Guided tissue regeneration with heterologous materials in primary subtalar arthrodesis: a case report
Frangez et al. Journal of Medical Case Reports
Guided tissue regeneration with heterologous materials in primary subtalar arthrodesis: a case report
Igor Frangez 0
Tea Kasnik 1
Matej Cimerman 0
Dragica Maja Smrke 0
0 Department of Traumatology, University Medical Center Ljubljana , Zaloska cesta 2, 1000 Ljubljana , Slovenia
1 Medical Faculty of Ljubljana , Vrazov trg 2, 1000 Ljubljana , Slovenia
Background: Calcaneal fractures are relatively rare and difficult to treat. Treatment options vary based on the type of fracture and the surgeon's experiences. In recent years, surgical procedures have increasingly been used due to the better long-term results. We present a case where guided tissue regeneration was performed in a calcaneal fracture that needed primary subtalar arthrodesis. We used the principles of guided tissue regeneration from oral surgery to perform primary subtalar arthrodesis and minimize the risk of non-union. We used a heterologous collagen membrane, which acts as a mechanical barrier and protects the bone graft from the invasion of unwanted cells that could lead to non-union. The collagenous membrane also has osteoconductive properties and is therefore able to increase the osteoblast proliferation rate. Case presentation: A 62-year-old Caucasian woman sustained multiple fractures of her lower limbs and spine after a fall from a ladder. Her left calcaneus had a comminuted multifragmental fracture (Sanders type IV) with severe destruction of the cartilage of her subtalar joint and depression of the Böhler's angle. Therefore, we performed primary arthrodesis of her subtalar joint with elevation of the Böhler's angle using a 7.3 mm titanium screw, a heterologous cortico-cancellous collagenated pre-hydrated bone mix, a heterologous cancellous collagenated bone wedge, and a heterologous collagen membrane (Tecnoss®, Italy). The graft was fully incorporated 12 weeks after the procedure and a year and a half later our patient walks without limping. We present a new use of guided tissue regeneration with heterologous materials that can be used to treat extensive bone defects after bone injuries. Conclusions: We believe that guided tissue regeneration using heterologous materials, including a heterologous collagen membrane that presents a mechanical barrier between soft tissues and bone as well as a stimulative component that enhances bone formation, could be more often used in bone surgery.
Guided tissue regeneration; Heterologous bone graft; Heterologous collagen membrane; Subtalar arthrodesis
Calcaneal fractures are relatively rare and difficult to
treat. They represent about 2 % of all fractures.
Approximately 60–75 % of fractures lie within the joint
]. There are many classifications for calcaneal
fractures based either on plain radiographs or CT scan.
The most used classification is Sander’s system and it
divides fractures into four stages, where stage I are all
non-displaced fractures and stage IV are fractures with
three or more fragments. Treatment options depend
upon the stage and can be conservative or surgical. In
recent years, surgical procedures have gained more
]. The aim of operative treatment is to reduce
the subtalar joint and to restore the anatomical
morphology and function of the bone.
Despite many new surgical techniques, the long-term
outcomes of patients with comminuted calcaneal
fractures remain poor. Over the years, these patients are
prone to develop painful posttraumatic joint disease that
reduces the quality of life [
]. In such cases, primary
subtalar arthrodesis can be used to prevent early
arthrosis. However, this procedure is rarely performed and its
indications are controversial [
]. Usually it is indicated
in patients with severe comminuted calcaneal fractures
with destruction of cartilage and severe depression of
Böhler’s angle [
Many reports have suggested that, despite using
different treatments that preserve the joint, subtalar arthrosis
almost universally occurs [
]. This has resulted in
primary subtalar arthrodesis becoming more common:
patients who have undergone primary arthrodesis have
better outcomes than patients who retain some motion
in the joint [
Instead of an autologous corticospongiosus graft from
the iliac crest, a heterologous porcine or equine bone
graft can be used. To accelerate bone formation, the
concept of guided tissue regeneration (GTR) can be
GTR, developed in 1976 by Melcher [
], uses the basic
principle of the different speed potentials of the cellular
components that migrate into the bone defect during
the healing process [
]. A mechanical barrier, in our case
a collagen resorbable membrane, prevents ingrowth of
unwanted cells and allows the passage of desired cells.
In the case of bone surgery, osteoprogenitor cells are
favorable to the site of the defects [
The purpose of this article is to present our results
after a primary subtalar arthrodesis was treated with
GTR using different heterologous materials. The use
of different bone substitutes is already well known in
bone surgery, but operative results can be improved
by the additional use of a heterologous collagen
membrane, which acts as a mechanical barrier that
protects the bone graft from the invasion of
unwanted cells that could lead to non-union. The
collagenous membrane also has osteoconductive
properties and is therefore able to increase the osteoblast
proliferation rate and enables faster incorporation of
A 62-year-old Caucasian woman fell approximately 6 m
from a ladder. At our emergency department she was
diagnosed with a comminuted dislocated fracture of her
left proximal tibia, a proximal fracture of her right tibia,
a pilon fracture of her right tibia, a comminuted fracture
of her left calcaneus, a fracture of her left lateral
malleolus, and an L-1 spinal fracture. We urgently operated,
performing external fixation of both tibial fractures and
osteosynthesis of her left fibula as well as external
fixation of her right pilon fracture.
Her left calcaneus had a comminuted
multifragmental fracture (Sanders type IV) with severe
destruction of the cartilage of her subtalar joint and
depression of Böhler’s angle (Fig. 1). Considering the
severity of the fracture, we decided to perform
primary arthrodesis of her subtalar joint with
elevation of the Böhler’s angle instead of osteosynthesis of
the calcaneus. Because of the severe damage to her
soft tissues, we decided to perform the primary
arthrodesis after 5 weeks. Because she had multiple
fractures and consequently multiple operations, we
decided to use a heterologous bone graft instead of
the autologous cortico-cancellous graft from her iliac
crest to avoid possible additional complications at
the donor site.
We used a 7.3 mm titanium screw for the subtalar
arthrodesis and a V block (an equine heterologous cancellous
collagenated bone wedge; OsteoBiol, Tecnoss®) to restore
the Böhler’s angle. This was used instead of an autologous
cortico-cancellous graft (Fig. 2). For spongioplasty, we used
an equine heterologous cortico-cancellous collagenated
pre-hydrated bone mix (mp3, Tecnoss®) (Fig. 3). A
resorbable collagen membrane (heterologous collagen membrane,
Evolution, Tecnoss®) was used to maintain tissue guidance
during regeneration and to avoid potential non-union
(Fig. 4). Our patient received antibiotic prophylaxis for 2
days; she was mobilized 1 day after the operation (in a
wheelchair due to her other fractures) and drainage was
removed on the second day. After 1 week she was sent to
our University Medical Rehabilitation Center. She had
regular check-ups every second week (with X-rays). Six
weeks after her last operation (subtalar arthrodesis on her
left side), she was allowed full weight-bearing with crutches
on her right foot and partial weight-bearing on her left foot
Four weeks after the subtalar arthrodesis, a plain X-ray
showed good incorporation of the graft. Eight weeks
later, the wound had healed properly and she was
allowed to begin full weight-bearing. The graft was fully
incorporated 12 weeks after the procedure.
A year and a half after her injury, our patient had no
pain and walked without limping (Fig. 5).
Calcaneal fractures are difficult to treat, especially when
extensive depression of Böhler’s angle is present. Primary
subtalar arthrodesis appears to be a good treatment
option, because most comminuted calcaneal fractures end
in post-traumatic subtalar arthrosis [
]. GTR has been
used in oral surgery for many decades and its principles
can also be used in orthopedic trauma surgery [
GTR for bone defect fulfillment, different grafts can be
used (an autologous or allogenous bone graft, synthetic
materials, or heterologous bone) but a main component
is a resorbable collagen membrane, which prevents
ingrowth of unwanted cells and allows the passage of
desired cells. In manufacturing the heterologous bone, the
antigenic components are neutralized but the collagen
matrix is preserved inside the granules of the
biomaterial. Collagen has a key role in the bone regeneration
process: (1) it acts as a valid substrate for platelet
activation and aggregation; (2) it serves to attract and
differentiate the mesenchymal stem cells in the bone marrow;
(3) it increases the proliferation rate of osteoblasts by up
to three times; and (4) it stimulates the activation of the
platelets, osteoblasts, and osteoclasts in the tissue
healing process [
Fig. 5 Final result after 1.5 years after operative treatment
We present a new application of GTR, using an equine
heterologous graft and a resorbable collagen membrane
together, which can be used for extensive bone defects
after comminuted calcaneal fractures. The main reason
we used an equine heterologous bone wedge was the
severe depression of the Böhler’s angle in our patient, which
would demand a large amount of autologous bone graft.
The described principles of GTR can also be also in
cases of secondary arthrodesis, fulfillment of large bone
defects in comminuted fractures, and in the case of
nonunion of the bone.
A comminuted calcaneal fracture can be difficult to
manage and it the approach is largely based on the surgeon’s
experience. In our case, where arthrodesis and
spongioplasty were needed, we used GTR with a resorbable
collagen membrane and an equine heterologous bone graft.
The rapid incorporation of the heterologous bone graft,
which was enhanced by the collagen membrane, supports
the efficacy of the described principles of GTR and we
suggest that this approach could be used more often in
cases where bone grafts are needed.
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
IF planned and performed the operation together with the co-authors, who
equally contributed to planning the operation, postoperative care, and in
manuscript preparation. All authors read and approved the final manuscript.
We thank Tecnoss® for donating the heterologous cortico-cancellous collagenated
pre-hydrated bone mix, the heterologous cancellous collagenated bone wedge,
and the heterologous collagen membrane for our patient.
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