The Infected Calcaneus

doi:10.1016/j.fcl.2010.04.002

Foot and Ankle Clinics

Volume 15, Issue 3, September 2010, Pages 477-486

https://doi.org/10.1016/j.fcl.2010.04.002 Get rights and content

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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 Reports
Chronic calcaneal osteomyelitis is a challenging condition associated with high relapse rates, requiring a multidisciplinary approach and various therapeutic options for effective management. We report a very rare case of a pyogenic osteomyelitis of the os calcis presented as a bone abscess.
A diabetic male patient presented with chronic osteomyelitis of the calcaneus in the form of bone abscess with a cavity of 6*5 cm. After pus evacuation and debridement of the cavity, gentamycin-impregnated polymethylmethacrylate cement was used to locally assist in controlling the infection and to assure mechanical support. Antibiogram-based oral antibiotic was administrated for 6 weeks. At final follow-up, the patient could walk without any assistance and was able to raise his body on the operated heel, with no signs of infection.
This case illustrates successful conservative surgical treatment of calcaneal abscess using antibiotic-impregnated cement for mechanical support and local infection control.
Incorporating antibiotic-impregnated cement into conservative foot surgeries for deeply embedded calcaneal abscesses provides effective infection control, mechanical support, and functional preservation, leading to successful treatment outcomes.
Recurrent heel ulcers with calcaneal osteomyelitis in myelomeningocele: Treatment by partial calcanectomy and posterior transfer of tibialis anterior tendon
2023, Foot and Ankle Surgery
Citation 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.
Calcaneus deformity of the foot is common in patients with myelodysplasia, mainly due to muscle imbalance. This deformity, especially in ambulatory patients, can result in gait problems and development of pressure sores, which can be complicated by calcaneal osteomyelitis.
This retrospective cross-sectional study included 12 patients (18 feet), with calcaneus deformity due to myelomeningocele, and presented with penetrating heel ulcers complicated by calcaneal osteomyelitis. The mean age of the included cases was 11 years. The ulcers were unilateral in six patients and bilateral in six. Sensation was absent on the plantar aspect of the foot in all cases. The treatment was done in two stages; The first stage was eradication of infection and obtaining good soft tissue coverage, and the second stage was obtaining motor balance to achieve a more plantigrade and braceable foot.
The average follow-up period was 19.2 months. In the final follow-up, twelve feet were graded as good, five as fair and one as poor according to Legaspi grading system.
The combination of partial calcanectomy and subsequent transfer of tibialis anterior tendon, to improve the foot position and gait, can efficiently prevent ulcer recurrence in myelomeningocele patients with calcaneal deformity.
Retrospective case series study.
Risks Factors Associated With Major Lower Extremity Amputation After Vertical Contour Calcanectomy
2022, Journal of Foot and Ankle Surgery
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.
Total calcanectomy in calcaneal osteomyelitis: An alternative to major amputation
2022, Foot
Citation 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].
Hindfoot ulcers associated with chronic calcaneus osteomyelitis are very difficult to manage and many patients need a limb amputation for resolution. Total calcanectomy can be a salvage procedure for these patients. The purpose of this study is to present our results of total calcanectomy.
Retrospective analysis of six patients undergoing total calcanectomy at our institution between 2008 and 2019. Patient data and ambulatory status were analyzed.
In 4 of the 6 patients, infection control and wound closure was achieved with total calcanectomy with follow-up ranging from 1 to 12 years. The 4 patients maintain walking ability. Two major complications: an early death caused by a respiratory infection and a below the knee amputation due to recurrence of the foot infection.
Total calcanectomy is an useful procedure for limb salvage in foot ulcers with chronic calcaneus osteomyelitis.
The Vertical Contour Calcanectomy, an Alternative Approach to Surgical Heel Ulcers: A Case Series
2019, Journal of Foot and Ankle Surgery
Citation 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).
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.
Osteomyelitis of the Calcaneus With Pathologic Fracture
2019, Journal of Foot and Ankle Surgery
Citation 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.
Pathologic fractures of the calcaneus secondary to osteomyelitis (OM) have rarely been reported in the literature. This case series describes 5 patients who were treated in our institution for chronic OM of the calcaneus and subsequently suffered a fracture of the involved calcaneus in the absence of trauma. All 5 patients had a history of insulin-dependent diabetes mellitus and were treated with a range of surgical treatments including open reduction and internal fixation, external fixation, and excision of the fracture fragment. Three (60%) of the patients required a below-the-knee amputation of the ipsilateral limb, 1 (20%) expired, and 1 (20%) experienced healing of the fracture and the associated heel wound. Pathologic fracture of the calcaneus secondary to OM is a recognized entity, although case descriptions have rarely been reported for this challenging condition.

View all citing articles on Scopus

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The Infected Calcaneus

Section snippets

Bone

Operatively Treated Calcaneal Fractures

Clinical evaluation

Laboratory studies

Imaging studies

Inability to Achieve Primary Wound Closure

Chronic osteomyelitis

Skin Grafts

Local Muscle Flaps

Summary

First page preview

Injury

Orthop Clin North Am

Orthop Clin North Am

J Foot Ankle Surg

Foot Ankle Clin

Foot Ankle

Foot Ankle

Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures

J Orthop Trauma

Current therapy in plastic surgery

The management of soft-tissue problems associated with calcaneal fractures

Clin Orthop Relat Res

Clinically oriented anatomy. The lower limb

Surgery of the foot & ankle

The mechanism, reduction technique, and results in fractures of the os calcis

Br J Surg

Angiosomes of the leg: anatomic study and clinical implications

Plast Reconstr Surg

Tobramycin-impregnated calcium sulfate prevents infection in contaminated wounds

Clin Orthop Relat Res

Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures

Foot Ankle Int

Open fractures of the calcaneus: soft-tissue injury determines outcome

J Bone Joint Surg Am