| BackgroundCalcaneal fractures usually affect subtalar joint surface, and severe fractures classified as Sanders Type Ⅲ and Type Ⅳ are often found to compound bone defects. The open reduction and internal fixation (ORIF) is currently considered the primary surgical treatment for calcaneal fractures. However, no consensus has yet been reached over whether to perform bone grafting as part of bone defect repair.ObjectiveTo evaluate the efficacy of ORIF combined with and without bone grafting for displaced intra-articular calcaneal fractures (DIACFs) classified as Sanders Type Ⅲ and Type Ⅳ in adults.MethodsRetrieval method:Randomized controlled trials published in Chinese and other languages were retrieved by computer and manual search (to March 2015) from Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica Database by Elsevier Science (EMBase), the Cochrane Central Register of Controlled Trials (CENTRAL), Foreign Evidence-Based Medicine (FEBM), Foreign Medical Journal Service(FMJS) and other authoritative foreign databases, as well as Chinese databases (to March 2015) including China National Knowledge Infrastructure (CNKI), Chinese BioMedical Literature Database (CBM), Weipu Database (lib.cqvip.com) and Wanfang China Dissertation Database (CDDB). Additionally, WHO International Clinical Trials Registry Platform and Curent Controlled Trials (WHO ICTRP), ClinicalTrials.gov Database and Chinese Clinical Trial Register (ChiCTR) were also searched for ongoing studies. Besides, we searched Ovid Technologies Database, CNKI, Wanfang CACP and Wanfang CDDB for gray literature such as documents of annual conference held by the Orthopaedic Trauma Society, unpublished theses and academic theses. Do not setting limits on time or languages in the retrieval, studies were identified and collected extensively via various methods from different databases. Inclusion criteria:Randomized controlled trials (RCTs) and quasi-RCTs that tested the effects of ORIF combined with bone grafting and ORIF without bone grafting on DIACFs were enrolled and compared. Data collection and analysis:Data was retrieved and extracted independently by two reviewers. The quality and risk of bias were then evaluated to determine the inclusion of articles and samples. Review Manager (RevMan) and R were used to test the heterogeneity and merger effects in the length of operation, postoperative complications, function evaluation, radiological results and other indicators. Also, GREAD profile (GREADpro) was used to rank studies.ResultsSeven articles (three in English and four in Chinese) consisting of 431 patients (431 feet in total) with severe DIACFs (classified as Sanders III and IV) were included, among which 223 feet were in bone grafting group and 208 feet were in non-grafting group. Through the modified Jadad Quality Scale, five articles were assessed to be of poor quality while two were of high quality; Using the Cochrane Collaboration’s Tool For Assessing Risk Of Bias, three articles were identified with high risk of bias while four were identified with unclear risks. Data from the included literature was then analyzed using RevMan. The results were as follows:Between the bone grafting group and the non-grafting group, no statistical difference was found in the pooled rate of "excellent" and the pooled rate of "poor" in the function and pain assessment at Year 1 and Year 2 after the operation (P>0.05); Postoperative complications were not statistically different between the two groups(P>0.05); There were no significant differences in the Bohler’s angle, Gissane’s angle and calcaneal length and height at Year 1 after the operation, as well as in the Bohler’s angle, Gissane’s angle at Year 2 after the operation between the two groups; The length of operation in the bone grafting group was significantly longer than that in the non-grafting group(P<0.05). According to general statistical analysis, no difference was found between the bone grafting group and non-grafting group regarding fracture healing time and health-related life quality; However, the blood loss in the bone grafting group was significantly greater than that in the non-grafting group (P<0.05).ConclusionsThe Meta-analysis provided evidence that for the treatment of severe DIACFs (classified as SandersⅢ and Ⅳ), there were no statistically significant differences between ORIF with and without bone grafting regarding the short-term and long-term effects on function, pain, postoperative complications, radiological results and some other indicators (P>0.05). However, as compared to ORIF without bone grafting, the length of operation was longer if the bone grafting was performed as part of the operation (P<0.05).Based on general statistical analysis, ORIF combined with bone grafting and ORIF without bone grafting in the treatment of severe DIACFs were not markedly different in fracture healing time and health-related life quality (P>0.05). The volume of blood loss, however, was found to be larger for ORIF combined with bone grafting than that for ORIF without bone grafting. |
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