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The Journal of Bone and Joint Surgery (American) 85:2276-2282 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome

Keith A. Heier, MD1, Anthony F. Infante, DO2, Arthur K. Walling, MD2 and Roy W. Sanders, MD2

1 Metrocrest Orthopedics, 4780 Josey Lane, Carrollton, TX 75010. E-mail address: kaheier{at}aol.com
2 Florida Orthopedic Institute, 4 Columbia Drive, Tampa, FL 33606.

Investigation performed at Tampa General Hospital, Tampa, Florida

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

* This study was retrospective by design. All data were obtained from either the patient's private office medical records or radiology jacket. These files contained not only a complete record of follow-up visits and radiographs, but also a complete duplicate of all hospital admissions data, both radiographic and with respect to records documentation. Upon accepting care by the physicians at our private facility, patients agree to sign the Authorization to Use Patient Medical Information for Medical Research form, which gives us permission to use their data for research purposes. All patients in this study signed these forms. As a result, approval was not sought from the hospital institutional review board, as neither files nor radiographs from that institution were used.

Background: Studies of open calcaneal fractures have been limited and have not analyzed results according to wound location, severity of soft-tissue disruption, fracture type, or treatment method. In this study, results were evaluated on the basis of the hypothesis that early surgical intervention was indicated.

Methods: Between 1989 and 1997, 503 calcaneal fractures were treated at our institution, and forty-three of these fractures, in forty-two patients, were open (8.5%). According to the Gustilo classification there were nine type-I, eight type-II, twelve type-IIIA, and thirteen type-IIIB open fractures as well as one type-IIIC open fracture. All fractures were treated according to the same protocol, consisting of intravenous administration of antibiotics chosen on the basis of the wound type, irrigation and débridement in the operating room, temporary wound coverage, and initial stabilization of the limb. Definitive final fixation was performed after the wound was clean, and soft-tissue swelling was minimal. The final follow-up examinations were performed at a minimum of two years after treatment. Clinical results were graded with use of the AOFAS (American Orthopaedic Foot and Ankle Society) score.

Results: An infection developed at the sites of 37% of the forty-three fractures, with osteomyelitis developing at the sites of 19%. Seven of the nine type-I open fractures were treated with open reduction and internal fixation or with primary fusion, with no major complications and a good-to-excellent short-term result. Three of the eight type-II open fractures were complicated by an infection. Three of the twelve type-IIIA open fractures and ten of the thirteen type-IIIB open fractures were complicated by an infection. Six of the infections associated with a type-IIIB open fracture progressed to osteomyelitis, and three of those cases led to an amputation. Overall, thirteen (50%) of the twenty-six type-III open fractures were complicated by an infection, with osteomyelitis occurring in seven (27%). Thirty-three patients with a total of thirty-four open calcaneal fractures were available for follow-up at a minimum of two years, and an average of fifty-five months. The average AOFAS hindfoot score for the twenty-seven patients who had not undergone amputation was 71 points.

Conclusions: Open calcaneal fractures have a high propensity for deep infection despite the use of an aggressive treatment protocol to prevent it. It appears that type-I and type-II open fractures associated with a medial wound can be treated with open reduction and internal fixation. Type-II fractures associated with a wound in another location should be treated with limited or no internal fixation. Type-III open fractures, and especially type-IIIB open fractures, require extensive débridement and prompt soft-tissue coverage as soon as possible. Early internal fixation should be avoided in this subgroup because of the high rates of osteomyelitis and subsequent amputation.

Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.


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Related articles in JBJS:

Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome • K.A. Heier, A.F. Infante, A.K. Walling, and R.W. Sanders reply:
Steven J. Lawrence, Gregory F. Grau, Keith A. Heier, Anthony F. Infante, Arthur K. Walling, and Roy W. Sanders
JBJS 2004 86: 2568-2569. [Extract] [Full Text]  



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Treatment of Open Fracturnes of the Calcaneus
Steven J. Lawrence, MD, et al.
JBJS Online, 6 Apr 2004 [Full text]
Dr. Heier and colleagues respond:
Keith A Heier, et al.
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