Tag Archives: platelet rich plasma (PRP)

The Use of Platelet-Rich Plasma with Autologous Bone Graft in Arthrodesis: A Salvage Procedure to correct the failure of a Keller Arthroplasty

by Antonio Córdoba-Fernández, PhD1, Jesús Álvarez-Jiménez, PhD2pdflrg

The Foot and Ankle Online Journal 6 (2): 2

Sometimes the success of orthopedic and podiatric surgery may be compromised by inadequate bone repair. In recent years, new tools have been used to improve bone healing by accelerating the rate of bone formation and maturation of the matrix. For instance, there is currently great interest in the use of platelet gel to repair bone defects and accelerate the bone healing process. We report the case of a patient with recurrent hallux valgus following Keller resection arthroplasty for whom the problem was resolved with the use of an autologous cancellous bone graft enriched with platelet-rich plasma as a salvage procedure to enhance arthrodesis. The use of bone graft enriched with platelet-rich plasma (PRP) is a technology in the field of foot surgery should be investigated further.

Key words: Bone graft, Platelet- rich plasma, Keller arthroplasty, Salvage surgery

Accepted: January, 2013
Published: February, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0602.002

Address correspondence to: Antonio Córdoba-Fernández, Departamento de Podología, Universidad de Sevilla, Edificio Docente de Fisioterapia y Podología, Calle Avicena s/n 41009- Sevilla, Spain.

1Titular Professor. Departamento de Podología, Sevilla, Universidad de Sevilla, Edificio Docente de Fisioterapia y Podología, Calle Avicena s/n 41009- Sevilla, Spain. (034) 954486539 acordoba@us.es
2Assistant Professor. Departamento de Podología, Sevilla, Universidad de Sevilla, Edificio Docente de Fisioterapia y Podología, Calle Avicena s/n 41009- Sevilla, Spain. (034) 954486539 jalvarez@us.es

The Keller-Brandes excision arthroplasty technique has been used for decades for the treatment of symptomatic hallux valgus and hallux rigidus. It is even today still sometimes considered a valid procedure for the management of painful adult hallux valgus associated with arthritis of the metatarsophalangeal joint.[1,2] However, the technique often causes the patient dissatisfaction because it fails to maintain the proper alignment and biomechanical functionality of the hallux.

The most common complications associated with the procedure that have been reported in the literature include recurrence of the deformity, transfer metatarsalgia, excessive shortening of the toe, and “cock up” deformity.[3-6] In most cases, the recurrence of the deformity is the result of poor correction of the inter-metatarsal angle after the procedure. Although the technique is out-dated today, it is still relatively common to find patients who have complications after undergoing a Keller arthroplasty. Salvage of the failed procedure by metatarsophalangeal joint arthrodesis (MTPJ-A) of the hallux is a complex surgical problem, especially if it results in shortening of the hallux.

The use of bone graft enriched with platelet-rich plasma (PRP) is a relatively novel technology in the field of podiatric and orthopedic surgery. It is used to enhance bone formation and reduce the risk of delayed consolidation or non-union. The positive impact of PRP on bone healing is attributed to the angiogenic, proliferative, and differentiating effect on osteoblasts of the growth factors and tissue adhesion molecules it contains.[7] The results of numerous studies that have used PRP associated with autologous or heterologous bone grafts show promise for achieving the regeneration of long bones and for the treatment of bone defects. Investigators have shown that PRP and its growth factors and cytokines enhance mesenchymal stem cell proliferation.[8,9]

Case Report

A 61 year-old woman presented with painful hallux valgus of the left foot. According to her surgical history, in 1989 she had had an operation to correct hallux valgus of both feet by the Keller technique. In 1996, she had a revision on the left foot by means of re-excision arthroplasty and soft tissue reconstruction due of recurrence of the deformity. Our radiographic examination showed severe joint destruction in both feet with the result of asymptomatic hallux rigidus of the right foot, and hallux valgus of the left foot without significant shortening of the great toe. In both feet, there was broadening and flattening of the second and third metatarsal heads secondary to Freiberg’s disease. (Fig. 1)

Surgery was planned for the left foot, consisting in MTPJ-A of the hallux. The procedure consisted of excision of the base of the proximal phalanx of the second toe, and metatarsal remodeling of the second metatarsal head with stabilization of the joint by means of a Kirschner wire. A cancellous bone graft was extracted from the base of the phalanx, second metatarsal head and first metatarsal head (bunion). This was triturated and mixed with 5 ml of PRP which was subsequently activated with 10% calcium chloride in accordance with the PRGF System® protocol (Biotechnology Institute, Vitoria, Spain).[10] (Fig. 2)


Figure 1 Preoperative radiograph shows destruction of the first metatarsophalangeal joint in both feet. Recurrence of hallux valgus with hallux shortening of the left hallux can be observed.

Figure 2

Figure 2 Autologous bone graft triturated and mixed with activated PRP.

A flat osteotomy was performed on the first metatarsal head, and decortication and revascularization at the base of the hallux’s proximal phalanx, with interposition of the graft that had been obtained, and stabilization by means of a 1.5 mm Kirschner wire (Fig. 3). Following surgery, the foot was immobilized in a short leg cast and the patient allowed walk aided by crutches. Progress postoperatively was normal until the fourth week with the onset of inflammation affecting the hallux accompanied by pain and increased local temperature compatible with an infectious process.

Figure 3

Figure 3 Immediate postoperative radiograph of the left foot show interposition of the bone graft with stabilization by Kirschner wire.

This forced the premature withdrawal of the Kirchner wire, and the initiation of antibiotic therapy for three weeks until remission of the clinical signs of infection. The foot remained immobilized in a short leg cast for 4 weeks.

After removal of the cast, the patient was placed in a reverse camber shoe for 4 weeks that elevates and protects the forefoot and allowed full weight bearing assisted by a crutch. Follow-up examinations with radiological control were conducted at 4, 8, 12, and 24 weeks, and one year postoperatively. The 12-week radiological examination showed the presence of lytic lesions at the level of the interphalangeal joint consistent with sequelae of osteoarthritic sepsis. (Fig. 4)

Figure 4 (2)

Figure 4 Twelve week anterior posterior radiograph demonstrating the resorption of graft with partial consolidation. Lytic lesions at the level of the interphalangeal joint by septic osteoarthritis can be observed.

Despite the early removal of the fixation, no delay was observed in consolidation of the bone in the zone of the graft. Instead there was steady progression to full fusion. (Fig. 5)


Numerous salvage techniques have been described to resolve complications associated with the Keller-Brandes arthroplasty. These include arthrodesis, re-excision and reconstruction of soft tissue, and placement of hemi-implants or total implants.[6,11] The existing evidence shows that MTPJ-A of the hallux is a good option for the restoration of the biomechanical integrity of the first ray after a Keller arthroplasty.[12]

Figure 5 (2)

Figure 5 One year postoperatively radiograph. Complete fusion and satisfactory alignment of the hallux has been attained.

A prospective study with long-term monitoring carried out sequentially on 28 feet which underwent an MTPJ-A following a failed Keller-Brandes arthroplasty found the procedure to be safe and effective, and to result in functional improvement with high patient satisfaction [13].

However, the technique is sometimes difficult to perform as a result of the resection arthroplasty drastically altering the anatomical configuration of the joint, producing a significant shortening of the hallux with the risk of non-union. In many cases, this circumstance requires the use of an autologous bicortical iliac crest graft combined with rigid fixation elements (low profile plates with cortical screws), thus increasing the technical difficulty of the procedure and its associated risk, as well as donor site morbidity.[12-16]

Although there are no conclusive data on the non-fusion rate following MTPJ-A as a salvage procedure after a failed Keller, according to the literature data, even with stable fixation systems the risk of non-fusion in patients who have undergone a hallux MTPJ-A with interposition of a bone graft as a salvage procedure is in the range 10%–24% compared to only 5%–8% in patients who have undergone the technique as the primary procedure.[15-17] Some of these studies advise against re-fusion after a failed hallux MTPJ-A except for removal of the osteosynthesis material.[18]

New therapies have been used to increase the effectiveness of autologous grafts in bone regeneration for the treatment of bone defects, delayed consolidation, and non-fusion. Some studies have reported satisfactory results associated with the use of PRP for the treatment of bone defects. In the realm of orthopedic surgery, PRP has been used to improve osseous healing in fusion, fracture repair, and limb-lengthening procedures, and to accelerate soft-tissue healing in acute and chronic tendinous injuries.[19-21] Similarly, good results have been reported with the use of PRP to treat recalcitrant nonunions of the lower limbs and in the treatment of post-traumatic spinal fusions.[22-24] PRP has also been successfully employed in association with bone substitutes that have osteoconductive and osteoinductive properties to accelerate the healing process after tibial osteotomy in both animals and humans.[25,26] Although recent studies seem to demonstrate the superiority of other preparations such as recombinant bone morphogenetic protein (rhBMP) associated with bone graft,[27] the recombinant production technique usually involves higher costs than the systems for obtaining autologous PRP.

In the present case, the association of PRP with autologous bone graft led to complete fusion in a bone of poor quality and without rigid fixation elements. Despite the early withdrawal of the Kirschner wire due to the appearance of infection in the interphalangeal joint of the hallux, there was no delay in consolidation, and complete radiological fusion was observed at 24 weeks.

Although the use of a graft obtained from the patient’s own foot has already been reported in the literature as a salvage procedure following a failed Keller,[28] to the best of our knowledge, the present case is the first to use an autologous graft taken from the foot in association with a platelet gel as the salvage procedure.

According to the literature, the use in the technique of non-rigid osteosynthesis material such as Kirschner wires or Steinmann pins in association with the ankle brace surgical shoe is effective, even with immediate loading, and as in the present case, has the advantage of its easy removal in case of complication.[12,29] Nonetheless, it has to be borne in mind that the use of intramedullary fixation elements can lead to increased risk of infection, ankylosis of the hallux’s interphalangeal joint or breakage of the osteosynthesis material in patients who do not adequately comply with postoperative recommendations.


We consider that MTPJ-A with interposition of PRP-enriched autologous bone graft may be a useful alternative for the salvage of failures following Keller arthroplasty when there is no excessive shortening of the hallux. In particular, it can avoid the risks associated with the use of autologous bicortical bone graft and complex osteosynthesis material, with a concomitant reduction in donor site morbidity, better cosmetic results, and reduction in the costs associated with the use of complex osteosynthesis material. We consider that use of bone graft enriched with platelet-rich plasma (PRP) is a relatively novel technology in the field of foot surgery should be investigated further.


1. Putti AB, Pande S, Adam RF, Abboud RJ. Keller’s arthroplasty in adults with hallux valgus and hallux rigidus. Foot Ankle Surg 2012 18: 34-38. [PubMed]
2. Schneider W, Kadnar G, Kranzl A, Knahr K. Long-Term Results Following Keller Resection Arthroplasty for Hallux Rigidus. Foot Ankle Int 2011 32: 933-939. [PubMed]
3. Leonhardt K. Results of Keller-Brandes method of hallux valgus surgery. Beitr Orthop Traumatol.1990 37: 510-517. [PubMed]
4. Schneider W, Knahr K. Keller procedure and chevron osteotomy in hallux valgus: five-year results of different surgical philosophies in comparable collectives. Foot Ankle Int 2002 23: 321-329. [PubMed]
5. Axt M, Wildner M, Reichelt A. Late results of the Keller–Brandes operation for hallux valgus. Arch Orthop Trauma Surg 1993 112: 226-229. [PubMed]
6. Machacek F, Easley M, Gruber F, Ritschl P, Trnka HJ. Salvage of a failed Keller resection arthroplasty. JBJS 2004 86: 1131-1138. [PubMed]
7. Marx RE, Carlson ER, Schimmele SR. Platelet rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radio Endod 1998 85: 638-646. [PubMed]
8. Vogel JP, Szalay K, Geiger F, Kramer M, Richter W, Kasten P. Platelet-rich plasma improves expansion of human mesenchymal stem cells and retains differentiation capacity and in vivo bone formation in calcium phosphate. Platelets 2006 17: 462- 469. [PubMed]
9. Kocaoemer A, Kern S, Klueter H, Bieback K. Human AB-serum as well as thrombin activated platelet-rich-plasma are suitable alternatives to fetal calf serum for the expansion of mesenchymal stem cells. Stem Cells 2007 25: 1270-1278. [PubMed]
10. Anitua E. The use of plasma-rich growth factors (PRGF) in oral surgery. Pract Proced Aesthet Dent 2001 13: 487-493. [PubMed]
11. Simpson-White R, Joseph G, Khan M. Prosthetic replacement arthroplasty as a salvage operation for failed procedures of the first metatarsophalangeal joint: A small series and literature review. The Foot 2007 17: 174-177. [Website]
12. Coughlin MJ, Mann RA. Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure. JBJS 1987 69: 68-75. [PubMed]
13. Georgousis H, Patsalis T, Bertram R. Salvage of the failed Keller-Brandes operation by metatarsophalangeal fusion. Foot Ankle Surg 1996 2: 3-11. [Website]
14. Vienne P, Sukthankar A, Favre P, Werner CML, Baumer A, Zingg PO.  Metatarsophalangeal joint arthrodesis after failed Keller-Brandes procedure. Foot  Ankle Int.  2006 27:824-901. [PubMed]
15. Myerson MS, Schon LC, McGuigan FX, Oznur A. Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int  2000 21: 297-306. [PubMed]
16. Bennet GL, Kay DB, Sabatta J. First metatarsophalangeal joint arthrodesis: an evaluation of hardware failure. Foot Ankle Int  2005 26: 593-596. [PubMed]
17. Roukis TS. Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. J Foot Ankle Surg  2011 50: 710-713. [PubMed]
18. Hope M, Savva N, Whitehouse S, Elliot R, Saxby TS. Is it necessary to re-fuse a non-union of a hallux metatarsophalangeal joint arthrodesis? Foot Ankle Int 2010 31: 662-669. [PubMed]
19. Dallari D, Savarino L, Stagni C, Cenni E, Cenacchi A, Fornasari PM, Albisinni U, Rimondi E, Baldini N, Giunti A. Enhanced tibial osteotomy healing with use of bone grafts supplemented with platelet gel or platelet gel and bone marrow stromal cells. JBJS  2007 A89: 2413-2420. [PubMed]
20. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 2009 37: 2259-2272. [PubMed]
21. Kitoh H, Kitakoji T, Tsuchiya H, Katoh M, Ishiguro N. Transplantation of culture expanded bone marrow cells and platelet rich plasma in distraction osteogenesis of the long bones. Bone 2007 40: 522-528. [PubMed]
22. Chiang CC, Su CY, Huang CK, Chen WM, Chen TH, Tzeng YH. Early experience and results of bone graft enriched with autologous platelet gel for recalcitrant. J Trauma 2007 63: 655-661. [PubMed]
23. Hartmann EK, Heintel T , Morrison RH ,Weckbach A. Influence of platelet-rich plasma on the anterior fusion in spinal injuries: a qualitative and quantitative analysis using computer tomography. Arch Orthop Trauma Surg 2010 130: 909-914. [PubMed]
24. Sanchez M, Anitua E, Cugat R, et al. Nonunions treated with autologous preparation rich in growth factors. J Orthop Trauma. 2009 23: 52-59. [PubMed]
25. Dallari D, Savarino L, Stagni C, Cenni E, Cenacchi A, Fornasari PM, Albisinni U, Rimondi E, Baldini N, Giunti A. Enhanced tibial osteotomy healing with use of bone grafts supplemented with platelet gel or platelet gel and bone marrow stromal cells. JBJS 2007 A89: 2413-2420. [PubMed]
26. Kanthan SR, Kavitha G, Addi S, Choon DS, Kamarul T. Platelet-rich plasma (PRP) enhances bone healing in non-united critical-sized defects: a preliminary study involving rabbit models. Injury 2011 42: 782-789. [PubMed]
27. Calori GM, Tagliabue L, Gala L, D’Imporzano M, Peretti G, Albisetti W. Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone nonunions: a prospective randomized clinical study on 120 patients. Injury 2008 39: 1391-1402. [PubMed]
28. Patel S, Mistry RS, Dodd LE, Shaikh N, Palmer SH. Second toe proximal phalanx interposition bone graft to correct a failed Keller’s arthroplasty. A new technique. Foot Ankle Surg 2009 15: 149-151. [PubMed]
29. Mah CD, Banks AS. Immediate weight bearing following first metatarsophalangeal joint fusion with Kirschner wire fixation. J Foot Ankle Surg 2009 48: 3-8. [PubMed]

Incorporating Platelet Rich Plasma and Platelet Poor Plasma into Open Reduction Internal Fixation of Closed Calcaneus Fractures to Reduce Wound Complication: A Case Study

by Travis A. Motley, DPM, FACFAS1 , John Randolph Clements, DPM, FACFAS2 ,
J. Kalieb Pourciau, DPM3

The Foot and Ankle Online Journal 2 (11): 1

Background: Calcaneal fractures are high energy injuries. There is some debate with the advantages and disadvantages of treating calcaneal fractures with open reduction and internal fixation based on surgical complication rates.
Methods: We describe the management of 12 patients who presented to our emergency department with 14 closed intra-articular calcaneal fractures (7 Sanders Class III fractures, 7 Sanders class IV fractures). These 14 fractures were treated with open reduction and internal fixation. We describe a technique using platelet rich plasma and platelet poor plasma in the closing of the soft tissues after open reduction of calcaneal fractures.
Results: While complications with open reduction of calcaneal fractures include poor wound healing and infection and can range between 26 and 60 percent, we observed no complications in our small series.
Discussion: Wound complications are the most common and potentially threatening consequence of open reduction and internal fixation of calcaneal fractures. The purpose of this case study is to offer the addition of platelet rich plasma (PRP) and platelet poor plasma (PPP) in the treatment of these complicated injuries. The study also attributes the low complication rate to application of pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach and “hands off” retraction. As well as low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting. Our series matched that of previous studies without a single wound complication.

Key Words: Trauma, calcaneal fractures, Algower-Donati suture technique, platelet rich plasma (PRP), platelet poor plasma (PPP).

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: October, 2009
Published: November, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0211.0001

The calcaneus is the most commonly fractured tarsal bone constituting 60% of all major tarsal injuries, but only 2% of all fractures of the body. [1] Calcaneus fractures are high energy injuries [2] and most commonly occur with a fall from a height. [1]

A study by Lance, et al.,[3] has recorded calcaneal fractures from falls ranging three to fifty feet with an average of 14 feet. There is debate over the appropriate treatment for closed calcaneal fractures. The majority of this debate deals with complication rates and functional outcomes of conservative versus surgical management.

Complications of open reduction internal fixation (ORIF) include, but are not limited to, wound complications (dehiscence, hematoma, erythema, cellulitis, and infection), thromboembolism (deep venous thrombosis and pulmonary embolus), malreduction, compartment syndrome, nerve conditions (entrapment, numbness, reflex sympathetic dystrophy), osteomyelitis, and shoewear modifications. Subsequent operations may be required such as fasciotomy, secondary arthrodesis, peroneal nerve neurolysis, hardware removal, exostectomy, and irrigation and debridements for deep surgical site infections. [4,5] Several predisposing factors contribute to wound complications. Furthermore, the Sanders classification [6] can be predictive of complication rates. A previous study reported Sanders Class II calcaneal fractures have an overall complication rate of 27%, Class III fractures are 26%, and Class IV fractures are 60%. [4] The overall complication rate with ORIF of all closed calcaneal fractures is between 0% and 25% with wound complications being between 0% and 16%. [4,5]

Soft tissue and bone healing are mediated by a cascade of intra- and extracellular events. These events are regulated by signaling proteins and specific healing stages. Wound healing has three overlapping stages: inflammation, proliferation, and remodeling. Inflammation is the initial response to tissue injury. The main goal of the inflammatory phase is to provide rapid hemostasis and begin the sequence of events that leads to regeneration of tissue. During the proliferative phase, the damaged, necrotic tissue that is being removed via phagocytosis starts to be replaced with living tissue that is specific to the local tissue environment. During remodeling, the newly generated tissue reshapes and reorganizes to more closely resemble the original tissue. [7]

Platelets play a prominent role as one of the first responders during the acute inflammatory phase. In response to tissue damage, platelets are activated resulting in the formation of a platelet plug and blood clot for hemostasis. The alpha granules of activated platelets contain numerous proteins that influence wound healing. These include platelet derived growth factor, transforming growth factor, insulin-like growth factor, and Factor V, among others. In the presence of calcium, Factor V binds to activated factor X to produce prothrombin activator which converts prothrombin to thrombin. Thrombin then converts fibrinogen to fibrin which binds to platelet surface receptors. This activates another series of factors which are involved in activating factor X via the intrinsic pathway. [7] These proteins from platelet degranulation are partly responsible for cellular chemotaxis, proliferation, and differentiation. This includes removal of tissue debris, angiogenesis, establishing the extracellular matrix, and regeneration of the appropriate type of tissue.

Platelet rich plasma (PRP) is, by definition, a volume of the plasma fraction of autologous blood having a platelet concentration above baseline. [8] Therefore, PRP has the full complement of clotting factors and higher concentration of platelets. The portion of plasma that remains deficient in platelets is known as platelet poor plasma (PPP). PPP has clinical roles as fibrin sealant for hemostasis. Platelet concentrations in PRP range from 2 – 8.5 times that of normal plasma. [7]


Each patient enrolled in our study was stabilized by one of the three authors in our emergency department. The optimal time for operation was determined by soft tissue indicators: absence of fracture blisters, positive skin wrinkle test, and restoration of elastic properties within the area of incision. Preoperatively, all patients received one gram of Cephalexin, or one gram of Vancomycin if patient had an allergy to penicillin, intravenously 30 minutes prior to the procedure.

Patients were placed in a lateral decubitus position depending on the operative side. A pneumatic thigh cuff was used for hemostasis. The operative foot was supported with a Seattle pillow. The operative leg was then prepped and draped using aseptic technique. The leg was elevated and exsanguinated and the tourniquet was then inflated. A surgical marking pen was then used to draw an L-shaped lateral extensile incision over the lateral aspect of the calcaneus as to maximally preserve the blood supply to the lateral subperiosteal flap as described by Borelli. [9] The horizontal arm was 2 cm superior to the plantar fat pad, the vertical arm of this incision was 1 cm anterior to the Achilles tendon. Each arm of the “L” measured approximately 8 cm in length. The incisions were initially made to the level of the bone. The subperiosteal flap, including the peroneal tendons and the sural nerve, was elevated from the lateral wall of the calcaneus superiorly and retracted with Kirschner wires in the fibula, talus, and cuboid. (Fig. 1) This allowed visualization of the lateral calcaneal body, the calcaneocubiod joint and the subtalar joint.

Figure 1 Extensile lateral approach with Kirschner wires retracting full-thickness skin flap.

After reduction of the articular surfaces, calcaneal body and the lateral calcaneal wall, a low profile titanium perimeter plate and screws (ACE-Depuy®, Warsaw, Indiana) was utilized for fixation.

The wound was copiously irrigated with normalized saline using bulb syringe. A 4-mm flat Jackson-Pratt facial drain was then placed exiting dorsally and sutured into place. Next, PRP derived from the Gravitational Platelet Separation System (GPS® III, Biomet®, Inc., Warsaw, Indiana) was then applied to any body defects and the operative field. The wound was then carefully closed in layers using 2-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) for deep tissue, 3-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) subcutaneously, and 4-0 Ethilon (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) to reapproximate the skin using the horizontal Allgower – Donati suture technique. [10] (Fig. 2)

Figure 2 Closed extensile lateral approach with Allgower-Donati suture technique. Drain exit site is beyond region of the elevated flap.

Platelet poor plasma from the GPS® III system was then applied above the incision. The wound was bandaged with sterile gauze, kling, and a bulky Curity™ Lakeside™ cotton roll (The Kendall Company, Boston, Massachusetts) compressive posterior splint. The tourniquet was deflated and there were typical hyperemic responses to all the digits. Patients were admitted for postoperative pain management. Drain output was recorded until it produced 30 cc or less in 24 hours. Then, the drain was removed. All patients received one gram of Cephalexin every eight hours or one gram of Vancomycin every 12 hours post operatively until discharged.

Patients were discharged home when their pain was managed appropriately with oral medication. Utilizing this technique, none of our patients had wound complications. Each patient healed the surgical site without incident.


We report on open treatment of 14 calcaneal fractures from 12 patients. Thirteen of the fourteen were sole ORIF of intra-articular calcaneal fractures. One of the fourteen had a primary subtalar joint arthrodesis in addition to reduction of the calcaneus. This patient was included in the study because the surgical approach and timing resembled the other patient who received ORIF. Eleven patients were male, one was female. One patient sustained bilateral injury, and received bilateral repair. Ten of our patients had no pertinent past medical history. One male had a past medical history of transient ischemic attacks, hypertension, and hypothyroidism. One female had a history of numerous psychiatric disorders. Fifty percent (6 of 12) of our patients had social histories significant for tobacco use. There were seven right and seven left calcaneal fractures. Average follow up time period was 11.4 months (range 7-18 months). Average patient age was 35.25 (range from 21 – 69). There were no wound complications in our series utilizing our technique.


Calcaneal fractures are high energy injuries with reported complications after ORIF of 0 – 25%.4,5 There is still debate regarding ORIF compared conservative treatment of closed calcaneal fractures based on these complications. In a prospective randomized trial comparing open reduction and internal fixation with non-operative treatment, Howard, et al., [4] reported complication rates of 25% in ORIF of 226 intra-articular calcaneus fractures.

This was then subcategorized into 16% wound complications, 5.8% malpositions of fixation, 1.2% thromboembolisms, 1.6% compartment syndromes, and 0.4% deep infections. All surgeons used the lateral extensile approach in their study.

According to a literature review done by Benirschke and Kramer5, serious infections (those requiring more than oral antibiotic therapy) after ORIF of closed calcaneus fractures range from 0% to 20%. They site three studies that claim 0% complication rates [11-13] and one study with a 20% complication rate. [14] The authors questioned the utility of these findings citing small sample sizes, short follow up times, multiple surgeons, and multiple approaches as concerns. To address those issues they reported on 341 closed calcaneal fractures treated by the senior author (Bernischke) with ORIF via an extensile lateral approach and a two layer closure. He reported only 1.8% of his subjects required further intervention. These finding were comparable to the largest study in their literature review which reported three deep infections in 114 fractures for a rate of 2.6%. [15] Benirschke cited non-compliance as the primary factor of his complications although smoking and predisposing medical conditions also contributed. Other authors have also found smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures. Cumulative risk factors increase the likelihood of wound complications, and consideration should be given to nonsurgical management. [16]

As previously concluded by Pietzrak and Eppley [7], platelets direct wound healing. They appear almost immediately at the site of soft tissue injury and create a local environment conducive to tissue generation by secretion of proteins from their alpha granules. Basic science supports the hypothesis of enhancing healing by the placement of a supraphysiologic concentration of autologous platelets at the site of soft tissue injury.

So far, PRP has been applied to the following areas of medicine: cardiopulmonary bypass, mandibular bone augmentation for dental implants, diabetic foot ulcers, periodontal, lumbar spine fusion, and cutaneous ulcers, bone grafting, and cardiovascular surgery with documented success. [17-24]

Wound complications are the most common and potentially threatening consequence of ORIF of calcaneal fractures. There have been previous papers describing techniques to help lower this complication. Our series matched that of previous studies without a single wound complication. While our series is limited to 14 fractures, several important points can be made. Most series of high energy injuries refer to several factors that can influence complication rates: energy of the injury, surgeon experience, soft tissue handling, medical history, patient compliance, social habits, and nutritional status. It can be said with some certainty that constant experience with calcaneal fractures leads to a decreased complication rate. Although the purpose of this case study is to offer the addition of PRP and PPP to the treatment of these complicated injuries, we believe that our low complication rate is multifactorial. This includes pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach, “hands off” retraction, low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting.


1. Ruch JA, Taylor GC: Calcaneal Fractures. In Comprehensive Textbook of Foot Surgery 2nd Edition, p1543, edited by ED McGlamry, AS Banks, MS Downey, Williams & Wilkins, Baltimore, 1992.
2. DiGiovanni CW, Benirschke SK, Hansen ST: Foot Injuries. In Skeletal Trauma 3rd Edition, pp 2406 – 2417, edited by BD Browner, JB Jupiter, AM Levine, PG Trafton. WB Saunders, Philadelphia, 2003.
3. Lance EM, Carey EJ: Fractures of the os calcis: a followup study. J Trauma 4: 15 – 56, 1964.
4. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R: Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 17(4): 241 –249, 2003.
5. Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 18(1): 1 – 6, 2004.
6. Sanders R, Fortin P, DiPasquale T, Walling A: Operative treatment in 120 displaced intraarticular calcaneus fractures. Results Using a Prognostic Computed Tomographic Scan Classification. Clin Orthop Rel Res 290: 87 – 95, 1993.
7. Pietrzak WS, Eppley BL: Platelet rich plasma: biology and new technology. J Craniofacial Surgery 16 (6): 1043 – 1054, 2005.
8. Marx RE: Platelet rich plasma (PRP): What is PRP and what is not PRP? Implant Dent 10: 225 – 228, 2001.
9. Borrelli J Jr., Lashgari C: Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma 13 (2): 73 – 77, 1999.
10. White RR, Babikian GM: Tibial shaft. In AO principles of fracture management pp 525 – 526, edited by TP Ruedi, WM Murphy, Thieme, New York, 2000.
11. Huang PJ, Huang HT, Chen TB, Chen JC, Lin YK, Cheng YM, Lin SY: Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus. J Trauma 52: 946 – 950: 2002.
12. Raymakers JT, Dekkers GH, Brink PR: Results after operative treatment of intra-articular calcaneal fractures with a minimum follow up of 2 years. Injury 29: 593 – 599, 1998.
13. Stiegelmar R, McKee MD, Waddell JP, Schemitsch EH: Outcome of foot injuries in multiple injured patients. Orthop Clin North Am. 32:193 – 204, 2001.
14. Assous M, Bharma MS: Should os calcis fractures in smokers be fixed? A review of 40 patients. Injury 32: 631 – 632, 2001.
15. Naovaratanophas P, Thepchatri A: The long term results of internal fixation of displaced intra-articular calcaneal fractures. J Med Assoc Thai 84: 36 – 44, 2001.
16. Early JS, Starr AJ, Folk JW: Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma 13(5): 369 – 372, 1999.
17. Del Rossi AJ, Cernaianu AC, Vertrees RA, Wacker CJ, Fuller ST, Cilley Jr JH, Baldino WA: Platelet-rich plasma reduces postoperative blood loss after cardiopulmonary bypass. J Thorac Cardiovasc Surg 100: 281 – 286, 1990.
18. Marx RE: Platelet concentrate: a strategy for accelerating and improving bone regeneration. In Bone Engineering, pp 447-453, edited by JE Davies, University of Toronto, Toronto, 2000.
19. Margolis DJ, Kantor J, Santanna J: Effectiveness of platelet releasate for the treatment of diabetic neuropathic foot ulcers. Diabetes Care 24 (3): 483 – 488, 2001.
20. Anitua E: Plasma rich in growth factors: preliminary results of use in the preparation of future sites for implants. J Oral Implantol 14: 529 – 535, 1999.
21. Hee HT, Majd ME, Holt RT, Myers L: Do autologous growth factors enhance transforaminal lumbar interbody fusion? Eur Spine J 12: 400 – 407, 2003.
22. Knighton DR, Ciresi K, Fiegel VD, Schumerth S, Butler E, Cerra F: Stimulation of repair in chronic, nonhealing, cutaneous ulcers using platelet-derived wound healing formula. Surg Gynecol Obstet 170: 56 – 60, 1990.
23. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR: Platelet-rich plasma. Growth factor for enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85: 638 – 646, 1998.
24. Englert SJ, Estep TH, Ellis-Stoll CC: Autologous Platelet Gel Applications During Cardiovascular Surgery: Effect on Wound Healing. JECT 37: 148 – 152, 2005.

Address correspondence to: Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com

Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com
J. R. Clements, DPM, FACFAS, The Carilion Clinic,Department of Orthopaedics, Three Riverside Place, Roanoke, VA 24014. jrclements@carilion.com
J. Kalieb Pourciau, DPM, Acadian Medical Center, 3521 Hwy 190 East, Suite U, Eunice, LA 70535. kpourciau@gmail.com

© The Foot and Ankle Online Journal, 2009