A technique to preserve the shape of the calcaneus after massive osteomyelitis

Extensive eggshell-like debridement technique plus antibiotic-loaded calcium sulphate for one-stage treatment of chronic calcaneal osteomyelitis

BACKGROUND

Management of chronic calcaneal osteomyelitis is challenging. At present, there is still no widely accepted, simple, and effective surgical method to eradicate the infection and prevent osteomyelitis recurrence. The objective of this study was to assess the outcomes of one-stage treatment of chronic calcaneal osteomyelitis with a shape-preserving debridement technique combined with antibiotic-loaded calcium sulphate.

METHODS

Between 2012 and 2018, 33 patients (33 limbs) with chronic calcaneal osteomyelitis were treated with a novel debridement technique, named "eggshell-like debridement", plus antibiotic-impregnated calcium sulphate. The infection remission rate, recurrence rate, and amputation rate were analyzed. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to assess postoperative hindfoot function.

RESULTS

26 patients (81.8%) achieved infection remission without recurrence. In the patients with osteomyelitis remission, pain, limitation of movement, sinus tracts, and typical redness and swelling were generally eliminated. Most of the patients could tolerate full weight-bearing without pain. The average AOFAS ankle and hindfoot score was 88 points (range, 67-100 points), implying the foot function was mostly restored. 6 patients (18.2%) had osteomyelitis recurrence but no amputation was required to elimilate the infection.

CONCLUSIONS

Eggshell-like debridement combined with antibiotic-loaded calcium sulphate is an effective method for one-stage management of chronic calcaneal osteomyelitis. With the application of this technique, secondary autogenous bone or muscle flap grafts are unnecessary. The surgical procedure can be simplified whlie the hindfoot function is well preserved.

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.

The infected calcaneus

Infections in and around the calcaneus can be quite challenging for the patients and physicians involved. These infections arise because of multiple potential etiologies including chronic pressure, trauma, and postsurgical wound-healing complications. The impediments to healing can be equally as diverse depending on patients' comorbidities, such as smoking, diabetes, and open injury. In this article the authors review the anatomy of the calcaneus and surrounding soft tissue, patient risk factors, and various treatment options that can be used through a multidisciplinary approach. The common limiting factor for most of these patients is the delicate soft-tissue envelope, and occasionally, the lack thereof. The ultimate goal is an infection-free limb with durable soft-tissue coverage and maximal maintenance of function.

Treatment of calcaneal osteomyelitis with free serratus anterior muscle flap transfer

BACKGROUND

Chronic calcaneal osteomyelitis is a difficult problem to eradicate. The infected bone and soft tissue can rarely be successfully treated conservatively. But after aggressive debridement, there is usually a large defect in the calcaneus and soft tissue. Free serratus anterior muscle flap can not only fill the defect but can help eliminate the infection of the bone and soft tissue.

MATERIALS AND METHODS

Thirteen patients with calcaneal osteomyelitis were treated with free serratus anterior muscle flap transfer and skin graft from 2000 to 2006. The mean patient age was 36 (range, 18 to 48) years. Four patients were women and nine were men. The followup averaged 34 months (range, 6 months to 6 years).

RESULTS

All flaps survived and there was no infection recurrence. The mean operation time was 6.3 +/- 1.3 hours. Partial skin graft necrosis was found in one patient, which resolved uneventfully after another skin graft. There was minimal donor site morbidity. Winged scapula or dysfunction of the shoulder was not found in any of the patients.

CONCLUSION

The serratus anterior muscle has many advantages owing to its anatomical features. We believe it is a good option for treatment of calcaneal osteomyelitis.

Calcaneogenesis

We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.

Calcium sulphate delivery system with tobramycin for the treatment of chronic calcaneal osteomyelitis

The case of a 24-year-old woman with Pseudomonas aeruginosa and Proteus mirabilis chronic calcaneal osteomyelitis is presented. Extensive debridement of the necrotic bone and application of tobramycin-loaded polymethylmethacrylate beads was performed and ciprofloxacin was given post-operatively. Three months later, laboratory tests, including complete blood cell count, erythrocyte sedimentation rate and C-reactive protein, were normal. At this time, extensive surgical debridement and filling of the osseous defect with autologous iliac cancellous bone graft and tobramycin-impregnated calcium sulphate pellets and paste were performed. Oral ciprofloxacin was administered for 3 months after surgery. At the latest follow-up, 2 years later, the patient had full weight-bearing function; there was no recurrence of the infection, and complete incorporation of the autologous bone and calcium sulphate graft with the host bone was observed. This case demonstrates that two-stage surgical treatment with extensive debridement and tobramycin-impregnated calcium sulphate was effective in treating chronic calcaneal osteomyelitis.