Screw tip augmentation leads to improved primary stability in the minimally invasive treatment of displaced intra-articular fractures of the calcaneus: a biomechanical study
To investigate if the stability of minimally invasive screw osteosynthesis of displaced intra-articular calcaneal fractures (DIACF) can be effectively increased by an innovative approach to screw tip augmentation.
In eight-paired human cadaver hindfoot specimens, DIACF of Sanders type IIB were treated with either standard screw osteosynthesis or with bone cement augmentation of the screw tips in the main fragments. The instrumented specimens were subjected to a cyclic loading protocol (9000 cycles, with stepwise increasing loads, 100–1000 N). The interfragment motions were quantified as tuber fragment tilt (TFT) and posterior facet inclination angle (PFIA) using a 3-D motion analysis system. Böhler’s angle (BA) was evaluated from X-rays. A load-to-failure test was performed after the cyclic loading protocol.
All but one specimen of the augmented group withstood more cycles than the respective specimens of the non-augmented group. Mean cycles to failure for the failure criterion of 5° TFT were 7299 ± 1876 vs. 3864 ± 1810, corresponding to loads of 811 N ± 195 vs. 481 N ± 180, (P = 0.043). There were no significant differences observed in the PFIAs. The failure criterion of 5° BA was reached after a mean of 7929 cycles ± 2004 in the augmented group and 4129 cycles ± 2178 in the non-augmented group, corresponding to loads of 893 N ± 200 vs. 513 N ± 218, (P = 0,090). The mean load-to-failure of the four specimens in the augmented group that completed the cyclic loading was 1969 N over a 1742–2483 N range.
Screw tip augmentation significantly improved the mechanical stability of the calcanei after osteosynthesis in terms of decreased tuber fragment tilts and less changes in Böhler’s angle.
KeywordsCalcaneus fracture Screw fixation Augmentation Cement Biomechanics
We want to thank Nora Klier for assisting with the surgical procedures and testings, Cornelia Qadri for her competent technical support and Clemens Unterwurzacher for photography and illustrations. Martin Eichinger received a research grant by DePuy Synthes, J&J Austria. Additionally, we would like to thank all body donors.
- 11.Carow JB, Carow J, Gueorguiev B, Klos K, Herren C, Pishnamaz M, Weber CD, Nebelung S, Kim BS, Knobe M (2018) Soft tissue micro-circulation in the healthy hindfoot: a cross-sectional study with focus on lateral surgical approaches to the calcaneus. Int Orthop. https://doi.org/10.1007/s00264-018-4031-7
- 12.Schepers T, Backes M, Dingemans SA, de Jong VM, Luitse JSK (2017) Similar anatomical reduction and lower complication rates with the sinus tarsi approach compared with the extended lateral approach in displaced intra-articular calcaneal fractures. J Orthop Trauma 31(6):293–298. https://doi.org/10.1097/BOT.0000000000000819 CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Kannus P, Niemi S, Sievanen H, Korhonen N, Parkkari J (2016) Fall-induced fractures of the calcaneus and foot in older people: nationwide statistics in Finland between 1970 and 2013 and prediction for the future. Int Orthop 40(3):509–512. https://doi.org/10.1007/s00264-015-2875-7 CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Rausch S, Klos K, Wolf U, Gras M, Simons P, Brodt S, Windolf M, Gueorguiev B (2014) A biomechanical comparison of fixed angle locking compression plate osteosynthesis and cement augmented screw osteosynthesis in the management of intra articular calcaneal fractures. Int Orthop 38(8):1705–1710. https://doi.org/10.1007/s00264-014-2334-x CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Riederer BM, Bolt S, Brenner E, Bueno-López JL, Circulescu ARM, Davies DC, De Caro R, Gerrits PO, McHanwell S, Pais D, Paulsen F, Plaisant O, Sendemir E, Stabile I, Moxham BJ (2012) The legal and ethical framework governing body donation in Europe – 1st update on current practice. Eur J Anat 16(1):1–21Google Scholar
- 21.Gonzalez TA, Ehrlichman LK, Macaulay AA, Gitajn IL, Toussaint RJ, Zurakowski D, Kwon JY (2016) Determining measurement error for Bohler’s angle and the effect of X-ray obliquity on accuracy. Foot Ankle Spec 9(5):409–416. https://doi.org/10.1177/1938640016656236 CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Eichinger M, Schmoelz W, Brunner A, Mayr R, Boelderl A (2015) Subtalar arthrodesis stabilisation with screws in an angulated configuration is superior to the parallel disposition: a biomechanical study. Int Orthop 39(11):2275–2280. https://doi.org/10.1007/s00264-015-2944-y CrossRefPubMedPubMedCentralGoogle Scholar
- 23.Chen W, Liu B, Lv H, Su Y, Chen X, Zhu Y, Du C, Zhang X, Zhang Y (2017) Radiological study of the secondary reduction effect of early functional exercise on displaced intra-articular calcaneal fractures after internal compression fixation. Int Orthop 41(9):1953–1961. https://doi.org/10.1007/s00264-017-3533-z CrossRefPubMedPubMedCentralGoogle Scholar
- 25.Qiang M, Chen Y, Jia X, Zhang K, Li H, Jiang Y, Zhang Y (2017) Post-operative radiological predictors of satisfying outcomes occurring after intra-articular calcaneal fractures: a three dimensional CT quantitative evaluation. Int Orthop 41(9):1945–1951. https://doi.org/10.1007/s00264-017-3577-0 CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Goldzak M, Simon P, Mittlmeier T, Chaussemier M, Chiergatti R (2014) Primary stability of an intramedullary calcaneal nail and an angular stable calcaneal plate in a biomechanical testing model of intraarticular calcaneal fracture. Injury 45(Suppl 1):S49–S53. https://doi.org/10.1016/j.injury.2013.10.031 CrossRefPubMedPubMedCentralGoogle Scholar