Follow-up evaluation of open intra-articular fractures of the calcaneus

The Concept of Treatment for Surgical Infection in the Hindfoot

Background

Chronic osteomyelitis of the calcaneus (OC) and open infected calcaneal fractures, especially when complicated by infected soft tissue defects, present significant surgical challenges. Accepted recommendations for the surgical treatment of this pathology are yet to be established.

Methods

Drawing from our experience and the consensus among experts, we have developed a concept for selecting optimal, well-known surgical approaches based on the specific pathologic presentation. This concept distinguishes 4 main forms of hindfoot infection: infected wounds, open infected fractures, OC, and their mixed forms. Patients with conditions that could confound the treatment outcomes, such as diabetes mellitus and neurotrophic diseases, were excluded from this analysis. We present a retrospective analysis of the treatment outcomes for 44 patients (4 women and 40 men) treated between 2009 and 2022 using some refined surgical techniques. Treatment success was evaluated based on the absence of disease recurrence within a 2-year follow-up, the avoidance of below-knee amputations, and the restoration of weightbearing function.

Results

The treatment results were considered through the prism of our proposed concept and according to the Cierny-Mader classification. There were 4 instances of disease recurrence, necessitating 6 additional surgeries, 2 of which (4.5% of the patient cohort) resulted in amputations. In the remaining cases, we were able to restore weightbearing function and eliminate the infection through reconstructive surgeries, employing skin grafts when necessary.

Conclusion

Surgical infections of the hindfoot area remain a significant challenge. The strategic concept we propose for surgical decision making, tailored to the specific pathology, represents a potential advancement in addressing this challenge. This framework could provide valuable guidance for orthopaedic surgeons in their clinical decision-making process.

Level of Evidence

Level IV, case series.

Calcaneogenesis: the use of tibial bone transport for treatment of massively infected hindfoot defects

Massive hindfoot defects which result after se- questrectomy of chronic osteomyelitis (COM) or Trauma or after tumors resection is a real challenge to the treating surgeons with either amputation or other reconstructive plastic procedures as the only available options, Calcaneal osteomyelitis is a major cause with classical surgical management to cure the infection has limited success in preservation of the hindfoot shape, function, and mechanical stability. The surgical procedure reported with the use of the Ilizarov apparatus for partial or total calcaneal OM is aimed to preserve the Hindfoot.

Materials and Methods

We retrospectively reviewed 10 patients which were treated by radical debridement of the infected area, Ilizarov frame application and arthrodesis with bone reconstruction by the Ilizarov apparatus using tibial transport for Hindfoot salvage. The mean age at presentation was 33.5 years (range; 24-57) and the mean follow-up was 5.1 years (range; 2-12).Patients clinical and radiographic data were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle- Hindfoot score.

Results

The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score was 48.3(range; 38-86) while the mean postoperative (AOFAS) was 58.5 (range; 45-73) , p value < 0.01 . Clinically all patients had anatomically stable feet with deformity correction and no signs of infection recurrence.

Conclusion

The use of Ilizarov distal tibial bone transport to fill massive hindfoot defects proved to be a reliable method for elimination of infection and reconstruction of large defects without the need for bony or soft tissue plastic procedures. The technique also has the ability to produce a rigid limb fixation following debridement and to fill in massive hindfoot defects due to other etiologies as well.

Management of Open Calcaneal Fractures with Medial Wounds by One-Stage Sequential Reduction and Frame Structure Fixation Using Percutaneous Kirschner Wires

Objective

To assess the clinical outcomes of open calcaneal fractures with medial wounds treated with one‐stage management, including early modern wound care, sequential reduction, and frame structure fixation using percutaneous Kirschner wires.

Methods

A total of 19 patients with open calcaneal fractures admitted to our hospital from May 2016 to March 2019 were selected in this study. Twelve type‐II and seven type‐IIIA medial open injuries were identified according to the classification of Gustilo and Anderson. Fractures were stratified by Sanders classification, including nine type‐II fractures, seven type‐III fractures, and three type‐IV fractures. All patients accepted one‐stage irrigation and debridement, sequential reduction of calcaneal fractures through the open medial wound, percutaneous Kirschner wire fixation, and primary closure of wounds covered with vacuum‐assisted closure (VAC) device. The Bohler angle, the Gissane angle, and the width of the calcaneus were compared before and after surgery. The functional results were evaluated according to the Paley and Hall score system, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Maryland Foot Score, and related complications.

Results

The follow‐up duration for all patients ranged from 14 to 28 months (mean, 22.7 months). The angle of Bohler and Giasane was increased from (−7.6° ± 15.0°) and (96.6° ± 7.6°) before surgery to (23.7° ± 6.1°) and (124.1° ± 7.1°) postoperatively (P < 0.05), respectively. Three cases of superficial infection and two cases of wound dehiscence were observed in our study, which were then successfully treated with wound debridement, VAC replacement, appropriate use of antibiotics, and delayed closure. The last follow‐up revealed three cases of lateral wall expansion and six cases of mild‐to‐moderate subtalar arthritis based on the Paley and Hall scoring system. According to the AOFAS ankle and hindfoot score, one case showed excellent results, 14 cases exhibited good results, and four cases displayed fair results, with the mean of 80.7 ± 6.7 points (range, 70–90). The Maryland Foot Score revealed one case of excellent outcomes, nine cases of good outcomes, and nine cases of fair outcomes with an average of 76.8 ± 8.6 points (range, 62–90). The mean VAS for pain was 1.8 ± 1.5 (range, 0–5), and a total of 14 patients complained of mild‐to‐moderate pain when walking for a more extended period. Severe complications, such as deep infection, osteomyelitis, and soft tissue necrosis, were not observed during follow‐up.

Conclusions

Collectively, one‐stage management allowed the direct restoration of calcaneal morphology with a minimal invasion of soft tissues in most open calcaneal fractures with medial wounds, and the functional outcomes were comparable to previous data.

Infected open calcaneal fractures - A delayed reconstruction technique using calcium sulphate and hydroxyapatite antibiotic elucidating void filler

Treating open calcaneal fractures remains challenging, particularly when involving bone loss and infection.

CASE

We present the case of a 25-year-old woman who sustained an open AO 83-C2 calcaneal fracture with subsequent necrosis and presumed infection. Superseding necrosis and bone loss complicated the plan for definitive fixation. Residual bone was stabilised with Kirshner-wires and the void filled with a calcium sulphate and hydroxyapatite spacer, facilitating delayed surgical reconstruction.

CONCLUSION

Using calcium sulphate and hydroxyapatite spacer, as part of a 2-stage process represents a strategy in the treatment of complex calcaneal fractures with possible infection, and bone and soft tissue loss.

LEVEL OF CLINICAL EVIDENCE

4.

Calcaneal Osteomyelitis: Current Treatment Concepts

Calcaneal osteomyelitis can be a debilitating disease if proper treatment protocols are not initiated. This literature review details the epidemiology, clinical, diagnostic, and prognostic factors, and medical management in those who developed this disease.

Managing the open calcaneal fracture: A systematic review

INTRODUCTION

Open fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm.

MATERIAL AND METHODS

A literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions.

RESULTS

A total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points.

CONCLUSION

The complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.

Case Report: Late Reconstruction of the Land Mine-Injured Heel With an Osteomyocutaneous Composite Fibular Flap

The heel comprises the epidermis, minimal subcutaneous tissue, a dense septum, and the calcaneus. Injury to any of these structures can impair the ability to walk. The soft tissue or calcaneal bone can be injured by trauma. Injuries incurred in war are usually high-energy traumas caused by weapons such as rifles, rockets, and land mines. Such injuries can be life threatening and involve the loss of tissue, including skin, soft tissue, bone, and neurovascular tissue. Two main treatment protocols are used for such injuries with large tissue defects: amputation and reconstruction. We describe a reconstruction with an osteomyocutaneous fibular flap for a heel injury. At the 2-year follow-up point, the patient had 30% loss of ankle range of motion. The visual analog scale score had dramatically decreased from 8 to 1, and the patient was satisfied with the result. In conclusion, patients with significant problems such as infection, pain, and anatomic deterioration of the calcaneus can be successfully treated using an osteomyocutaneous fibular flap in a single surgery.

Salvage of Combat Hindfoot Fractures in 2003-2014 UK Military

BACKGROUND

Hindfoot fractures pose a considerable challenge to military orthopaedic surgeons, as combat injuries are typically the result of energy transfers not seen in civilian practice. This study aimed to characterize the pattern of hindfoot injuries sustained by UK military casualties in recent conflicts, define the early amputation and infection rate, and identify factors associated with poor early outcomes.

METHODS

The UK Joint Theatre Trauma Registry was searched for British military casualties sustaining a hindfoot fracture from Iraq and Afghanistan between 2003 and 2014. Data on the injury pattern and management were obtained along with 18-month follow-up data. Statistical analysis was performed with the chi-square test and binomial logistic regression analysis. The threshold for significance was set at P < .05. One hundred fourteen patients sustained 134 hindfoot injuries. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%).

RESULTS

The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, 32 (28%) underwent K-wire fixation, and 30 (26%) underwent internal fixation. Nineteen patients (17%) required transtibial amputation during this time. A deep infection requiring operative treatment occurred in 13 cases (11%) with Staphylococcus aureus, the most common infectious organism (46%). A deep infection was strongly associated with operative fracture management ( P = .0016). When controlling for multiple variables, the presence of a deep infection was significantly associated with a requirement for amputation at 18 months ( P = .023). There was no association between open fractures and a requirement for amputation at 18 months ( P = .640), nor was conservative management associated with a requirement for amputation ( P = .999). Thirty-six fractures (32%) required unplanned revision surgery within the first 18 months following salvage, of which 19 (53%) involved amputation.

CONCLUSION

A deep infection was the sole variable significantly associated with a requirement for amputation by 18 months. These results suggest that attempts at salvaging these injuries are at the limits of orthopaedic technical feasibility.

LEVEL OF EVIDENCE

Level III, comparative series.

Resection osteotomy for calcaneus flattening after micro-surgical flap: technical note

An open fracture of the calcaneus with loss of substance is a challenging injury and requires specialized care, involves high costs, and demands attention despite its lower incidence. The main complications are osteomyelitis, pressure ulcers, and fistulas, as well as pain conditions in the lateral, medial, and plantar regions. This is due to the wide loss of tissue and the change in anatomical conformation of the calcaneus in some cases. However, in cases of flattening of the calcaneus bone, these complications may be prevented or treated successfully. This technical note describes the resection osteotomy technique for calcaneus flattening to prevent and treat complications after micro-surgical flap in cases of open fracture or loss of substance.

Calcaneus fractures

Assessment and treatment of calcaneal fractures have made substantial progress over the last two decades. Open reduction and stable internal fixation without joint transfixation has been established as standard therapy for most displaced intra-articular fractures with good to excellent results in more than two-thirds of patients in larger clinical series. The use of bone grafting or bone substitutes appears unnecessary in most cases. Important prognostic factors are anatomical reduction of subtalar joint congruity and the overall shape of the calcaneus. Therefore, quality of joint reduction should be reliably proved intra-operatively either with open subtalar arthroscopy or high-resolution (3D) fluoroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days, a high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the subtalar and calcaneocuboid joints in complex fractures. In simple fracture patterns percutaneous screw fixation, supplemented by arthroscopic control if necessary, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage exploiting the full armamentarium of pedicled and free tissue transfer appears promising in improving the functional results and infection rates after open fractures. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, in situ or correctional subtalar arthrodesis and calcaneal osteotomies.

Comparison of Bone Preserving and Radical Surgical Treatment in 32 Cases of Calcaneal Osteomyelitis

Introduction. Radical procedures like calcanectomy and amputation performed for calcaneal osteomyelitis are regarded as effective in eradication of infection even though potentially functionally disabling. Bone sparing procedures offer better functional result at the expense of potentially worse infection control. The aim of the study has been to assess the influence of the surgical radicalism as much as the extent of bone infection on the final outcome in the surgical therapy of chronic calcaneal osteomyelitis (CO). Material and method. 32 patients with chronic CO have comprised the group under study: 8 with superficial type, 12 localised type and 12 with diffuse type according to Cierny-Mader classification. The aim of the treatment was to heal infection, preserve the heel shape and achieve good skin coverage over the calcaneus. The therapy consisted of 9 debridement surgeries with or without flaps, 8 drilling-operations of the calcaneus with application of collagen-gentamicin-sponge in bore holes, 15 partial and 2 total calcanectomies, and 4 below-the knee amputations. Results. The healing of infection and wound has been achieved after 7 of 9 debridements, 6 of 8 drilling-operations, 13 of 15 partial and all total calcanectomies. Conclusion. Bone preserving operations in chronic calcaneal osteomyelitis provided inferior infection control (76,47% vs 88,24%) and worse patient satisfaction (88,24% vs 100%) and almost camparable ambulation (100% vs 93,33%). Drilling of the calcaneus with application of collagen sponge containing gentamicin performed in chronic diffuse calcaneal osteomyelitis seems to offer a viable alternative to partial or radical calcanectomy.

LEVEL OF EVIDENCE

V.

Effectiveness of MIS technique as a treatment modality for open intra-articular calcaneal fractures: A prospective evaluation with matched closed fractures treated by conventional technique

Twenty-five displaced intra-articular calcaneal fractures in 21 patients, aged 15-55 years were included in this study. Sanders' type I fractures, severe crushing or partial amputation, were excluded from the study. Patients were divided into group 1 (open fractures treated by MIS), and group 2 (closed fractures treated by ORIF). Group 1 had 16 and group 2 had 9 cases. Seven of 25 fractures (28%) developed wound related issues postoperatively. One patient (11.1%) in group 2 had wound margin necrosis, while 6 patients (37.5%) in group 1 developed pin tract and/or wound infection. At 1-year follow-up, the mean MFS for group 1 was 79 and mean MFS for group 2 was 84.4 (66.67% were good). The AOFAS score for group 1 was 77.37 and for group 2 was 86.1. The Bohlers' angle was restored in 81.16% cases in group 1 and 88.8% in group 2, while Gissane angle was restored in 68.75% of group 1 cases and 77.79% of group 2 cases. This study shows that acceptable fracture reduction can be obtained and maintained by MIS technique and it can be used as the primary definitive treatment option in open calcaneal fractures.

High incidence of post-operative infection after 'sinus tarsi' approach for treatment of intra-articular fractures of the calcaneus: a 5 year experience in an academic level one trauma center

BACKGROUND

The optimal management of displaced intra-articular calcaneal fractures remains a topic of debate among trauma surgeons. The purpose of this study was to assess the safety of the sinus tarsi approach in regard to the incidence of deep infection and amputation following open reduction and internal fixation intra-articular calcaneal fractures.

METHODS

We conducted a retrospective chart review of all patients with displaced intra-articular calcaneus fractures treated with internal fixation through the sinus tarsi approach in a five year period. All surgeries were performed in a single level one trauma center by a single orthopedic trauma fellowship trained surgeon.

RESULTS

Seventeen patients with an average age of 36.6 ± 13.6 years (range 12-61 years) met the inclusion criteria. The time between injury and surgery was on average 6.1 days (range 1-22 days). Average follow up was 116 ± 78.2 days (range 3-276 days). Two patients (11.7%) had diabetes mellitus. None of the patients required amputation. Three patients (17.6%) developed deep infection and underwent subsequent formal irrigation and debridement, two of these requiring multiple repeat surgeries in addition to hardware removals. Negative pressure wound therapy and long term antibiotics via peripherally inserted central catheter (PICC) were necessary in these three patients with wound infections.

CONCLUSION

The sinus tarsi approach for intra fixation intra-articular calcaneal fractures is safe as compared to the traditional extensile approach in regard to flap necrosis and amputation. However, the rate of deep infection was higher than previously described in the literature.

Clinical Analysis of Internal Fixation Treatment of Intra-articular Calcaneal Fractures with Titanium Plate

To explore the clinical effect of internal fixation treatment of intra-articular calcaneal fractures with titanium plate, we used open reduction and internal fixation with titanium plate to 48 treated feet from 42 patients with intra-articular calcaneal fractures. The efficacy of surgical treatment was evaluated based on assessment of pain, function, and line of force aspects according to the American Orthopedic Foot and Ankle Society scoring system. Our data show that internal fixation with titanium plate is an effective treatment for calcaneal fractures. It provides satisfactory reduction, reliable fixation, and early rehabilitation.

Open fractures of the foot and ankle

Open fractures of the lower extremity cover a wide gamut of injuries ranging from the mangled, pulseless leg necessitating amputation to the more innocuous pinhole open wounds associated with simple fracture patterns. Prompt diagnosis and appropriate care can make a dramatic difference in decreasing complication rates and improving ultimate outcomes. Principles of management of open fractures have been created with the main goal of decreasing infection rates, while providing for stabilization of the bone and soft tissue injury.

A model to predict limb salvage in severe combat-related open calcaneus fractures

BACKGROUND

Open calcaneus fractures can be limb threatening and almost universally result in some measure of long-term disability. A major goal of initial management in patients with these injuries is setting appropriate expectations and discussing the likelihood of limb salvage, yet there are few tools that assist in predicting the outcome of this difficult fracture pattern.

QUESTIONS/PURPOSES

We developed two decision support tools, an artificial neural network and a logistic regression model, based on presenting data from severe combat-related open calcaneus fractures. We then determined which model more accurately estimated the likelihood of amputation and which was better suited for clinical use.

METHODS

Injury-specific data were collected from wounded active-duty service members who sustained combat-related open calcaneus fractures between 2003 and 2012. One-hundred fifty-five open calcaneus fractures met inclusion criteria. Median followup was 3.5 years (interquartile range: 1.5, 5.1 years), and amputation rate was 44%. We developed an artificial neural network designed to estimate the likelihood of amputation, using information available on presentation. For comparison, a conventional logistic regression model was developed with variables identified on univariate analysis. We determined which model more accurately estimated the likelihood of amputation using receiver operating characteristic analysis. Decision curve analysis was then performed to determine each model's clinical utility.

RESULTS

An artificial neural network that contained eight presenting features resulted in smaller error. The eight features that contributed to the most predictive model were American Society of Anesthesiologist grade, plantar sensation, fracture treatment before arrival, Gustilo-Anderson fracture type, Sanders fracture classification, vascular injury, male sex, and dismounted blast mechanism. The artificial neural network was 30% more accurate, with an area under the curve of 0.8 (compared to 0.65 for logistic regression). Decision curve analysis indicated the artificial neural network resulted in higher benefit across the broadest range of threshold probabilities compared to the logistic regression model and is perhaps better suited for clinical use.

CONCLUSIONS

This report demonstrates an artificial neural network was capable of accurately estimating the likelihood of amputation. Furthermore, decision curve analysis suggested the artificial neural network is better suited for clinical use than logistic regression. Once properly validated, this may provide a tool for surgeons and patients faced with combat-related open calcaneus fractures in which decisions between limb salvage and amputation remain difficult.

Plantar medial wounds associated with calcaneal fractures

BACKGROUND

Calcaneal fractures with open wounds are prone to soft tissue complications. We describe a particular subclass of open injury that occurs on the plantar surface of the foot, medial to the anterior process of the calcaneus, the plantar medial wound (PMW). The purpose of this study was to evaluate soft tissue healing and potential complications in open calcaneal fractures that have a PMW.

METHODS

We established the time to soft tissue healing and the status of the injured limb of 11 adults with 12 calcaneal fractures with a PMW. This was a retrospective review of prospectively gathered data at a Level I trauma center.

RESULTS

Five fractures developed an infection requiring intravenous antibiotics. Two patients required split thickness skin grafts and 1 patient required a free gracilis flap 10 months after injury to treat a chronic open PMW with resolving osteomyelitis and required a below-knee amputation secondary to flap failure. The most commonly associated bony injury with a PMW was a transcalcaneal-talonavicular fracture dislocation (8/13 injuries). Nonunion of the calcaneal fracture occurred in 3 patients.

CONCLUSION

Patients with this type of injury-even those with Gustilo Type I open fractures-need to be apprised that their injury is associated with long-term sequelae, including complications with wound healing, high infection rates, and a higher potential for subsequent amputation than other open hind foot wounds. The Tscherne classification of open wounds should be used in the future.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Partial or total calcanectomy as an alternative to below-the-knee amputation for limb salvage: a systematic review

BACKGROUND

Below-the-knee amputations are regarded as definitive treatment for calcaneal osteomyelitis. They may be less than desirable in patients with a viable midfoot and forefoot. Partial and total calcanectomies have been reported as an alternative for limb salvage. However, the durability of the residual limb is questionable.

METHODS

A systematic review was undertaken to identify material relating to the potential for limb salvage with partial or total calcanectomy in ambulatory patients with calcaneal osteomyelitis. Studies eligible for inclusion consecutively enrolled ambulatory patients older than 18 years who underwent partial or total calcanectomy without adjunctive free tissue transfer for the treatment of calcaneal osteomyelitis and had a mean follow-up of 12 months or longer.

RESULTS

Sixteen studies involving 100 patients (76 partial and 28 total calcanectomies) met all of the inclusion criteria. Weighted mean follow-up was 33 months. Minor complications with subsequent healing occurred in less than 24% of patients. Most major complications were related to residual soft-tissue infection and osteomyelitis. Approximately 10% of patients required a major lower-extremity amputation. Major complications and major lower-extremity amputations occurred more frequently after total calcanectomy and in patients with a diagnosis of diabetes. Eighty-five percent of patients maintained or improved their ambulatory status postoperatively. Only 3% of patients decreased their ambulatory status postoperatively, becoming unlimited household ambulators.

CONCLUSIONS

This systematic review provides evidence that partial or total calcanectomy is a viable option for limb salvage in ambulatory patients with calcaneal osteomyelitis.

Risk factors for infection and amputation following open, combat-related calcaneal fractures

BACKGROUND

High-energy open calcaneal fractures are severe injuries complicated by high rates of infection, uncertain functional outcomes, and frequent need for later amputation.

METHODS

We conducted a retrospective review of 102 consecutive combat-related open calcaneal fractures. Patient demographics, injury mechanisms, fracture and wound characteristics, associated fractures, and methods of fracture fixation were reviewed to determine risk factors for eventual amputation or infection.

RESULTS

Eighty-nine patients, with a mean age of twenty-six years, sustained 102 open calcaneal fractures (thirteen bilateral). After a mean follow-up of four years (range, five to ninety-two months), 42% (forty-three limbs) underwent amputation. A delayed amputation (more than twelve weeks from the time of injury) was performed in 15% (fifteen) of 102 open calcaneal fractures. In a multivariate Cox proportional-hazards survival model with time to amputation as the end point, the blast mechanism of injury, plantar wound location, larger size of open wound (in square centimeters), and escalating Gustilo and Anderson classification types (p < 0.05 for all) were predictive of eventual amputation. At the time of the final follow-up, patients who had undergone amputation had lower visual analogue scale scores for pain (2.1 compared with 4.0; p < 0.0001) and higher Tegner activity levels (5.4 compared with 3.5; p < 0.0001) than limb salvage patients.

CONCLUSIONS

Lower-extremity amputation following open calcaneal fractures is predicted by the injury mechanism, wound location and size, and open fracture type and severity. After short-term follow-up, patients with open calcaneal fractures eventually requiring amputation exhibit improved pain and activity levels compared with patients with continued, ostensibly successful limb salvage.

The spectrum of open fractures of the foot in adults

BACKGROUND

Open foot fractures are rare, and few surgeons see the whole spectrum of these injuries. There has been no previous study of the epidemiology and severity of open foot fractures.

METHODS

A 23-year study of the epidemiology of open fractures was undertaken in a hospital with a catchment area of about 530 000 adults. The results were used to calculate the incidences of open foot fractures and to study their epidemiology and severity.

RESULTS

In 23 years, 348 open foot fractures were treated. Analysis showed 3 levels of severity with the least severe fractures being isolated open forefoot fractures, which occurred in 69% of the patients. Patients with multiple forefoot fractures had a higher Injury Severity Score (ISS), prevalence of Gustilo type III fractures, and amputation rate. The most severely injured patients presented with open hindfoot and midfoot fractures. They had an average ISS of 12, and 65.9% had Gustilo type III fractures. In patients with open hindfoot fractures, the amputation rate was 17.1%. This rose to 30% in patients with open midfoot fractures. Open foot fractures tended to occur in younger patients, and only 13% were in patients aged at least 65 years.

CONCLUSIONS

Open foot fractures are uncommon. There were 3 levels of injury. Level 1 injuries were isolated fractures of the forefoot. Level 2 injuries were multiple forefoot fractures, and level 3 injuries were open fractures of the midfoot and hindfoot. These were severe injuries with a high amputation rate. They should be treated in level 1 trauma centers.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Outcomes of high-grade open calcaneus fractures managed with open reduction via the medial wound and percutaneous screw fixation

OBJECTIVE

To determine the clinical and functional outcomes of high-grade (types II and III) open calcaneus fractures managed with a protocol of modern wound care, open reduction via the medial hindfoot wound, and percutaneous screw fixation.

DESIGN

Retrospective clinical series of consecutively treated patients.

SETTING

Regional trauma center (level 2).

PATIENTS/PARTICIPANTS

Seventeen consecutive patients with open type II and III calcaneus fractures treated with fracture repair by a single surgeon.

INTERVENTION

Soft tissue debridement and modern wound care, reduction of calcaneus fractures through the open medial wound, and percutaneous screw fixation.

MAIN OUTCOME MEASUREMENTS

Patient demographics and injury data, radiographic analyses, complications of treatment, and hindfoot outcomes assessed with American Orthopaedic Foot and Ankle Surgeon and Maryland Foot Scores and general health with the Short Form 36 measurement at a minimum of 12 months post injury.

RESULTS

Seventeen patients were available for follow-up at >12 months, with 15 completing all outcome measures. Four fractures were graded as type II, 9 as type IIIA, and 4 as type IIIB. There was 1 deep infection, and 1 wound dehiscence, both in type III open injuries; both were successfully treated with local wound care, delayed closure, and appropriate antibiotics. Overall, 7 of 17 (41%) patients required secondary surgical procedures, including 4 hindfoot fusions (23.5%). The average American Orthopaedic Foot and Ankle Surgeon score was 77 (range, 32-95), and the Maryland Foot Score was 64 (range, 16-93). The physical and mental components of the Short Form 36 averaged 44.4 and 49.1, respectively.

CONCLUSIONS

Limb-threatening catastrophic complications are uncommon for high-grade open calcaneus fractures treated with modern soft-tissue care, fracture reduction using the medial open fracture wound, and percutaneously placed screw fixation. Limb and whole body functional outcomes are comparable to previously published reports of both closed and open calcaneus fractures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Adult calcaneal osteitis: incidence, etiology, diagnostics and therapy

Calcaneal osteomyelitis presents a complicated situation. The specific anatomy of the os calcis and its surrounding soft tissues plays an important role in the planning and realization of the procedures needed in order to eradicate the osteomyelitic focus. The calcaneus represents a spongious bone; a fact that supports the developement of an osteomyelitis. It is the strongest bone of the foot and is highly important for the biomechanical features of physiological walking. The surrounding soft tissues are thin and contain various important anatomical structures. These might be damaged during the treatment of the osteomyelitis. In addition the vascularization of the os calcis is delicate and may be compromized during the surgical osteomyelitis treatment. Calcaneus osteomyelitis may be classified based on the routes of infection into exogenous and endogenous forms. Additionally from the clinical point of view acute and chronic forms may be distinguished from an early and a late infection. Exogenous calcaneal osteomyelitis mostly is the result of an infection with S. aureus. The treatment is equal to the therapy in other locations and based on: Eradication of the bone infectionSanitation of the soft tissue infectionReconstruction of bone and soft tissue Especially the preservation and restoration of the soft tissue is important. Thus plastic surgical procedures play an essential role. The main object of treatment is the preservation of a biomechanical functioning foot. This may be impossible due to the local situation. Calcanectomy or even below knee amputation may be needed in those cases.

Complications associated with open calcaneus fractures

BACKGROUND

Literature on open calcaneus fractures is limited and inconsistent. This study's purpose was to report complications such as osteomyelitis, amputations, and soft tissue infections in open calcaneus fractures that were treated at a Level I Trauma Center.

METHODS

From January 1995 through December 2007, 1,157 calcaneus fractures were identified with 127 fractures being open (11.0%). Average followup time was 9.1 (range, 2 to 53) months. All open fractures were treated by a similar protocol of intravenous (i.v.) antibiotics, emergent irrigation and debridement (I&D), initial fracture stabilization if possible, subsequent I&Ds as needed, and delayed definitive fixation. One hundred fifteen open calcaneus fractures in 112 patients had sufficient followup for study inclusion. For this study complications were classified into four categories: superficial infections, deep infections, osteomyelitis, and amputations.

RESULTS

Medial based wounds occurred in 63 (54.8%) fractures. The overall complication rate was 23.5% with 16 fractures (13.9%) requiring a reoperation. Eleven (9.6%) fractures experienced superficial wound infection and 14 (12.2%) had deep wound infection. Six (5.2%) amputations were required with three being for either soft tissue infection or wound necrosis. Culture-positive osteomyelitis occurred in six (5.2%) patients.

CONCLUSION

Utilizing a standardized protocol, open calcaneus fractures were found to have a lower complication rate than has been previously reported.

Transcalcaneal talonavicular dislocation associated with an open comminuted calcaneal fracture: a case report

The combination of dorsal dislocation of the navicular from the talus and a comminuted fracture of the calcaneus (transcalcaneal talonavicular dislocation) is an unusual and severe injury. It occurs due to a forced plantarflexion of the talar head through the anterior portion of the calcaneum and is usually associated with a potential for skin and neurovascular compromise. Few cases have been reported in the literature. This article reports an unusual case of an open transcalcaneal talonavicular dislocation associated with the presence of a calcaneal comminuted calcaneal fracture.

Early clinical and radiographic outcomes after treatment of displaced intra-articular calcaneal fractures using delta-frame external fixator construct

Intra-articular calcaneal fractures are associated with high morbidity, persistent pain, and long-term disability. This retrospective study assesses early clinical and radiographic postoperative findings of intra-articular calcaneal fractures following treatment by ligamentotaxis using a delta frame construct with a large fragment external fixator. Minimally invasive percutaneous reduction of calcaneal fractures is an alternative treatment for Sanders type II, III, and IV fractures. Ten patients from the Detroit Medical Center were followed between January 2002 and December 2004 for follow-up over a mean of 353.5 ± 85.45 days postoperatively. The mean age of the patients was 45.8 ± 12.3 years. There were 2 patients with Sanders type IIA, 3 patients with type IIIAB, 1 patient with type IIIAC, and 4 patients with type IV fracture patterns. The results demonstrated that the mean calcaneal width decreased, the calcaneal height increased, and the calcaneal length increased when comparing preoperative to postoperative measurements. Böhler's angle increased from 20.8 ± 8.27° preoperatively to 25.7 ± 5.21° postoperatively, and Gissane's angle decreased from 127.4 ± 45.22° preoperatively to 111.2 ± 39.38° postoperatively. The posterior facet step-off on CT examination reduced from 2.6 ± 0.82 mm preoperatively to 0.4 ± 0.26 mm postoperatively. The mean postoperative total subtalar joint range of motion was 19.0 ± 4.5° on the affected side and 34.4 ± 4.58° on the contralateral foot. The mean Maryland Foot score was 85.8 ± 6.41 in the 10 patients. With the exception of the change from preoperative to postoperative Böhler's angle, and the comparison of the ipsilateral (side of the fracture) to contralateral resting calcaneal stance position, all of the comparisons revealed statistically significant (P ≤ .05) differences. The authors conclude that the delta frame construct is a viable alternative method to open reduction and internal fixation for treating intra-articular calcaneal fractures.

A staged treatment plan for the management of Type II and Type IIIA open calcaneus fractures

OBJECTIVE

To assess the results of a standardized staged treatment strategy for displaced open calcaneal fractures with medial wounds.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Fourteen displaced open Type II or Type IIIA Orthopaedic Trauma Association (OTA) 73 Type B or C calcaneal fractures treated between January 2000 and December 2007 who were managed with a standardized regimen.

INTERVENTION

Patients were treated in a staged fashion with antibiotics, irrigation, débridement, and percutaneous Kirschner wire fixation followed by definitive open reduction and internal fixation when soft tissues were amenable to fixation.

MAIN OUTCOME MEASURES

Data regarding demographics, injury characteristics, time to fixation, interventions, and treatment complications were documented. The complication rate, time to bony union, and additional procedures were determined.

RESULTS

There were four OTA 73B and 10 OTA 73C injuries with open Type II or Type IIIA wounds on the medial side. All patients had débridement, irrigation, and percutaneous fixation within 8 hours of presentation. Definitive fixation was carried out on average 18 days after initial presentation with 10 patients only requiring the initial débridement and stabilization procedure followed by definitive fixation All 14 patients underwent definitive fixation through an extensile lateral approach. A superficial infection developed in one patient and a deep infection in one patient. All patients went on to union at an average follow up of 19 months.

CONCLUSION

Open Type II and IIA wounds associated with displaced OTA Type 73 B or C calcaneal fractures represent high-energy injuries with potential increased risk for wound complications. In our series, a staged treatment strategy consisting of urgent débridement, provisional internal stabilization, and late definitive reconstruction offers a protocol that may reduce infections associated with open calcaneal fractures.

The mangled foot and leg: salvage versus amputation

Determining whether to perform limb salvage or amputation in the traumatized lower extremity continues to be a difficult problem in the military and civilian sectors. Numerous predictive scores and models have failed to provide definitive criteria for prediction of limb-salvage success. Excellent support is available in the military health care system for soldiers electing to undergo either limb salvage or amputation. Recent experience with soldiers who sustained limb-threatening injuries has shown that delayed amputation after limb-salvage attempts is a viable option for soldiers wounded in combat.

The treatment of intra-articular calcaneus fractures with severe soft tissue damage with a hinged external fixator or internal stabilization: long-term results

We developed a hinged external fixator for the treatment of dislocated intra-articular calcaneus fractures with severe soft tissue damage. The external fixation was performed with a known external fixator system. The screw insertion points were biomechanically tested by defining a virtual rotation axis through the center of the talus to allow early active motion in the ankle joint. Long-term follow-up was performed after an average of 7.3 years. Results were graded with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed according to Sanders classification. Four open fractures and 33 cases with extremely swollen soft tissue, blisters, or compartment syndromes were treated. In 24 cases (64.9%), the hinged fixator was the final method of treatment (group I). A change to open reduction with internal fixation was performed in 13 fractures (35.1%) when soft tissue problems were minimal (group II). There were no late amputations, osteomyelitis, or malunions. According to Sanders classification, group I consisted of 14 type II, 8 type III, and 2 type IV fractures. Pin loosening or pin infection was seen in 4 cases, but there was no redislocation. The Böhler's angle improved in 43%, gaps in the posterior facet were closed in 41%, and any shortening or deviation of the axis was corrected in 82% of the cases. The AOFAS score for the group averaged 66.5. According to Sanders classification, group II consisted of 8 type II and 5 type III fractures. The Böhler's angle improved in 88%, and gaps in the posterior facet were closed in 87%. Any shortening or deviation of the axis was corrected in 95%, and the AOFAS score averaged 61.3. Significant differences in patient outcome scores between open reduction with internal fixation and hinged fixator were not found. P value was > .05. The hinged external fixator frame can be used in all calcaneus fracture types without soft tissue limitation. The hinged fixator allows early movement in the ankle joint, the risk of infection is minimized, and secondary plate fixation remains possible.

Successful treatment of bilateral open calcaneal fractures with concomitant lower extremity injuries: A case report

Open calcaneal fractures are high morbidity injuries and the risk of complications depends on the concomitant injuries, on the size and the position of the traumatic wound. A 53-year-old male patient with bilateral open calcaneal fractures and associated concomitant lower extremity injuries such as subtalar dislocation, talonavicular dislocation and open distal tibial metaphyseal fracture was immediately operated by percutaneous Kirschner wire fixation combined with external fixators. He was able to walk with full weight bearing without any assistance at the end of the first postoperative year. Early aggressive debridement and irrigation followed by fixation with percutaneous Kirschner wires and external fixator can supply bony alignment in open comminuted calcaneal fractures associated with concomitant lower extremity injuries and should be considered for the healthy and active patients before primary arthrodesis.

High-energy foot and ankle trauma: principles for formulating an individualized care plan

Care of the patient with high-energy foot and ankle trauma requires an individualized care plan. Staged treatment respecting the traumatized soft tissue envelope is often advisable. Wound care is a priority, and the vacuum-assisted closure dressing serves an integral role. Before definitive reconstruction, the surgeon needs to develop a treatment plan designed to match the unique personality of the patient and injury. Amputation is considered a rational treatment option for the patient with severe injury and poor host biology. Despite the most appropriate management, many severe foot and ankle injuries have a guarded prognosis.

Treatment of select open calcaneus fractures with reduction and internal fixation: an intermediate-term review

BACKGROUND

Open calcaneal fractures are devastating, high-energy injuries frequently occurring in multiply-injured patients. Unsatisfactory outcomes with significant complications rates are frequently reported. Our purpose was to assess outcomes of delayed ORIF for open calcaneal fractures with medial hindfoot wounds and limited posterior facet comminution.

MATERIALS AND METHODS

Following acute management of the open fractures, seven patients were determined to have stable medial hindfoot wounds and posterior facet comminution of three or fewer fracture fragments. The average age was 32.5 years. These patients were treated with operative management with a plate-and-screw construct using the extensile lateral approach. RAND-36 Item Health, AOFAS Ankle-Hindfoot Survey, and physical examinations were undertaken to access outcomes.

RESULTS

All open calcaneal injuries were initially treated with irrigation and debridement, intravenous antibiotics, and plaster immobilization. Definitive fixation was performed at an average of 11.7 days. Six of seven patients were multiply injured. Prior to injury, five were employed on a full-time basis. Four returned to their original or a comparable job. The results of the RAND-36 Item Health Survey and the AOFAS Ankle-Hindfoot scores were 56.7 and 71, respectively. There were no postoperative infections. No patients required additional operative hindfoot procedures. Five continued to use tobacco products. None reported chronic narcotic usage.

CONCLUSION

Aggressive treatment of select open calcaneal fractures with delayed ORIF produced satisfactory functional results. Most patients were able to return to gainful employment. There were no infections or wound complications.

A biomechanical evaluation to optimize the configuration of a hinged external fixator for the primary treatment of severely displaced intraarticular calcaneus fractures with soft tissue damage

The purpose of this investigation was to develop an optimized hinged external fixator for the primary treatment of dislocated, intra-articular calcaneus fractures with associated soft tissue damage. To this end, a calcaneus model was made out of a polyurethane block, and a steel cylinder served as the ankle joint and was connected to a synthetic model of the tibia via a metal clamp. A saw cut served as the fracture in the model. A Steinmann nail and Schanz screw were placed in defined positions in the model and connected medially and laterally with longitudinal support rods. The fixator allowed a total of 20 degrees of plantar- and dorsiflexion, with rotation in the virtual axis of the upper ankle joint. Changes in the model fracture were measured during cyclical strain, and at different screw positions in the model tibia and calcaneus. Miniature force sensors located on the longitudinal support rods, and a plantar tension spring, were used to measure pressure and tension. Reproducible values were determined and, with the optimal configuration, shifting within the osteotomy was minimal. In the experimental configuration, optimal tibial screw placement was 70 mm proximal to the rotation axis of the upper ankle joint, and optimal placement of the Steinmann nail was in the posterior surface of the calcaneus. These findings indicated that the hinged fixator allows 20 degrees of ankle movement without alteration of the rotation axis, and suggest that this type of external fixator can be used in all types of calcaneal fracture regardless of the soft tissue damage. ACFAS Level of Clinical Evidence: 5c.

[Free scapular or parascapular flaps for soft tissue damage accompanying talus or calcaneus fractures]

BASIS

Fractures of the talus or calcaneus with accompanying soft tissue damage require precisely planned treatment to prevent infection of the wound over time, especially in severely injured patients.

MATERIAL AND METHODS

Seven patients with fractures of the talus or calcaneus and accompanying 2nd and 3rd degree open or 3rd degree closed soft tissue injuries were followed up retrospectively. These patients were operated on between January 1999 and January 2006 with free fasciocutaneous scapular or parascapular flaps. The average age was 34 (range 16-54). Follow-up was at 6-36 months.

RESULTS

Osteosynthesis was primarily in six cases, post-primarily in one, and in four cases exterior fixation was used additively. Temporary vacuum therapy was performed for a mean of 28 days (6-42). Parascapular, scapular, and Latissimus dorsi flap coverage was performed six, one, and one times, respectively. Six flaps healed without complication. One necrosis of a parascapular flap occurred and made a Latissimus dorsi flap necessary. In one case of donor-site wound dehiscense, a local rotation flap became necessary. There was no joint infection or osteomyelitis. Bony consolidation was achieved within all fractures.

CONCLUSION

Traumatic soft tissue damage must be taken into account when primary or secondary internal fixation is performed and should influence the choice of implant. Free fasciocutaneous parascapular or scapular flaps are a powerful tool for preventing infection if local flaps are not sufficient to achieve stable soft tissue coverage.

Open hindfoot injuries

Successful management of open talar and calcaneal injuries of the hindfoot is a formidable orthopaedic challenge. The soft-tissue disruption associated with these high-energy traumatic injuries adds to treatment complexity. Extensive fracture comminution and cartilage damage are often present with calcaneal fracture. Osteonecrosis is commonly associated with talar injury. Treatment may be divided into acute and reconstructive phases. Successful outcome is dependent on several variables--accurate fracture reduction, timing of intervention, prevention of infection, and meticulous soft-tissue handling. Anatomic fracture or joint reconstruction may not be possible. Joint stiffness and posttraumatic arthritis are common and may be debilitating. Complications, such as infection and osteonecrosis, also can be devastating. Long-term outcomes are frequently unsatisfactory. Chronic ambulatory dysfunction and persistent neurogenic pain may result despite appropriate management. With severe complex open fractures and extended soft-tissue injury, limb amputation may be the best treatment option.

Soft tissue complications following calcaneal fractures

Soft tissue complications following calcaneal fractures can be frustrating to the patient and present reconstructive challenges for the surgeon. Preoperative patient assessment may define a group of patients who are best treated nonoperatively in an effort to avoid disastrous soft tissue complications. Late sequelae will continue to be seen and through the use of differential injections, physical exam, and appropriate intervention, the practitioner can usually decrease symptoms and improve a patient's function. Further studies in the treatment of open calcaneal fractures are necessary to better define treatment algorithms. A working knowledge of these complications and their management is necessary for the surgeon treating calcaneal fractures.

Percutaneous treatment of displaced intra-articular calcaneal fractures

BACKGROUND

The outcome after displaced intra-articular calcaneal fractures is influenced by the condition of the surrounding soft tissues. To avoid secondary soft tissue complications after surgical treatment, several less-invasive procedures for reduction and fixation have been introduced. The percutaneous technique according to Forgon and Zadravecz is suitable for all types of displaced intra-articular calcaneal fractures and was therefore introduced in our clinic. The aim of this study was to evaluate the long-term outcome of percutaneous treatment according to Forgon and Zadravecz in patients with displaced intra-articular calcaneal fractures.

METHODS

A cohort of patients with displaced intra-articular calcaneal fractures treated with percutaneous surgery was retrospectively defined. Clinical outcome was evaluated by standardized physical examination, radiographs, three published outcome scores, and a visual analogue scale of patient satisfaction.

RESULTS

Fifty patients with 61 calcaneal fractures were included. After a mean follow-up period of 35 months, the mean values of the Maryland foot score, the Creighton-Nebraska score, and the American Orthopaedic Foot and Ankle Society score were 79, 76, and 83 points out of 100, respectively. The average visual analogue scale was 7.2 points out of 10. The average range of motion of the ankle joint was 90% of normal and subtalar joint movements were almost 70% compared with the healthy side or normal values. Superficial wound complications occurred in seven cases (11%) and deep infections in two (3%). A secondary arthrodesis of the subtalar joint was performed in five patients and was scheduled in four patients (15%).

CONCLUSIONS

Compared with the outcome of historic controls from randomized trials and meta-analyses, this study indicates favorable results for the percutaneous technique compared with the open technique. Despite similar rates of postoperative infection and secondary arthrodesis, the total outcome scores and preserved subtalar motion are overall good to excellent.

Calcaneal fractures: indirect reduction and external fixation

BACKGROUND

The current treatment of displaced intra-articular calcaneal fractures has been surgical fixation. The objective of this study was to evaluate the use of indirect reduction with Ilizarov external fixation as a viable alternative in the surgical treatment of certain calcaneal fractures.

METHODS

Thirty-one patients with 33 fractures of the calcaneus (Sanders types II, III, and IV) were treated using small wire circular external fixation. A limited percutaneous plantar skin incision was used to improve reduction of the posterior facet. Fractures were evaluated by preoperative CT scans and classified by an independent observer. Patients were evaluated by physical examination as well as by the AOFAS hindfoot score questionnaire. Followup ranged from 6 months to 4 years.

RESULTS

The average AOFAS score for 18 patients available for examination was 66 (42 to 92). The average score increased to 74 for patients with more than 10 months followup and to 77 for patients with isolated calcaneal fractures. Open fractures also had early debridement and soft-tissue coverage; no deep infections were seen in this subgroup. There were 11 complications, including nine superficial pin track infections, one superficial skin necrosis under an area of fracture blister, and one deep infection in a diabetic smoker with severe hemorrhagic fracture blisters. All superficial infections responded to local pin or wound care and oral antibiotics. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. All open fractures healed and maintained soft-tissue coverage.

CONCLUSIONS

Indirect reduction and external fixation is a viable surgical alternative for intra-articular calcaneal fractures. Particularly favorable results were obtained in open fractures when soft-tissue reconstruction also was done. Advantages include shorter time to surgery, immediate weightbearing, minimal invasiveness, few serious wound problems, and no residual hardware. Disadvantages include technical difficulty, incomplete reduction of fracture fragments, and the need for secondary surgery (fixator removal).

Treatment of open intra-articular calcaneal fractures: evaluation of a treatment protocol based on wound location and size

BACKGROUND

Effective treatment algorithms for open, displaced, intra-articular calcaneal fractures and their potential early complications have not yet been established. This is a retrospective review of the management of open displaced calcaneal fractures at a Level 1 trauma center and their resulting soft-tissue complications in an effort to establish guidelines for management.

METHOD

Between November, 1994, and April, 2002, 31 open intra-articular calcaneal fractures in 29 patients were treated at our institution. All fractures were treated with a standard protocol based on the appearance of the traumatic wound after initial debridement and stabilization. Fracture stabilization was determined by the wound characteristics and was either standard internal fixation or percutaneous fixation. Data on associated injuries, comorbidities, smoking, and subsequent soft-tissue complications were collected and reviewed.

RESULTS

Overall there was a 29% soft-tissue complication rate with this protocol. Two of the four laterally based traumatic wounds had complications. Twenty-seven wounds were medial. Nine were considered unstable and were treated with aggressive wound management and percutaneous fixation of the tuberosity reduction; two developed deep infections and required amputation and seven were salvaged with patients returning to full weightbearing. Eighteen fractures with medial wounds were treated with standard internal fixation; soft-tissue complications occurred in five. Initial size greater than 4 cm was associated with an increased complication rate in this group.

CONCLUSION

Management of open calcaneal fractures and the risk of complications depend on the size and position of the traumatic wound. Lateral wounds are rare and in this review, two of the four had complications using this protocol. Medial wounds of less than 4 cm can be treated with open reduction and standard internal fixation if the wound can be closed and remain stable off antibiotics. Larger wounds (more than 4 cm) or unstable wounds should not be treated with open reduction and internal fixation but can be reduced and held in alignment with percutaneous wire fixation.

[Fracture of the calcaneus]

Although screw or plate fixation of the fractured calcaneus was first described in the 1920s, surgical treatment using open anatomical reduction and stable internal fixation only commenced at the start of the 1980s. This treatment was made possible by the introduction of new imaging methods such as CT which allowed better detection of the fracture pathology and provided the basis for new surgical strategies. New procedures, including modified surgical approaches related to vascular anatomy, arthroscopic control of the subtalar joint during open or closed reduction, early free flap coverage in severe open or closed fractures with full-thickness skin necrosis, increasingly available (3)D intraoperative radiographic monitoring, and the use of interlocking calcaneus plates, have significantly improved the functional outcome in the treatment of fractures of the calcaneus.

Open calcaneal fractures: assessment and management

Open calcaneal fractures are obscure fractures. Typically, these injuries result in a high-energy, polytraumatized patient population. Initial management consists of irrigation and debridement. Secondary forms of management continue to evolve. High-energy fracture subtypes and severe soft tissue injuries portend an unsatisfactory outcome, despite appropriate management. Standards for the type and timing of treatment have not been established.

Open calcaneal fractures

Open calcaneal fractures can be managed with an array of treatment techniques and result in a wide range of outcomes. Due to the fracture's relative obscurity, the optimal form of intervention remains controversial. Consequently, treatment for these hindfoot fracture-disruptions continues to evolve. Timing of intervention may be a key factor in decreasing complication rates. The goals of open calcaneal fracture management include timely healing of the soft-tissue envelope without infection and maintenance of bony alignment. Unfortunately, restoration of joint congruence may be impossible. Unsatisfactory outcomes may result from neurogenic pain, infection, malunion, arthrosis, and bony impingement. Future advancements in treatment are anticipated and will depend on an improved understanding of this devastating orthopedic injury.

Calcaneus fractures: facts, controversies and recent developments

The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be reliably proven intra-operatively either with Brodén views, high-resolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures. The benefits of newly developed plate designs and subtalar arthrolysis at the time of hardware removal remains to be proven in further studies. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.

Open fractures of the calcaneus: a review of treatment and outcome

OBJECTIVES

The aim of this study was to evaluate the functional and clinical outcome of patients with open calcaneus fractures and to determine what factors were associated with these outcomes.

DESIGN

Retrospective review of 2 level 1 prospective databases. SETTING/PATIENTS/PARTICIPANTS: All patients admitted with an open calcaneal fracture to 2 level 1 trauma units between January 1, 1987 and April 1, 1996 were identified. Data regarding demographics, injury characteristics, and treatment and complications were documented using a standardized data abstraction form. Radiographs were reviewed to document the fracture type according to Essex-Lopresti. For those patients who had computed tomography scans available, the Sanders et al classification was applied and documented. Patients were contacted and asked to return for follow-up evaluation including the American Orthopaedic Foot and Ankle Society ankle/hindfoot score, the Maryland Foot Score, and the Short Form 36 (SF-36). For patients not willing to return for examination, the questionnaires were completed over the telephone, and the objective scoring components were assigned to lowest score possible.

RESULTS

Of 177 calcaneal fractures in patients treated as inpatients during the study period, we identified 30 open fractures in 29 patients. Twenty-seven patients had associated injuries. Two patients underwent amputation within 24 hours due to severe crush injury. Following urgent debridement, soft tissues were closed primarily (22 fractures) or with split thickness skin grafting (4 fractures) and free flap coverage (2 fractures); temporary spanning external fixation was used in 3 patients. Definitive fracture care was at the discretion of the treating surgeon and consisted of closed reduction without fixation (10 fractures), open reduction and bone grafting (1 fracture), minimal Kirschner wire (K wire) fixation (12 fractures), and formal lateral open reduction and internal fixation (5 fractures). There were no late amputations. There were no deep infections. Twenty-one of the 28 patients with salvaged limbs returned for follow-up evaluation, and 3 additional patients agreed to be interviewed by telephone. The average time to follow-up was 49 months with a range of 25 to 106 months. The overall American Orthopaedic Foot and Ankle Society ankle/hindfoot scores and Maryland Foot Scores were fair to poor. The average SF-36 results were within 1 standard deviation of published Canadian norms. Worse function was observed in patients with plantar wounds. Severely comminuted fractures had the worst function, whereas single joint depression injuries had the best functional outcome.

CONCLUSION

Infection is uncommon following open calcaneus fractures treated with aggressive soft tissue management. Patients with plantar wounds and comminuted fractures are expected to have particularly poor functional results.

Open calcaneal fractures: results of operative treatment

OBJECTIVE

To review our series of open calcaneal fractures compared with other series.

DESIGN

Retrospective review.

SETTING

All patients were treated at a single Level 1 trauma center.

PATIENTS/PARTICIPANTS

We reviewed 19 consecutive patients, each with an open fracture of the calcaneus. Fracture morphology ranged from Sanders type II to type IV; associated soft tissue injuries were variable, ranging from Gustilo type I to type IIIC.

INTERVENTION

All patients were treated with intravenous antibiotics, tetanus prophylaxis, and immediate and repeat irrigation and debridement. Definitive fracture reduction was performed at an average of 7 days after injury (range 0-22 days). Fixation methods included lateral plate and screws (11), Kirschner wires and/or screws (6), or none (2).

MAIN OUTCOME MEASUREMENTS

AOFAS ankle-hindfoot scores, clinical examination, and radiographs.

RESULTS

All 19 patients were available for follow-up with a physical examination and radiographs at an average of 26.2 months. The AOFAS ankle-hindfoot scores averaged 81.6 (range 58-94). Five patients required free tissue transfer for wound coverage. Two patients developed chronic, draining calcaneal osteomyelitis, for which one patient underwent a below-knee amputation. In our series, for the patients with Gustilo type II and type III open calcaneal fractures, there was an 11% complication rate with higher than expected health-related quality-of-life indices.

CONCLUSIONS

Our findings do not reflect as high a complication rate for open calcaneal fractures as previously reported. We support previous claims that definitive hardware placement at the time of initial irrigation and debridement probably is not warranted: Definitive fracture stabilization can and should wait until soft tissue coverage is fully assessed.