REVIEW PAPER |
https://doi.org/10.5005/jp-journals-10040-1213 |
Surgical Options for Calcaneal Bony Defects: Current Clinical Evidence
1,6-8Department of Surgery, University of Toronto, Toronto, Ontario, Canada
2Department of Surgery, University of Calgary, Calgary, Alberta,Canada
3,4University of Glasgow, Glasgow, Scotland, United Kingdom
5Department of Surgery, Western University, London, Ontario, Canada
Corresponding Author: Richard Buckley, Department of Surgery, University of Calgary, Calgary, Alberta, Canada, Phone: +1 4036307741, e-mail: buckclin@ucalgary.ca
ABSTRACT
Autografts, allografts, bone graft substitutes, and bone replacement materials have been utilized in isolation or in combination to fill bony defects and enhance fracture healing or arthrodesis in all subspecialties of orthopedics. Although there is a robust literature on the effect of bone grafts on managing large bone defects in long bones and arthrodesis, little has been published on the management of calcaneal bony defects. In this review, we aim to discuss the various options for calcaneal bony defects and the current clinical evidence behind each graft option.
How to cite this article: Lee JM, Buckley R, Clark A, et al. Surgical Options for Calcaneal Bony Defects: Current Clinical Evidence. J Foot Ankle Surg (Asia Pacific) 2022;9(2):56-60.
Source of support: Nil
Conflict of interest: None
Keywords: Best evidence, Bone substitute, Calcaneal fracture
INTRODUCTION
Bony defects that alter the alignment, height, and/or width of the calcaneus can lead to significant changes in gait mechanics, pain with weight-bearing, and may ultimately result in a secondary amputation.1,2 Accordingly, surgical management must be carefully planned regardless of the bony defect’s etiology (trauma, fracture nonunion, infection, or tumor).3 The surgeon should consider the quality of surrounding soft tissues and blood supply, the size of the defect, and patient factors (age, presence of comorbidities, nutritional status, and smoking) prior to selecting an appropriate surgical graft option.3
Autografts, allografts, bone graft substitutes, and bone replacement materials have been utilized in isolation or in combination to fill bony defects and enhance fracture healing or arthrodesis in all subspecialties of Orthopedics.4,5 Although there is a robust literature on the effect of bone grafts on managing large bone defects in long bones and arthrodesis, little has been published on the management of calcaneal bony defects.
In this review, we aim to discuss the various options for calcaneal bony defects and the current clinical evidence behind each graft option.
Autograft
Autograft has been the gold standard in managing bone defects due to its osteoconductive, osteoinductive, and osteogenic properties.5 Commonly described harvest sites for nonvascularized autograft include the iliac crest and proximal tibia.3 The main difference between the sites is the volume of the graft obtainable. The iliac crest provides the most, at approximately 30 mL, and can provide coverage up to 5-7 cm of uncontained or contained defects.3,6 Autogenous iliac crest bone graft (AICBG) has been well published in hindfoot arthrodesis, with union rates greater than 90%.5,7 However, harvest site morbidity can be a disadvantage.3,8
Bone marrow graft harvesting from the femoral or tibial shaft using a reamer irrigator aspirator (RIA) has been gaining popularity in recent years as it provides high union rates with potential for less harvest site morbidity and a larger volume of bone graft compared to AICBG at approximately 58 mL.3,10 Fractures of the donor’s bone have been reported in up to 10% case series using RIA.9
In a massive, uncontained calcaneus bone defect with compromised soft tissues secondary to blast trauma or osteomyelitis, the following options have been described: vascularized iliac crest, fibula, and rib grafts. This is part of a complex osteocutaneous flap to reconstruct the calcaneus and fuse the subtalar joint if necessary.11-14 Opportunistic grafting using the “spare parts” concept is also described. This is when a body part from a contralateral amputation is used as autograft.15
Allografts
Structural allograft such as fresh frozen femoral head is an alternative option to autograft for managing a bony defect.16 It has the distinct advantage of avoiding the donor site morbidity whilst reducing the operative time and inpatient stay.16,17 It can be sculptured to the defect, acting as an osteoconductive scaffold. Allografts can provide larger volumes of graft than autografts, especially if one has access to a Regional Bone Bank.16-18 One of its disadvantages is the longer incorporation time due to diminished or absence of osteoinductive properties, compared with autografts.19 Graft rejection secondary to immune response and disease transmission from the donor have also been described.5,19
Demineralized bone matrix (DBM) is a convenient option, as it is more readily available.5,18 It is highly osteoconductive and can be added to autogenous bone grafts as a graft extender but its osteoinductivity is relatively limited.3 DBM is frequently described in the treatment of a contained bone defect, following curettage of unicameral bone cysts in the calcaneus.20 It is available in a powder or chip formulation, permitting percutaneous filling of the defect with minimal patient morbidity, and a shorter hospital stay.20
Bone Graft Substitutes
Calcium sulfate and calcium phosphate cement are two of the most extensively studied bone graft substitutes for the management of bone defects with or without auto- or allografts.21 Both are biocompatible, are available in an injectable formulation that hardens at body temperature, and contain osteoconductive properties.21 Calcium sulfate resorbs faster and allows for the ingrowth of vascular and new bone formation as it resorbs.21 One of its disadvantages is the weak internal strength that prevents it from acting as a structural scaffold and limits its utility to small bone defects with rigid internal fixation.21 A hybrid calcium sulfate biocomposite with hydroxyapatite (Cerament®) may provide superior structural support, mimicking real bone integration.19 The injection of Cerament® around a contained void has also shown increased screw purchase and pull-out strength by 100-200%.22,23
Custom Implants
Since 1995, additive manufacturing technologies including three-dimensional (3D) printed custom implants have gained increasing attention for the management of bone defects.24 In particular, 3D printed titanium alloy implants have been used to fill massive bone defects primarily in the setting of limb salvage following tumor resection.25 The main perceived advantage is its biocompatibility with the ability to be personalized to fit the defect’s shape and size.26
A Case Example Illustrating the Options Available
A 43-year-old female nurse presented with an avulsion fracture of the base of the 5th metatarsal of the left foot in January 2017. There was no history of trauma. The patient was an active cigarette smoker. After an initial orthopedic review, this was treated conservatively in a Velcro boot. After 2 months of conservative management, the patient continued to have pain and no evidence of callous formation on repeat radiographs. On further clinical examination, it was noted that the patient had a varus hindfoot.
To treat the 5th metatarsal fracture and concurrently address the varus, a lateralizing calcaneal osteotomy was performed, using a step plate as a fixation. After a prolonged period, the calcaneus failed to unite (Fig. 1), leading to revision surgery 18 months after the index procedure using two 6.5 mm cannulated screws. Infection was ruled out prior to the operation via laboratory investigations including CBC, CRP, ESR, and the patient was counseled on cigarette cessation and calcium and vitamin D supplementation.
Fig. 1: Left axial radiograph and left lateral radiograph. These show 18-month postlateralizing calcaneal osteotomy demonstrating nonunion with varus collapse and height loss
Further nonunion and metalwork failure resulted in 3 months and a third fixation procedure was undertaken with a screw plus lateral plate construct. Five months after this procedure the metalwork failed again (Fig. 2) due to nonunion and mechanical overload. Throughout this time the patient was unable to work and struggled severely with pain and immobility, leading to increased BMI (54).
Fig. 2: Lateral radiograph of the left ankle demonstrating a third nonunion with additional hardware failure
The decision was made to proceed with a staged limb salvage reconstruction at this stage. In the first stage, thorough debridement of the calcaneus and removal of all metalwork with deep tissue sampling was performed. This resulted in a large uncontained bone defect in the calcaneus tuberosity (Fig. 3). A 3-month gap was taken to allow the wound to heal and to treat the chronic infection with antibiotics. In the second stage, the calcaneal bone defect was treated utilizing a tricortical iliac crest graft and medullary femoral autograft (harvested via RIA). A piecemeal subtalar fusion was performed using cannulated screws and a lateral plate construct. An injectable synthetic void filler was also used to fill the remaining gaps and screw holes.
Fig. 3: Intraoperative photo of the large uncontained bony defect following calcaneal debridement
Surgical Technique-Second Stage
The patient was positioned in the lateral decubitus position. The skin was prepared from the affected foot to the ipsilateral hemipelvis. This was to facilitate the harvest of both tricortical iliac crest bone graft and medullary femoral autograft via RIA. The primary surgeon approached the calcaneus via an extensile lateral approach (using the previous incision) and performed a thorough debridement and deep tissue sampling for microbiology. At the same time, a second surgeon harvested a large tricortical graft from the iliac crest and subsequently reamed the femoral canal utilizing RIA to harvest medullary canal graft (Fig. 4A).
Figs 4A and B: (A) Reamer-Irrigator-Aspirator (RIA) on the ipsilateral left femur. (B) Filling in the uncontained bony defect with tricortical iliac crest autograft and bone marrow autograft from RIA
The subtalar joint surfaces were then prepared for fusion using a burr and curette. The tricortical graft was prepared into three sections and was decorticated using a handheld burr. This was utilized as a strut graft to fill the defect in the calcaneus (). The autograft from RIA was packed around this. Once the graft was positioned and the calcaneal shape and position were deemed acceptable, guidewires were passed under fluoroscopic guidance through the reconstructed calcaneus, across the subtalar joint, and into the talus. A mixture of partially and fully threaded 6.5 mm cannulated screws were used to hold the construct, with a further 5-hole straight plate on the lateral border of the calcaneus to support the graft. We also injected the gentamicin-loaded synthetic Cerament® to fill the screw holes that were remaining (Fig. 5). The wound was gently washed out and 1 gm of vancomycin powder was inserted along its length. A negative pressure VAC dressing was then applied, and the foot was immobilized in a boot for 2 months, nonweight bearing.
Fig. 5: Filling in the screw holes and remaining voids with Cerament® bone graft substitute
CASE DISCUSSION
The patient has been followed up for 12 months. The wounds have completely healed (Fig. 6). And she is ambulating without any aids. Radiographs demonstrate bony union within the calcaneus and the subtalar joint at one year (Fig. 7).
Fig. 6: One year follow-up demonstrating well-healed surgical incision
Fig. 7: One year follow-up demonstrating radiographic union of the left hindfoot
We decided to maximize our graft volume and biology by combining the tricortical iliac crest bone with the femoral medullary autograft obtained from RIA. We decided against using an allograft given its potential risk of further nonunion particularly with the patient actively smoking cigarettes. Cerament® bone void filler was added to fill up the screw holes to augment the structural support provided by the iliac crest. Additionally, this also provided a steady release of gentamicin to decrease the chance of further infection. Despite the complexity of the case, we did not feel that a custom metallic implant was indicated, especially given the size and the location of the bone defect.
CONCLUSION
Autograft, allograft, bone graft substitutes, and custom implants are all viable options to manage bone defects in the calcaneus. The options chosen will be dictated whether the defect is contained or not (Figs 8 and 9). The current evidence is weak and is primarily based on retrospective case reports and small case series. The benefits and risks of each option must be carefully evaluated to the specific patient and defect prior to proceeding, to secure an optimal patient outcome.
Fig. 8: Proposed algorithm for uncontained bone loss
Fig. 9: Proposed algorithm for contained bone defect
LEVEL OF EVIDENCE
III; Retrospective case series with Review of the Literature
GRANTS AND OTHER ACKNOWLEDGMENTS
The authors received no financial support for the research, authorship, and/or publication of this article.
REFERENCES
1. Keeling JJ, Hsu JR, Shawen SB, et al. Strategies for managing massive defects of the foot in high-energy combat injuries of the lower extremity. Foot Ankle Clin 2010;15(1):139-149. DOI: 10.1016/j.fcl.2009.10.003
2. Chan CW, Rudins A. Foot biomechanics during walking and running. Mayo Clin Proc 1994;69(5):448-461. DOI: 10.1016/s0025-6196(12)61642-5
3. Nauth A, McKee MD, Einhorn TA, et al. Managing bone defects. J Orthop Trauma 2011;25(8):462-466. DOI: 10.1097/BOT.0b013e318224caf0
4. Scranton PE, Jr. Use of bone graft substitutes in lower extremity reconstructive surgery. Foot Ankle Int 2002;23(8):689-692. DOI: 10.1177/107110070202300802
5. Arner JW, Santrock RD. A historical review of common bone graft materials in foot and ankle surgery. Foot Ankle Spec 2014;7(2):143-151. DOI: 10.1177/1938640013516358
6. Keating JF, Simpson AH, Robinson CM. The management of fractures with bone loss. J Bone Joint Surg Br 2005;87(2):142-150. DOI: 10.1302/0301-620x.87b2.15874
7. Azi ML, Aprato A, Santi I, et al. Autologous bone graft in the treatment of post-traumatic bone defects: a systematic review and meta-analysis. BMC Musculoskelet Disord 2016;17(1):465. DOI: 10.1186/s12891-016-1312-4
8. Boone DW. Complications of iliac crest graft and bone grafting alternatives in foot and ankle surgery. Foot Ankle Clin 2003;8(1):1-14. DOI: 10.1016/s1083-7515(02)00128-6
9. Cox G, Jones E, McGonagle D, et al. Reamer-irrigator-aspirator indications and clinical results: a systematic review. Int Orthop 2011;35(7):951-956. DOI: 10.1007/s00264-010-1189-z
10. Sagi HC, Young ML, Gerstenfeld L, et al. Qualitative and quantitative differences between bone graft obtained from the medullary canal (with a Reamer/Irrigator/Aspirator) and the iliac crest of the same patient. J Bone Joint Surg Am 2012;94(23):2128-2135. DOI: 10.2106/JBJS.L.00159
11. Stanec Z, Krivic A, Stanec S, et al. Heel reconstruction with an iliac osteocutaneous free flap: 10-year follow-up. Ann Plast Surg 2004;53(2):174-177. DOI: 10.1097/01.sap.0000099704.02280.d6
12. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004;114(6):1457-1466. DOI: 10.1097/01.prs.0000138811.88807.65
13. Peek A, Giessler GA. Functional total and subtotal heel reconstruction with free composite osteofasciocutaneous groin flaps of the deep circumflex iliac vessels. Ann Plast Surg 2006;56(6):628-634. DOI: 10.1097/01.sap.0000205768.96705.1e
14. Endo J, Kuniyoshi K, Mochizuki M, et al. Two-staged hindfoot reconstruction with vascularized fibula graft for calcaneal osteomyelitis caused by methicillin-resistant Staphylococcus aureus: a case report. Microsurgery 2013;33(3):232-235. DOI: 10.1002/micr.22070
15. Bansal R, Halai M, Matthews JL, et al. Partial calcaneus reconstruction using ’Opportunistic Grafts’: a case report. J Foot Ankle Surg 2021;60(1):199-203. DOI: 10.1053/j.jfas.2020.08.025
16. Neufeld SK, Uribe J, Myerson MS. Use of structural allograft to compensate for bone loss in arthrodesis of the foot and ankle. Foot Ankle Clin 2002;7(1):1-17. DOI: 10.1016/s1083-7515(01)00002-x
17. Myerson MS, Neufeld SK, Uribe J. Fresh-frozen structural allografts in the foot and ankle. J Bone Joint Surg Am 2005;87(1):113-120. DOI: 10.2106/JBJS.C.01735
18. Fitzgibbons TC, Hawks MA, McMullen ST, et al. Bone grafting in surgery about the foot and ankle: indications and techniques. J Am Acad Orthop Surg 2011;19(2):112-120. DOI: 10.5435/00124635-201102000-00006
19. Wee J, Thevendran G. The role of orthobiologics in foot and ankle surgery: allogenic bone grafts and bone graft substitutes. EFORT Open Rev 2017;2(6):272-280. DOI: 10.1302/2058-5241.2.160044
20. Rougraff BT, Kling TJ. Treatment of active unicameral bone cysts with percutaneous injection of demineralized bone matrix and autogenous bone marrow. J Bone Joint Surg Am 2002;84(6):921-929. DOI: 10.2106/00004623-200206000-00005
21. Wang W, Yeung KWK. Bone grafts and biomaterials substitutes for bone defect repair: a review. Bioact Mater 2017;2(4):224-247. DOI: 10.1016/j.bioactmat.2017.05.007
22. Yeo QY, Kee Kwek EB. Use of a biphasic cement bone substitute in the management of metaphyseal fractures. J Clin Orthop Trauma 2019;10(4):789-791. DOI: 10.1016/j.jcot.2018.08.014
23. Whisstock C, Volpe A, Ninkovic S, et al. Multidisciplinary approach for the management and treatment of diabetic foot infections with a resorbable, gentamicin-loaded bone graft substitute. J Clin Med 2020;9(11):3586. DOI: 10.3390/jcm9113586
24. Jariwala SH, Lewis GS, Bushman ZJ, et al. 3D printing of personalized artificial bone scaffolds. 3D Print Addit Manuf 2015;2(2):56-64. DOI: 10.1089/3dp.2015.0001
25. Imanishi J, Choong PF. Three-dimensional printed calcaneal prosthesis following total calcanectomy. Int J Surg Case Rep 2015;10:83-87. DOI: 10.1016/j.ijscr.2015.02.037
26. Park JW, Kang HG, Kim JH, et al. New 3-dimensional implant application as an alternative to allograft in limb salvage surgery: a technical note on 10 cases. Acta Orthop 2020;91(4):489-496. DOI: 10.1080/17453674.2020.1788698
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