N = 38). Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores. Radiological results were assessed using plain radiographs and computed tomography (CT) scans, and postoperative wound-related complications were also recorded. RESULTS: The average time from initial injury to operation and the average operation time in the PR+CSC group were both significantly shorter than those in the MISTA group (p < 0.05). There were significantly fewer complications in the PR+CSC group than those in the MISTA group (7.1 % vs 28.9 %, p < 0.001). The calcaneal width immediate postoperatively and at the final follow-up in the MISTA group were obviously improved compared to those in the PR+CSC group (p < 0.001). The variables of sagittal motion and hindfoot motion of the AOFAS scoring system in the PR+CSC group were significantly higher than those in the MISTA group (p < 0.05). The good and excellent results in the two groups were comparable for Sanders Type-II calcaneal fractures, but the good to excellent rate in the MISTA group was significantly higher for Sanders Type-III fractures (p < 0.05). CONCLUSION: The clinical outcomes are comparable between the two minimally invasive techniques in the treatment of Sanders Type-II DIACFs. The PR+CSC grafting is superior to the MISTA in terms of the average time between initial injury and operation, operation time, wound-related complications and subtalar joint activity. However, the MISTA has its own advantages in improving the calcaneal width, providing a more clear visualization and accurate reduction of the articular surface, especially for Sanders Type-III DIACFs. TRIAL REGISTRATION: ChiCTRIOR16008512 . 21 May 2016.

Treatment of Unicameral Bone Cysts of the Calcaneus: A Systematic Review.

The calcaneus is the most common tarsal affected by unicameral bone cysts (UBCs); however, the treatment of calcaneal UBCs remains controversial. The purpose of the present systematic review was to evaluate the treatment modalities for calcaneal UBCs. A systematic review was performed using clinical studies of calcaneal UBCs with a minimum of 1 year of follow-up and level I to IV evidence. Ten studies with 171 patients (181 cysts) were selected. Heel pain and radiographic cyst consolidation were the primary outcomes. A series of Z tests were used to compare the outcomes in the nonoperative and operative groups, cannulated screw and bone augmentation groups, and autografting and allografting groups. All patients treated with open curettage and bone augmentation had significant improvements in heel pain (p < .001). Only 1.1% ± 1.0% of the cysts treated conservatively had healed on radiographs compared with 93.0% ± 13.0% of the cysts after surgery (p < .001). A greater percentage of patients treated with bone augmentation had preoperative heel pain and resolution of that pain than did patients treated with cannulated screws (p < .001). Autografting had a significantly greater percentage of radiographic cyst consolidation than did allografting (97.4% ± 11.1% versus 85.1% ± 15.8%, p < .001, Z = 3.5). Objective outcomes data on calcaneal UBCs are relatively sparse. The results of the present review suggest that open curettage with autograft bone augmentation is the most effective procedure. We would encourage future comparative clinical studies to elucidate differences in UBC treatment modalities.

[One-stage compound grafting of antibiotic-impregnated calcium sulfate and autogenous cancellous bone for the treatment of chronic calcaneal osteomyelitis].

OBJECTIVE: To explore the treatment of chronic calcaneal osteomyelitis with bone defect after debridement and evaluate its clinical outcomes. METHODS: From June 2009 to June 2011, 52 patients with chronic calcaneal osteomyelitis were treated with stage-one compound grafting of antibiotic-impregnated calcium sulfate and autogenous cancellous bone,including 12 females and 40 males with an average age of 43 years old ranging from 18 to 67. According to Cierny-Mader classification, there were 34 cases with stage III and 18 with stage IV. There were 32 cases on right side and 20 on left,with a course of 6 months to 3 years. The area of soft tissue wound ranged from 3.0 cm x l.5 cm to 23.0 cm x l2.0 cm. The clinical effects were evaluated according to infection controlling, calcium sulfate absorption,bone defect repair and heel functional recovery. RESULTS: All patients were followed up for 2 to 3.8 years (averaged 2.8 years). Primary healing was achieved in 52 patients. Two cases of recurrence were found post-operatively, 1 case in 3 months and another in 5 months,which were cured after a second operation. Bone repair healing was gained in 1.5 to 3.5 months (averaged 2.5 months). Complete radiological absorption of calcium sulfate was found in 1.2 to 3 months(averaged 2.2 months). Local exudation after removal of drainage tube had been persisting in 10 patients for 2 to 3 months, which was consistent with the time when cacium sulfate were totally absorbed. Flap had partial necrosis in 4 cases,and the wounds were closed after appropriate treatment finally. The mean Maryland score was 88.15±7.70. There were excellent results in 32 cases, good in 14, fair in 6. CONCLUSION: A satisfactory short-term clinical results can be gained by one-stage compound grafting of antibiotic-impregnated calcium sulfate and autogenous cancellous bone in chronic calcaneal osteomyelitis, but the long-term results need further follow-up. And much more study is also demanded to reduce the exudation of calcium sulfate.

Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle.

BACKGROUND: Tibiotalocalcaneal arthrodesis in patients with large segmental bony defects presents a substantial challenge to successful reconstruction. These defects typically occur following failed total ankle replacement, avascular necrosis of the talus, trauma, osteomyelitis, Charcot, or failed reconstructive surgery. This study examined the outcomes of tibiotalocalcaneal (TTC) arthrodesis using bulk femoral head allograft to fill this defect. METHODS: Thirty-two patients underwent TTC arthrodesis with bulk femoral head allograft. Patients who demonstrated radiographic union were contacted for SF-12 clinical scoring and repeat radiographs. Patients with asymptomatic nonunions were also contacted for SF-12 scoring alone. Preoperative, intraoperative, and postoperative factors were analyzed to determine positive predictors for successful fusion. RESULTS: Sixteen patients healed their fusion (50% fusion rate). Diabetes mellitus was found to be the only predictive factor of outcome; all 9 patients with diabetes developed a nonunion. In this series, 19% of the patients went on to require a below-knee amputation. CONCLUSIONS: Although the radiographic fusion rate was low, when the 7 patients who had an asymptomatic nonunion were combined with the radiographic union group, the overall rate of functional limb salvage rose to 71%. TTC arthrodesis using femoral head allograft should be considered a salvage procedure that is technically difficult and carries a high risk for complications. Patients with diabetes mellitus are at an especially high risk for nonunion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Union rate of tibiotalocalcaneal nails with internal or external bone stimulation.

INTRODUCTION: The use of bone growth stimulation has been reported in the application of hindfoot and ankle arthrodesis. Most studies have been retrospective case series with few patients. The authors present a comparative analysis of patients undergoing tibiotalocalcaneal (TTC) arthrodesis via a retrograde intramedullary arthrodesis nail to evaluate the influence of internal versus external bone stimulation in this population. METHODS: One hundred fifty-four patients were treated with retrograde intramedullary nailing. A comprehensive chart and radiographic review was performed from a database of patients who underwent TTC fusion with or without bone stimulation. Ninety-one patients with retrograde TTC nailing were treated with direct current internal bone stimulation at the time of the index procedure (internal group) and 63 were treated with combined magnetic field external bone stimulation (external group). The primary end point was fusion with potential variables evaluated for influence on fusion rates. RESULTS: Demographically the cohorts were similar groups in age and comorbidities. Surgical and outcome data were examined, and there were few statistically significant differences between the two groups. There was no statistically significant difference in rate of union (52.7% and 57.1%, p = .63) or rate of complications between the internal and external groups. Overall, the success rate for achieving a stable, functional limb for the groups was 81.3% (74/91 patients) and 82.5% (52/63 patients) in the internal and external groups, respectively (p = .62). CONCLUSION: The authors demonstrated there were no statistically significant differences between the union and complication rate when comparing these types of internal and external bone stimulation in this patient population. Consideration of these results may help guide physicians when considering bone stimulation as an adjunct to TTC fusions with a retrograde intramedullary nail.

Percutaneous treatment of calcaneus fractures associated with underlying bone cysts.

BACKGROUND: Calcaneal bone cysts with pathological fractures are rare. There is no clear consensus on their management with a few reports of open curettage, bone grafting and internal fixation in the treatment of pathological calcaneal fractures. No minimally invasive management has been reported before. METHODS: We reviewed our experience in treating five patients with pathologic calcaneus fractures associated with pre-existing bone cysts who underwent percutaneous cyst curettage, fracture reduction, screw fixation and calcium sulfate cement injection between 2004 and 2009. RESULTS: All of the pathologic fractures healed with satisfactory radiological results. There were no soft tissue complications or cyst recurrences. Partial weightbearing with plaster cast immobilization was allowed at 4 weeks postoperatively and full weightbearing was allowed at 6 weeks postoperatively. CONCLUSION: This percutaneous technique provided a minimally invasive option for treatment of a calcaneal bone cyst with pathologic fracture.

[Bone setting manipulation combined with surgery for the treatment of calcaneal fractures].

OBJECTIVE: To investigate the clinical effects of bone setting manipulation on simplified operation and swelling reduction in treating calcaneal fractures. METHODS: From December 2005 to November 2010, 42 patients with calcaneal were reviewed, including 25 males and 17 females, ranging in age from 18 to 74 years, with an average of 41.4 years. Twenty patients had fractures in the left and 22 in the right. Twenty-three patients were treated with anatomical plate fixation, 19 patients were treated with Kirchners wires or cannulated screws fixation. The average period of swelling in soft tissue, joint function and complications were evaluated. RESULTS: Forty-two patients were followed up, and the duration ranged from 3 to 18 months, with a mean of 8.3 months. The pain was markedly relieved at the next day after reduction, and the swelling was relieved in 3 to 5 days. The operative was simplified and the average operative time was 90 minutes. The swelling was relieved in 4 to 7 days after the operation, and the necrosis of skin was not found. The average postoperatively Böhler angle was (31 +/- 3.2) degrees. Gissane angle was (112 +/- 5.3) degrees. Calcaneal width was (30.2 +/- 0.89) mm. According to Maryland foot function score system, 16 patients got an excellent result, 18 good, 6 fair and 2 bad. CONCLUSION: The operation is simplified, and skin complications decrease, as well as the detumescence period is shortened.

Repair of insertional achilles tendinosis with a bone-quadriceps tendon graft.

BACKGROUND: While conservative treatment may be successful in most cases, partial rupture at the calcaneal insertion point is a significant concern with insertional Achilles tendinopathy. We report on the outcomes of a surgical technique for Achilles tendon augmentation using a bone-tendon graft harvested from the knee extensor system. MATERIALS AND METHODS: Our retrospective case series includes 25 surgical procedures performed in 24 patients, 19 males and five females, with a mean age of 47 (range, 30 to 59) years, 18 of whom were athletes. The mean followup period was 52 (range, 12 to 156) months. All patients underwent MRI examination prior to surgery which showed partial Achilles tendon rupture. The Achilles tendon was debrided through a posterolateral approach. The bone-quadriceps tendon graft was harvested, then the bone plug of the graft was inserted into a blind tunnel drilled into the calcaneus and fixed with an interference screw. The fibers of the quadriceps tendon were sutured to the residual part of the Achilles tendon with the foot at an angle of 90 degrees. RESULTS: Patients were able to resume their sporting activity after an average of 6.7 months. At last followup examination, physical activity was scored 5.2 on the 10-point Tegner Scale; the mean AOFAS score was 98.4. MRI examination showed good graft integration 1 year postoperatively. CONCLUSION: The bone-quadriceps tendon grafting technique was a good alternative for the insertional Achilles lesions with partial detachment which we felt required augmentation.

[Controlled clinical trials of cost-effectiveness analysis on poking reduction and open reduction for the treatment of sanders type II calcaneal fractures].

OBJECTIVE: To evaluate cost-effectiveness of poking reduction and open reduction for the treatment of Sanders type II calcaneal fractures, in order to provide evidence for standard treatment. METHODS: From 2006.10 to 2008.10, 80 patients with Sanders type II calcaneal fractures were selected from Shandong Provincial Hospital of Traditional Chinese Medicine and randomly divided into poking reduction group and open reduction group with 40 cases in each group. There were 26 males and 14 females in poking reduction group and 30 males and 10 females in open reduction group. The average age of patients in poking reduction group was (36.60+/-3.15) years, and (37.10+/-3.45) years in open reduction group. Bohler angle, Gissane angle, the width of central calcaneus, stance phase of gait, HM-HL,arch index and subtalair joint flexibility were measured. The clinical results and expenses of the two treatment schemes were compared and concluded with the method of cost-effetiveness analysis. RESULTS: In the poking reduction group and open reduction group, the Böhler angle were (30.32+/-1.72) degree and (30.54+/-3.13) degree, Gissane angle were (133.73+/-6.73) degree and (134.86+/-4.90) degree, the width of central calcaneus were (30.18+/-1.59) mm and (30.24+/-1.25) mm, stance phase of gait were (0.679+/-0.070) s and (0.715+/-0.090) s, HM-HL were--(36.49+/-7.56) N and -(34.32+/-6.50) N,arch index were (30.26+/-2.69) and (30.47+/-1.89), and subtalair joint flexibility were (10.53+/-2.30) degree and (10.89+/-1.86) degree respectively. The cost-effectiveness ratio (C/E) were 6.06 and 136.19 respectively. CONCLUSION: Cost-effectiveness ratio of the poking reduction is superior to that of the open reduction in treating Sanders type II calcaneal fractures. Poking reduction is a useful method to treat Sanders type II calcaneal fractures with rapid wound healing and less cost.

The effect of demineralized bone matrix-calcium sulfate with vancomycin on calcaneal fracture healing and infection rates: a prospective study.

BACKGROUND: Displaced intra-articular calcaneal fractures may have a central cancellous bone defect area. We hypothesized that human demineralized bone matrix (DBM) calcium sulfate (CaSO(4)) might act as a reasonable alternative to autograft in calcaneal fractures. When combined with antibiotic powder, this bone graft substitute also may act as a local antibiotic delivery device. This is the first clinical study evaluating bone healing and complications associated with DBM-calcium sulfate bone graft substitute in the treatment of displaced intra-articular calcaneal fractures with a central cancellous bone defect. METHODS: Over a 29-month period, 33 displaced intra-articular calcaneal fractures with central cancellous defects were treated with open reduction and internal fixation (ORIF) and grafting with vancomycin/DBM-calcium sulfate bone graft substitute. Eleven fractures without bone defects were treated with ORIF only. Patient demographics, medical history, and CT fracture classification were recorded. Postoperatively, fractures were monitored every 2 weeks for healing and complications. RESULTS: The mean time to union was 8.2 weeks in the grafted, while the control group mean time to union was 10.4 weeks (p = 0.0117). Wound problems occurred in five (15%) of the 33 patients with grafting, all in type III fractures with severe soft-tissue swelling, and included two minor wound healing delays, and three serious wound problems. At a mean followup time of 22.4 months, no DBM-calcium sulfate grafted calcaneus demonstrated evidence of osteomyelitis. CONCLUSIONS: This is the first study examining human DBM-calcium sulfate bone graft substitute to treat displaced intra-articular calcaneal fractures. Based on these initial data, human DBM-calcium sulfate acted as an acceptable and safe autograft alternative in displaced intra-articular calcaneal fractures with moderate (5 cc to 10 cc) central cancellous bone defects.

Percutaneous intramedullary decompression, curettage, and grafting with medical-grade calcium sulfate pellets for unicameral bone cysts in children: a new minimally invasive technique.

Several treatment options exist for unicameral bone cysts (UBCs), including observation, steroid injection, bone marrow injection, and curettage and bone grafting. These are all associated with high recurrence rates, persistence, and occasional complications. Newer techniques have been described, most with variable success and only short follow-up reported. Because of these factors, a new minimally invasive percutaneous technique was developed for the treatment of UBCs in children. Twenty-eight children with UBCs who underwent percutaneous intramedullary decompression, curettage, and grafting with medical-grade calcium sulfate (MGCS) pellets by the senior author (J.P.D.) between April 2000 and April 2003 were analyzed as part of a pediatric musculoskeletal tumor registry at a large tertiary children's hospital. Four patients were lost to follow-up, and the remaining 24 patients had an average follow-up of 21.9 months (range 4-48 months). Twelve patients were followed for at least 24 months. Six of the 24 children had received previous treatment of their UBC, most often at an outside institution. Follow-up was performed through clinical evaluation and radiographic review. Postoperative radiographs at most recent follow-up showed complete healing, defined as more than 95% opacification, in 22 of 24 patients (91.7%). One patient (4.2%) demonstrated partial healing, defined as 80% to 95% opacification. One patient had less than 80% radiographic healing (4.2%). All 24 patients returned to full activities and were asymptomatic at most recent follow-up. The only complication noted was a superficial suture abscess that occurred in one patient; this resolved with local treatment measures. The new minimally invasive technique of percutaneous intramedullary decompression, curettage, and grafting with MGCS pellets demonstrates favorable results with low complication and recurrence rates compared with conventional techniques. The role of intramedullary decompression as a part of this percutaneous technique is discussed.