A retrospective assessment of partial calcanectomies and factors influencing postoperative course

Long-term limb salvage and functional outcomes for patients undergoing partial calcanectomy

INTRODUCTION

Partial calcanectomy (PC) can be performed to treat chronic heel ulcers in patients with calcaneal osteomyelitis. Patients undergoing PC often have multiple comorbidities, limited mobility, and face high risk of major limb amputation. This study examined the extent of vascular diagnostic testing and interventions as well as long-term outcomes in patients undergoing PC.

METHODS

A retrospective analysis was performed on patients who underwent PC for non-healing calcaneal ulcer over a ten-year period. Demographics, comorbidities, vascular testing, and procedural data were recorded. Additional subgroup analysis was performed according to presence or absence of peripheral arterial disease (PAD). Primary outcomes were major limb amputation (above or below the knee) and mortality. Secondary outcomes included successful wound healing, time to complete wound healing, re-interventions, and change in ambulatory status.

RESULTS

A total of 157 patients underwent partial calcanectomies on 162 limbs. 78.3% of patients had diabetes mellitus and 47.8% were diagnosed with PAD. Ankle brachial index with pulse volume recording (ABI/PVR) was performed for 46.5% (73/157) of patients, arterial duplex in 44.6% (70/157), and 19.7% (31/157) had a computed tomography angiogram. Lower extremity revascularization was performed in 28.4% of limbs (46/162). Independent ambulatory status was reported in 40.1% prior to PC and decreased to 17.9% by the time of last recorded follow-up (p < .00001). Long-term amputation-free survival was significantly higher in patients without PAD at 7 years (78.4% vs 57.1%, p = .02). Multivariate logistic regression analysis demonstrated that PAD and end-stage renal disease (ESRD) increased the odds of major limb amputation (OR 3.5 and 2.8, respectively), whereas ESRD and adjuvant podiatric procedures were associated with increased mortality (OR 4.8 and 4.8, respectively).

CONCLUSION

Non-invasive vascular testing should be obtained in all patients undergoing PC, in order to stratify risk of amputation and identify candidates for revascularization. Over the long-term, patients undergoing PC face significant risk of prolonged wound healing, decline in ambulatory status, and major limb amputation.

Outcomes of Partial Calcanectomy in an Academic Limb Salvage Center: A Multicenter Review

Chronic nonhealing heel ulcerations have been established as an independent risk factor for major amputation, with poor rates of limb salvage success. Partial calcanectomy is a controversial limb salvage procedure reserved for patients with these heel ulcerations. We conducted a retrospective cohort study reviewing 39 limbs that underwent a partial calcanectomy from 2012 to 2018 to evaluate the proportion of patients healed, time to healing, ulcer recurrence, and postoperative functional level compared to the preoperative state. In addition, age, gender, body mass index, smoking status, coronary artery disease, diabetes mellitus, renal insufficiency, dialysis, peripheral arterial disease, method of closure, and percent of calcaneus resected were evaluated. Mean follow-up for our cohort was 2.3 years. We had a 1 year mortality rate of 11%, and a major amputation rate of 18%. Our results demonstrated a 77% healing rate with a median time to healing of 162 days. We found that patients who were closed primarily had a faster time to healing compared to patients who underwent closure by secondary intention. Our data showed that ulcer recurrence developed in 57% of healed limbs. We found that 76% of our patients were ambulatory postoperatively. These results suggest that partial calcanectomy is a viable limb salvage procedure with a predictable level of ambulation and function in a high-risk patient population.

An novel and alternative treatment method for large heel ulceration in diabetic patients: Proximal tibial cortex transverse distraction

Heel ulceration in patients with diabetes mellitus (DM) is a major clinical challenge, manifesting with a protracted and uncertain healing process. The prefer treatment of heel ulceration is still controversial. This study aims at describing a newly alternative surgical method with the proximal transverse tibial bone transport technique, as an attempt to achieve wound healing in diabetic patients with large heel ulceration. Retrospective clinical study. A total of 21 diabetic patients with large heel ulceration were enrolled and followed up at least 6 months. The following parameters were assessed: Visual analogue scale (VAS), healing time, ulcer healing rate, ulcer recurrence rate and limb salvage rate. All patients got fully follow-up and achieved wound healing uneventfully. Eighteen patients returned to independent walking without any helper while three patients walked using a crutch. Limb salvage was achieved in all 21 patients (100%). The mean wound area was 67.43 ± 13.31 cm2 (range: 46-97 cm2 ). The mean healing time was 128.62 ± 16.76 days (range: 91-160 days). 16 out of 21 patients without calcaneal osteomyelitis achieved ulcer healing with a mean duration of 124.69 ± 14.42 days (range: 91-143 days), while the other five patients with calcaneal osteomyelitis were 141.20 ± 19.12 days (range: 110-160 days). 2 out of 21 patients got superficial rupture at the previous wounds and healed after outpatient dressing change combined with oral antibiotics. The novel technique described is particularly applicable for large heel ulceration in diabetic patients. It offers a better alternative for achieving wound healing with a favourable encouraging outcome.

Risks Factors Associated With Major Lower Extremity Amputation After Vertical Contour Calcanectomy

The primary aim of the study is to determine risks for major lower extremity amputation after undergoing Vertical Contour Calcanectomy. Subanalysis was performed comparing patients who underwent Vertical Contour Calcanectomy who were fully ambulatory to those who were partially or nonambulatory postoperatively. Within the cohort of 63 patients included in the Vertical Contour Calcanectomy 85.71% (54/63) of patients had diabetes mellitus, 53.97% (34/63) had peripheral arterial disease, and 19.05% (12/63) had Charcot Neuroarthropathy. Multivariate logistic regression, found that (1) patients that underwent primary closure at the time of the Vertical Contour Calcanectomy, were 79.9% more likely (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96) to have limb salvage and that (2) female patients were 85.4% less likely compared to male patients (OR 0.15; 95% CI 0.02-0.99) to undergo major lower extremity amputation. Patients with coronary artery disease were 5.2 times more likely (OR 5.18; 95% CI 1.120-23.94) and patients that were nonambulatory preoperatively, were 10.3 times more likely (OR 10.28; 95% CI 1.60-66.26), to be partially or nonambulatory after Vertical Contour Calcanectomy. Primary closure at time of Vertical Contour Calcanectomy significantly decreases the risk of major lower extremity amputation, and diminished preoperative ambulatory status as well as coronary artery disease makes it less likely that patients return to full ambulation after Vertical Contour Calcanectomy.

Early Clinical, Functional, and Mortality Outcomes for Heel Ulcers Treated With a Vertical Contour Calcanectomy

Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N = 51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state.

The Joint-Specific BACH classification: A predictor of outcome in prosthetic joint infection

BACKGROUND

There is currently no commonly accepted method of stratifying complexity of prosthetic joint infection (PJI). This study assesses a new classification, the Joint-Specific, Bone involvement, Anti-microbial options, Coverage of the soft tissues, Host status (JS-BACH) classification, for predicting clinical and patient reported outcomes in PJI.

METHODS

Patients who received surgery for PJI at two centres in the UK between 2010 and 2015 were classified using JS-BACH as 'uncomplicated', 'complex' or 'limited treatment options'. Patient reported outcomes were recorded at 365-days following the index operation and included the EuroQol EQ-5D-3L index score and the EQ-visual analogue score (VAS). Clinical outcome data were obtained from the most recent follow-up appointment.

FINDINGS

220 patients met the inclusion criteria. At 365-days following the index operation, patients with 'uncomplicated' PJI reported similar EQ-index scores (0.730, SD:0.326) and EQ-VAS (79.4, SD:20.9) compared to the age-matched population. Scores for 'uncomplicated' PJI were significantly higher than patients classified as having 'complex' (EQ-index:0.515 SD:0.323, p = 0.012; EQ-VAS:68.4 SD:19.4, p = 0.042) and 'limited treatment options' PJI (EQ-index:0.333 SD:0.383, p < 0.001; EQ-VAS:60.2, SD:23.1, p = 0.005). The median time to final follow-up was 4.7 years (inter-quartile range 2.7-6.7 years) where there were 74 cases (33.6%) of confirmed recurrence. Using death as a competing risk, the Cox proportional-hazards ratio of recurrence for 'complex' versus 'uncomplicated' PJI was 23.7 (95% CI:3.23-174.0, p = 0.002) and having 'limited options' verses 'uncomplicated' PJI was 57.7 (95% CI:7.66-433.9, p < 0.001).

INTERPRETATION

The JS-BACH classification can help predict likelihood of recurrence and quality of life following surgery for PJI. This will aid clinicians in sharing prognostic information with patients and help guide referral for specialist management of PJI.

Outcomes of partial and total calcanectomies for the treatment of diabetic heel ulcers complicated with osteomyelitis. A systematic review and meta-analysis

BACKGROUND

Infected diabetic foot ulcers (DFU) complicated with calcaneal osteomyelitis are a real challenge for limb preservation. Very few alternatives to amputation are available, mainly the resection of a part or the totality of the calcaneal bone. Calcanectomies were advanced as limb-sparing procedures in patients with heel osteomyelitis. However, there is a lack of pooled quantitative evidence on their efficacy and complications.

OBJECTIVES

The present systematic review and meta-analysis was conducted to determine the primary outcome of healing rates following partial (PC) and total calcanectomies (TC) in treating calcaneal osteomyelitis due to diabetic heel ulcers. Additionally, secondary outcomes such as secondary TC following PC, secondary below knee amputation (BKA), mortality and the change in the ambulation status were analyzed.

METHODS

Medline, Scopus, Web of science, Cochrane Library and Google Scholar were searched since inception. All types of study design were included. Single case report studies and studies reporting osteomyelitis due to other etiologies than DFU were excluded.

RESULTS

Twenty studies met the inclusion criteria comprising 295 patients with 300 calcanectomies (270 PC and 30 TC). With a mean follow-up period of 29.3±17.7 months, the weighted results were as follows: a) the osteomyelitis healing rate was of 80% (95% CI=0.728 to 0.861, I²=48.3%), b) the rate of secondary total calcanectomy was of 5.4% (95% CI=0.022 to 0.097, I²=7.5%), c) the rate of secondary BKA was of 17.1% (95% CI=0.111 to 0.241, I²=50.6%) with no difference between subgroups of TC and PC, and d) the combined mortality rate of both calcanectomies was of 13.4% (95% CI=0.064 to 0.224, I²=73.6%); however, significant higher mortality was found following TC compared to PC (p<0.0001).

CONCLUSION

Partial and total calcanectomies were found to yield very good healing rates with acceptable complication frequencies. When compared to the reported outcomes of below and above-knee amputations in the literature, calcanectomies could be fairly considered as good alternatives to above ankle amputations.

Systematic review of risk prediction studies in bone and joint infection: are modifiable prognostic factors useful in predicting recurrence?

Background: Classification systems for orthopaedic infection include patient health status, but there is no consensus about which comorbidities affect prognosis. Modifiable factors including substance use, glycaemic control, malnutrition and obesity may predict post-operative recovery from infection. Aim: This systematic review aimed (1) to critically appraise clinical prediction models for individual prognosis following surgical treatment for orthopaedic infection where an implant is not retained; (2) to understand the usefulness of modifiable prognostic factors for predicting treatment success. Methods: EMBASE and MEDLINE databases were searched for clinical prediction and prognostic studies in adults with orthopaedic infections. Infection recurrence or re-infection after at least 6 months was the primary outcome. The estimated odds ratios for the primary outcome in participants with modifiable prognostic factors were extracted and the direction of the effect reported. Results: Thirty-five retrospective prognostic cohort studies of 92 693 patients were included, of which two reported clinical prediction models. No studies were at low risk of bias, and no externally validated prediction models were identified. Most focused on prosthetic joint infection. A positive association was reported between body mass index and infection recurrence in 19 of 22 studies, similarly in 8 of 14 studies reporting smoking history and 3 of 4 studies reporting alcohol intake. Glycaemic control and malnutrition were rarely considered. Conclusion: Modifiable aspects of patient health appear to predict outcomes after surgery for orthopaedic infection. There is a need to understand which factors may have a causal effect. Development and validation of clinical prediction models that include participant health status will facilitate treatment decisions for orthopaedic infections.

Intraoperative Site Vancomycin Powder Application in Infected Diabetic Heel Ulcers With Calcaneal Osteomyelitis

BACKGROUND

Intraoperative site application of vancomycin powder has been found to be beneficial in foot and ankle surgery among diabetic patients undergoing elective procedures. However, there are concerns for risks such as selection of multidrug-resistant bacteria, local tissue irritation, and increased wound complications. The clinical utility of intraoperative site vancomycin powder application in infected diabetic foot ulcer surgery is unknown. We aimed to report the clinical outcomes of partial or total calcanectomy for diabetic heel ulcer (DHU) and determine if intraoperative site application of vancomycin powder placement at the time of wound closure leads to improved clinical outcomes.

METHODS

A current procedural terminology query (CPT 28120: partial excision bone; talus or calcaneus) was run that identified 35 patients representing 38 calcanectomies performed secondary to infected DHU with calcaneal osteomyelitis. An initial group of 25 patients did not receive intraoperative site vancomycin powder, whereas the following 13 cases received intraoperative site vancomycin powder. Demographics, clinical characteristics, comorbidities, operative complications, unexpected return to the operating room (RTOR), and revision amputations were recorded for each patient. Average follow-up was 26.1 (6.5-51.6) months.

RESULTS

There was a significantly higher rate of RTOR among the vancomycin powder cohort (VANC) relative to the no-vancomycin cohort (No-VANC) (84.6% vs 36.0%, P = .038). Of the 13 VANC patients, 3 healed the wound and did not require RTOR, 2 underwent below-knee amputation (BKA), 2 received irrigation and debridement (I&D), and 6 underwent revision or total calcanectomies. Of the 25 No-VANC patients, 17 healed the wound, 4 underwent BKAs, 1 received an I&D, and 2 required revision or total calcanectomy. There was a trend toward increased rates of revision calcanectomy and BKA among the VANC cohort, but this was not statistically significant (61.5% vs 28.0%, P = .079).

CONCLUSION

Partial or total calcanectomies for the management of infected DHU resulted in an overall healing rate of 50.0%, unplanned RTOR and revision calcanectomy rate of 39.5%, and a limb salvage rate of 82.6%. We found no clinical benefit with the intraoperative site application of vancomycin powder.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Medium-term outcomes of multi-disciplinary surgical management of non-ischemic diabetic heel ulcers

BACKGROUND

Heel ulcers in patients with peripheral neuropathy and diabetes pose a significant challenge to treating physicians. Infection spreading to the os calcis is associated with a poor prognosis. There is no consensus on which method of surgical treatments results in better outcomes. The aim of this study was to assess patients' survival, rate of ulcer healing following surgical treatment, along with limb salvage rate, time taken for healing, ulcer recurrence and patients' functional outcome after healing.

METHODS

We studied 29 patients (20 men, 9 women) presenting with diabetic neuropathic heel ulcers (30 feet) and no critical limb ischemia, were managed surgically in our unit and followed-up for a minimum of 12 months. We assessed their clinical and functional outcomes within a mean follow-up period of 28 months (12-83).

RESULTS

11 out of 29 patients died (38%) with mean duration of post op survival being 31months (range 4-70). 14 ulcers (50%) healed fully within a mean of 360 days (131-1676). Limb salvage was achieved in 29 feet (97%). Only 5 out of 17 patients with diabetic nephropathy (p value 0.016) and 9 out of 24 ulcers with calcaneal osteomyelitis (p value 0.044) achieved full ulcer healing. Ulcer recurrence rate was 36% (5/14) within 12 months of achieving ulcer healing. Six patients were able to return to independent walking in surgical shoes while 11 patients were mobilising using either a crutch or frame.

CONCLUSION

While excellent limb salvage can be anticipated from the outcome of surgically managed infected heel ulcers in patients with diabetes, complete healing can still be slow and unpredictable. Significant medical co-morbidities in these patients make them vulnerable to medium-term post-operative complication and survival.

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.

The Vertical Contour Calcanectomy, an Alternative Approach to Surgical Heel Ulcers: A Case Series

Heel ulcers have a significant impact on lower-extremity morbidity and confer high risk of major amputations. Treating these ulcers is difficult because of poor tissue coverage and the bony os calcis, often leading to proximal amputation. This case series shows the vertical contour calcanectomy (VCC) as a surgical alternative in functional limb salvage. Sixteen feet (14 patients) with recalcitrant heel wounds who underwent VCC were identified. The minimum follow-up time for inclusion was 1 year. Body mass index, diabetes, renal disease, peripheral vascular disease, lymphedema/venous insufficiency, smoking status, Charcot, amputation, vascular intervention, wound recurrence, reoperation rate, and ambulatory status were evaluated. The average follow-up time was 27.1 months (range 13.5 to 51.1). At 1 year of follow-up, 56% of heel wounds (9 of 16) treated with the VCC remained closed. An average of 1.44 subsequent surgeries were required per patient. Baseline or improved ambulatory status was achieved in 69% of patients (9 of 14) at 1-year follow up and 100% of patients (8 of 8) at 2-year follow up. The overall rate of major amputation was 19%. The long-term ambulatory status of patients treated with the VCC shows promise. The VCC should be considered as an alternative, reliable, surgical limb salvage tool for heel ulcerations.

The Vertical Contour Calcanectomy: An Alternative Surgical Technique to the Conventional Partial Calcanectomy

Heel ulcers have a significant impact on lower extremity morbidity and confer a high risk for major amputations. Although there are many conservative treatment options, once calcaneal osteomyelitis occurs or a heel ulcer becomes chronic or recalcitrant, more invasive management is required. The partial calcanectomy is a surgical solution that can address both pathologies-the ulceration and the infected bone. The conventional partial calcanectomy, however, does not ensure complete soft tissue closure. Often, closure under tension is required for primary closure of the soft tissue deficit or the wound must be closed by secondary intention. This process occurs, in part, when the proportion of bone resected is insufficient in relation to the size of the wound. Closure under tension increases the possibility of dehiscence and subsequent postoperative surgical site complications that lead to the same risks for major amputation as the index heel ulcer. This article introduces and describes a novel modification to the conventional partial calcanectomy and addresses these aforementioned concerns. The vertical contour calcanectomy incorporates improvements to an already accepted limb salvage technique. The purpose of this article was to describe the indications, contraindications, intraoperative technique and postoperative management of the vertical contour calcanectomy for patients who present with heel ulcers in the limb salvage setting.

Slow to heel: a literature review on the management of diabetic calcaneal ulceration

The diabetic heel ulcer (DHU) represents a reconstructive challenge to clinicians and the multidisciplinary team alike. It is traditionally viewed as a condition that is inherently difficult to treat due to the intrinsic anatomical vulnerabilities of the heel. In addition to this, several factors are associated with poorer end outcomes - namely, that of major amputation. These include peripheral vascular disease, infection/osteomyelitis and the size of the ulcer itself. In light of the significant morbidity, economic burden and mortality seen in this cohort of patients, this review aims to explore current treatment modalities that have been undertaken. Literature in this field has mostly been confined to a handful of small case studies, some of which reflect novel, multimodal approaches, and promising results. Management with osteotomy, flap reconstruction and acellular dermal matrices, amongst other options, is covered within this review.

Combination of Open Subtotal Calcanectomy and Stabilization With External Fixation as Limb Salvage Procedure in Hindfoot-Infected Diabetic Foot Ulcers

Diabetic hindfoot ulcers, complicated by osteomyelitis, are associated with a high risk of major amputation. Partial calcanectomy, preceded by an effective management of the infection and of the eventual peripheral artery disease, can be considered as valid therapeutic option. We have evaluated a therapeutic protocol for diabetic hindfoot ulcers complicated by osteomyelitis, which, besides an adequate surgical debridement, considers a reconstructive pathway assisted by the positioning of a circular external fixator. We made a prospective study of a cohort of diabetic patients affected by heel ulcer complicated by osteomyelitis. All patients underwent open partial calcanectomy associated with the positioning of a circular external frame specifically designed for hindfoot stabilization and offloading. A reconstructive procedure was implemented starting with the application of negative pressure wound therapy and coverage with dermal substitute and split thickness skin grafting. From November 2014 to November 2015, 18 consecutive patients were enrolled. Mean follow-up period was 212.3 ± 64.0 days. Healing was achieved in 18 (100%) patients. The mean healing time was 69.0 ± 64.0 days. No major amputation had to be performed during the follow-up. Open partial calcanectomy associated with external fixation and skin reconstruction was as efficient as limb salvage in patients with infected lesions of the hindfoot complicated by calcaneal osteomyelitis.

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.

Lower extremity function following partial calcanectomy in high-risk limb salvage patients

Partial calcanectomy (PC) is an established limb salvage procedure for treatment of deep heel ulceration with concomitant calcaneal osteomyelitis. The purpose of this study is to determine if a relationship exists between the amount of calcaneus removed during PC and the resulting lower extremity function and limb salvage outcomes. Consecutive PC patients were retrospectively divided into two cohorts defined by the amount of calcaneus resected before wound closure: patients in cohort 1 retained = 50% of calcaneus, while patients in cohort 2 underwent resection of >50% of the calcaneus. The Lower Extremity Function Scale (LEFS) was used to assess postoperative lower extremity function. The average amount of calcaneus resected was 13% ± 9.2 (1-39%) and 74% ± 19.5 (51-100) in cohorts 1 and 2, respectively (P < 0.0001). Below knee amputation was performed in 7 (28%) and 5 (29%) of subjects in cohorts 1 and 2, respectively (P = 1.0). The average LEFS score was 33.9 ± 15.0 for subjects in cohort 1 and 36.2 ± 19.9 for the subjects cohort 2 (P = 0.8257) which correlates to "moderate to quite a bit of difficulty." Our study suggests that regardless of the amount of calcaneus resected, PC provides a viable treatment option for high-risk patients with calcaneal osteomyelitis.

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.

Role of body mass index in acute charcot neuroarthropathy

Obesity has been posited as a predictor for the development of Charcot neuroarthropathy, a severe form of degenerative joint disease associated with peripheral neuropathy and diabetes mellitus. The present case-control study investigated the relationship between elevated (overweight and obese) body mass index and acute Charcot neuroarthropathy in a diabetic population. The final data set consisted of 49 patients, 20 (40.82%) of whom had Charcot foot and 29 (59.18%) who served as controls. In the present investigation, no statistically significant association was found between an elevated body mass index and the development of acute Charcot neuroarthropathy involving the foot.

Partial foot amputation in patients with diabetic foot ulcers

BACKGROUND

Transtibial amputations (TTA) are performed for recalcitrant or infected ulcers of the midfoot, hindfoot, or ankle. This procedure results in decreased ambulatory status caused by increased oxygen demands and energy expenditure. Partial foot amputations have the advantage of being an end-bearing limb and require less work to walk, theoretically suggesting improved functional outcome. The purpose of this research was to examine the longevity, outcome, and mortality of partial foot amputations as an alternative to TTA.

METHODS

Retrospective chart review identified diabetic patients with transmetatarsal, Chopart's, and calcanectomy amputations for osteomyelitis or nonhealing ulcers. A control group consisted of diabetic patients who underwent TTA. A comparison between groups examined mortality, proximal ipsilateral reamputation, and a validated ambulatory functional outcome measure.

RESULTS

Eighteen TTA patients were enrolled. The 5-year mortality rate was 0.45, one patient required reamputation, and the mean postoperative ambulatory score was 2.8. Twenty-one transmetatarsal patients were enrolled. The 5-year mortality rate was 0.30, two patients required reamputation, and the mean postoperative ambulatory score was 4.3. Ten Chopart's amputation patients were enrolled. The 5-year mortality rate was 0.36, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Seventeen partial calcanectomy patients were enrolled. The 5-year mortality rate was 0.69, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Sixteen total calcanectomy patients were enrolled. The 5-year mortality rate was 0.59, five patients required reamputation, and the mean postoperative ambulatory score was 3.3.

CONCLUSION

TTA is associated with high morbidity and mortality, which suggests that the advantage of partial foot amputations should be investigated. Only transmetatarsal amputations at 1 and 3 years were statistically lower for mortality than TTA. Partial foot amputations at the other levels failed to show statistically improved survivorship. Transmetatarsal and Chopart's amputations had high ambulatory levels and the longest durability, which suggests that these amputations may provide some ambulatory advantage.

Near total calcanectomy with rotational flap closure of large decubitus heel ulcerations complicated by calcaneal osteomyelitis

Osteomyelitis is a common late-stage sequela of deep heel ulceration and frequently results in leg amputation, because few options exist to effectively treat this challenging problem. A technique that has been successful at our institution is near total calcanectomy with rotational flap closure of large decubitus heel ulcers complicated by calcaneal osteomyelitis. A case series is presented of 3 patients with differing locations or "zones" of heel decubitus ulceration with acute osteomyelitis. A description of our preferred flap choice, given the zone of the ulceration, is demonstrated, as are the surgical principles for the treatment approach. This procedure is an effective option, provided specific principles are followed to achieve complete wound coverage and minimize pressure points both when in bed and when walking.

Partial calcanectomy: A procedure to cherish or to reject?

BACKGROUND

Large ulcers on the heel often lead to major amputations. When a conservative treatment fails, a partial or subtotal calcanectomy is a possible treatment option.

METHODS

24 Patients were evaluated regarding limb salvage and infection eradication. Fourteen of these completed a questionnaire regarding functional outcome and satisfaction.

RESULTS

Only 1 of 24 patients needed a below-knee amputation. Three patients did not heal and still have minor drainage of the wounds. However, hospital stay was long and in many cases additional surgery was necessary. Recurrences are seen, especially in patients with impaired sensation of the foot. In the fourteen patients who completed the questionnaire, pain was not a major problem. Many patients use orthotics and external support. The majority, however, is satisfied with the procedure and would consider the same treatment again.

CONCLUSION

Calcanectomy still has a place in the treatment of osteitis of the calcaneus.

Gait and functional implications of bilateral, partial calcanectomy: case report

Level of Evidence: V, Expert Opinion