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Calcaneus Fractures And The Impact Of Bone Grafting On Wound Infection

Calcaneus Fractures And The Impact Of Bone Grafting On Wound Infection


This research aimed to assess the efficacy of bone transplantation compared to non-bone transplantation in addressing intra-articular fractures of the calcaneus and their subsequent surgical complications.

Utilizing data obtained from esteemed databases such as PubMed, Embase, and Cochrane, we meticulously analyzed patient injury profiles and occurrences of wound infections.

Employing Revman 5.3 software, we scrutinized eight pertinent operative trials involving heel implants, meticulously chosen from a vast array of literature. Of the 804 cases necessitating heel surgery, 410 underwent bone grafting while 394 did not.

The analysis revealed no discernible discrepancy in the incidence of postoperative wound infections between patients undergoing bone-grafting procedures and those who did not (Odds Ratio [OR] 0.87; 95% Confidence Interval [CI] 0.51, 1.49; p=0.62).

Similarly, there was no significant variation in the risk of postoperative marginal necrosis between the two groups (OR 0.75; 95% CI 0.42, 1.36; p=0.34).

These findings unequivocally demonstrate that there is no statistically meaningful disparity in the occurrence of postoperative necrosis and infection following intra-articular heel surgery.


Fractures of the heel, a frequent occurrence in orthopedics often resulting from falls from heights or road accidents, present intricate challenges in treatment and management.

Among these, displaced intra-articular calcaneal fractures (DIACFs) stand out as particularly demanding due to the complexity of the fracture pattern and the critical role of the calcaneus in weight-bearing and locomotion.

The primary strategy for addressing Sanders Type III Calcaneus Fracture, considered the gold standard, involves open reduction and internal fixation (ORIF).

This surgical approach aims to meticulously restore the original anatomical alignment of the calcaneus, stabilize the heel during the healing process, minimize the occurrence of postoperative complications, and ultimately restore the foot’s normal function and biomechanics.


Despite the advancements in surgical techniques and fixation methods, such as plate and screw constructs, postoperative complications remain a significant concern.

These complications include but are not limited to, marginal necrosis, wound dehiscence, hematoma formation, surgical site infections, and nerve injury. Addressing these complications is crucial for achieving successful outcomes and preventing long-term disability.

To mitigate the risks associated with surgical intervention, a range of minimally invasive technologies have been developed in recent years.

These include External Fixation, Percutaneous methods, Arthroscopic-Assisted Fixation, and various Small Incision Techniques utilizing different approaches such as medial, lateral (for example, Tarsal Sinus), longitudinal, or syndesmotic access.

These techniques aim to minimize soft tissue damage, preserve vascularity, and reduce the incidence of complications associated with traditional open surgery.


However, despite these advancements, the role of bone transplantation in the management of heel fractures remains an area of debate and uncertainty.

While some studies suggest that bone grafting can effectively promote bone healing and decrease the risk of infection, particularly in cases of significant bone loss or highly unstable fractures, others argue that its efficacy may be limited in certain scenarios.


To address this ambiguity, a comprehensive meta-analysis was undertaken, systematically reviewing published controlled studies to investigate the comparative effects of bone grafting versus non-bone transplantation approaches in the management of intra-articular calcaneal fractures following surgical intervention.

By synthesizing the existing evidence, this analysis aims to provide valuable insights into the optimal treatment strategies for these complex fractures, ultimately improving patient outcomes and quality of life.



Access to electronic databases such as PubMed, Embase, and CochraneLibrary is universal and available to all users regardless of language, extending up to October 2023.

A meticulous literature search was conducted by two independent researchers utilizing specific search strategies focused on “calcane fracture” and “bone graft.” Additionally, manual retrieval of relevant randomized studies, review papers, and meta-analyses was performed to ensure comprehensive coverage.

The inclusion criteria encompassed randomized or nonrandomized controlled trials involving patients aged 18 and above, comparing the wound status of both bone transplantation and non-bone transplantation for calcaneal fractures.

Exclusion criteria included summary papers, case reports, conference papers, duplicate research, and non-wound-related calcaneal fractures.

The literature selection process involved initial screening of titles and abstracts to eliminate duplicates and irrelevant studies, followed by thorough examination and assessment of remaining articles.

Any discrepancies between the researchers were resolved through discussion or consultation with a third independent author. Data extraction was conducted independently by two reviewers using a standardized form, focusing on study details, surgical outcomes such as trabecular marginal necrosis and infection, and statistical measures for analysis.

Quality assessment of included studies was performed using Cochrane Collaboration tools and the ROBINS-I instrument to evaluate methodology and risk of bias, categorizing studies into low, ambiguous, or high risk of bias.

This rigorous approach ensured the selection of high-quality evidence for analysis and interpretation in the subsequent phases of the research process.

Statistical Analysis

The gathered data underwent meticulous analysis using Revman 5.3 software to conduct a comprehensive meta-analysis. A random-effects model was utilized in instances of measured heterogeneity or statistical heterogeneity, indicated by a p-value less than 0.05 or I^2 greater than 50%.

Conversely, a fixed-effect model was employed when homogeneity was observed, with a p-value exceeding 0.05 or an I^2 less than 50%. Sensitivity analysis was employed for heterogeneous data to assess the impact of individual trials on the overall results.

Meta-regression analysis was conducted to identify potential sources of heterogeneity within the data. For binary outcomes, Odds Ratios (OR) were calculated, while mean differences (MD) were computed for continuous variables.

This rigorous analytical approach ensured robust findings and enhanced understanding of the associations between variables under investigation.


In this comprehensive meta-analysis, a rigorous selection process was undertaken to identify and evaluate eight operative studies from a multitude of publications spanning from 2003 to 2019.

These studies, collectively encompassing a broad spectrum of clinical data, provided invaluable insights into the management and outcomes of heel fractures.


Within a substantial cohort of 804 cases necessitating surgical intervention for heel fractures, the comparative effectiveness of bone-grafting versus non-bone-grafting approaches was meticulously assessed.

Among these cases, 410 underwent bone-grafting procedures, while 394 did not receive this intervention. The diverse sample sizes, ranging from 10 to 202 individuals, underscored the variability inherent in clinical practice and the necessity for a robust analysis to elucidate treatment outcomes effectively.

Furthermore, the characteristics of the treatment of calcaneus fractures,  offered a detailed overview of the various factors influencing treatment decisions and patient outcomes.

These characteristics encompassed a wide array of variables, including patient demographics, fracture severity, surgical techniques, and postoperative care protocols, all of which played pivotal roles in shaping treatment efficacy and patient recovery trajectories.


Quality assessments of all included trials, meticulously illustrated in Figures 2 and 3, provided critical insights into the methodological rigor and potential biases inherent in each study.

These assessments served as foundational pillars upon which the subsequent analyses were built, ensuring the validity and reliability of the findings.


Specifically focusing on wound infection and marginal necrosis, two pivotal complications associated with heel fractures, the meta-analysis yielded compelling results.

Seven studies meticulously examined the occurrence of post-surgical wound infections in patients with calcaneus fractures, revealing no significant difference in infection rates between those who underwent bone transplantation and those who did not.

Similarly, five studies meticulously investigated the incidence of post-surgical marginal necrosis, demonstrating no substantial disparity in necrosis rates between the two groups.

These findings, encapsulated in robust statistical analyses, underscored the importance of evidence-based decision-making in the management of heel fractures.

By elucidating the comparative effectiveness of different treatment modalities and their impact on patient outcomes, this meta-analysis serves as a guiding beacon for clinicians striving to optimize care delivery and enhance patient outcomes in the challenging realm of orthopedic surgery.



The optimal management of displaced calcaneus fractures remains a subject of debate among orthopedic specialists. While surgical intervention is often favored for better outcomes, concerns regarding postoperative complications persist.

Microinvasive techniques like the Tarsal sinus procedure have gained traction due to their potential to minimize complications. 


In a meta-analysis of eight operative trials involving 804 patients, bone-grafting was compared to non-bone-grafting approaches. Results showed no significant difference in postoperative wound infection and marginal necrosis risk between the two groups. However, limitations such as small sample sizes and retrospective study designs warrant further research for conclusive findings.


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