The Infected Calcaneus
Section snippets
Bone
As the strongest bone in the foot, the calcaneus has a unique role in gait because it accepts axial load during heel strike then later transmits forces to the forefoot during push off.3 The calcaneus has four articular surfaces. The anterior, middle, and posterior facets that articulate with the talus allow heal inversion and eversion, which thereby enable accommodation of uneven surfaces. The calcaneal cuboid articulation plays an important role anteriorly in supporting the lateral column.4
Operatively Treated Calcaneal Fractures
Folk and colleagues1 looked at early wound complications in 190 operatively treated calcaneal fractures and found a 25% wound-complication rate with 21% requiring surgical treatment. They found the predictive variables in their study were smoking (37 out of 118 patients; P = .03; relative risk [RR] = 1.2); diabetes (7 out of 9; P = .02; RR = 3.4); and open injuries (13 out of 18 fractures; P<.0001; RR = 2.8).
Abidi and colleagues11 also looked at wound healing risk factors in 63 subjects with 64
Clinical evaluation
There are essentially two main etiologies for calcaneal osteomyelitis or surrounding wound infection: posttraumatic versus those related to chronic pressure. The posttraumatic can be divided into postsurgical, which includes wound dehiscence, acute infection, chronic infection, and open wounds acquired at time of injury. The chronic pressure wounds are usually neuropathic in etiology and are often associated with diabetes and polymicrobial infection. All patients should undergo a comprehensive
Laboratory studies
As a baseline in the workup of possible osteomyelitis, a complete blood count with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) should be checked. CRP is the most accurate indicator of osteomyelitis. It starts to elevate at 6 hours, peaks at 2 days, and normalizes in approximately 1 week after appropriate treatment is initiated. ESR can be sensitive, but lacks specificity as it becomes elevated in the presence of fracture and other inflammatory states. ESR
Imaging studies
Radiographs should be obtained for all patients to assess radiographic evidence of osteomyelitis in addition to evaluating reduction/fixation and degree of fracture healing. It takes approximately 3 weeks for osteomyelitis to become present on plain radiographs.2 MRI can provide earlier detection of osteomyelitis, though it is of limited utility in an instrumented calcaneus because of artifact.
Nuclear medicine imaging uses radionucleotides to better understand active physiologic changes
Inability to Achieve Primary Wound Closure
A tension-free primary closure may be difficult or impossible to obtain in patients with severe shortening or delay exceeding 2 weeks because of soft-tissue contracture. Rather than risking likely dehiscence by over tightening the deep sutures, a plastic surgeon should be made available to assist with closure.10 Alternatively, a vacuum assisted closure (V.A.C.) (KCI, San Antonia, TX, USA) dressing can be placed and delay primary closure versus a split thickness skin graft (STSG) on a later
Chronic osteomyelitis
Once osteomyelitis is recognized, adequate debridement is the cornerstone of treatment. In the setting of diffuse osteomyelitis, any internal fixation should be removed at the time of initial debridement.22 Depending on the extent of medullary involvement and the condition of the surrounding soft-tissue envelope, the spectrum of treatment can have significant variation in complexity. If a large cavitary lesion is left post-debridement, as is common with posttraumatic osteomyelitis, options
Skin Grafts
STSGs are used for wound coverage when there is a sufficient soft-tissue bed to accept the graft. These grafts include the epidermis and a portion of the dermis. Thinner grafts are more likely to take, but also shrink more than thicker grafts. Split-thickness skin grafts are often combined with muscular flaps to achieve adequate epidermal coverage.2
Local Muscle Flaps
Based on the angiosomes around the foot and ankle, there are local flaps that can be rotated for wound coverage. Unfortunately, these can be
Summary
Infections of the calcaneus can be extremely challenging to resolve. A thorough clinical examination with close follow-up is critical for any patients at risk for developing wound complications. In the diabetic population, education and prevention are essential for minimizing the frequency and severity of calcaneal infections. Open reduction and internal fixation improves outcomes in many intraarticular calcaneal fractures, but constant cognition of the condition of the delicate soft-tissue
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Cited by (22)
Gentamicin-permeated cement to sustain mechanical support for the treatment of a chronic calcaneal abscess. A case report
2023, International Journal of Surgery Case ReportsRecurrent heel ulcers with calcaneal osteomyelitis in myelomeningocele: Treatment by partial calcanectomy and posterior transfer of tibialis anterior tendon
2023, Foot and Ankle SurgeryCitation Excerpt :Calcaneal osteomyelitis is usually managed by calcanectomy either partial or complete, or even by below knee amputation. However, limb salvage remains the desired procedure [16]. In 1896, Landerer introduced partial and total calcanectomy for the treatment of calcaneal osteomyelitis.
Risks Factors Associated With Major Lower Extremity Amputation After Vertical Contour Calcanectomy
2022, Journal of Foot and Ankle SurgeryTotal calcanectomy in calcaneal osteomyelitis: An alternative to major amputation
2022, FootCitation Excerpt :Chronic osteomyelitis of the calcaneus accounts for about 7–8% of all osteomyelitis [1]. These are often due to hindfoot ulcers associated with trauma or comorbidities such as Diabetes Mellitus, neuropathies or peripheral vascular diseases [2]. Hematogenous dissemination is also described in rare cases [3].
The Vertical Contour Calcanectomy, an Alternative Approach to Surgical Heel Ulcers: A Case Series
2019, Journal of Foot and Ankle SurgeryCitation Excerpt :With the ultimate treatment goals of eradication of infection, soft tissue coverage, biomechanical stability, and function limb salvage, there are nonsurgical and surgical interventions available. Nonsurgical options include offloading, local wound care, antibiotics, and medical comorbidity management (1,14). Hyperbaric oxygen can be used as adjunctive treatment in wound care to accelerate the rate of healing because of possible physiological angiogenesis at the site of the ulcer (15).
Osteomyelitis of the Calcaneus With Pathologic Fracture
2019, Journal of Foot and Ankle SurgeryCitation Excerpt :In 1976, Waters et al (16) found that patients had a gait velocity significantly decreased from normal ambulation. If the decision is made to go forward with BKA, the surgeon and patient should be in agreement that this would indeed provide the best result based on the patient's needs and functional ability (1,17). The outcomes for the 5 patients included in this case series were significantly worse compared with previous reports that did not involve OM.