Session IV - Foot & Ankle

Wound Healing in Open, Displaced Calcaneal Fractures

Stephen K. Benirschke, MD; Patricia Ann Kramer, PhD; Sean E. Nork, MD, University of Washington, Seattle, WA

Purpose: We evaluated the complication rate for treatment of displaced calcaneal fractures associated with open wounds of the ipsilateral foot.

Methods: A retrospective review was conducted of the records of 37 patients with 39 open, displaced calcaneal fractures initially treated surgically by the senior author from 1989 to 1998 at our level-1 trauma center. Wound healing complications were also evaluated by follow-up contact with the patients.

Results: There were one 73A, four 73B, seven 73C1, thirteen 73C2 and fourteen 73C3 fractures. Soft tissue status was graded as O1 in 4 patients, O2 in 14 patients, O3A in 17 patients, and O3B in 4 patients. An extensile lateral approach was used in 34 fractures and a different surgical technique in the remaining 5 fractures. All open procedures were closed with a two-layer approach, with use of inverted mattress sutures in the deep layer and a horizontal modification of the Allgöwer-Donati suture in the superficial layer. Two patients treated surgically experienced wound-healing problems directly associated with the calcaneal fracture that required intervention beyond the administration of oral antibiotics. Both of these wounds and fractures eventually healed. The overall wound healing complication rate was under 6%; that for O1 fractures was 0%, for O2 fractures was 7%, for O3A was 6% and for O3B was 0%.

Discussion: Open calcaneal wounds are much more problematic than closed injuries because of the increased risk of infection. Nonetheless, meticulous and diligent soft tissue care can remove much of the risk of infection in these patients. Although our results indicate that open calcaneal fractures are associated with higher rates of complication than closed fractures (less than 3%), the overall rate of less than 6% should not be taken as a contraindication to open reduction and internal fixation as the preferred method of treatment for this type of injury. Both of the infections were treated with irrigation and debridement, intravenous antibiotics, and implant removal one year after injury, and both wounds healed. In no case was calcanectomy or amputation required because of persistent superficial or deep infection or other complication.

Conclusions: Although calcaneal fractures associated with open foot wounds present a substantial challenge, meticulous soft tissue management allows these cases to be treated with the same techniques as closed fractures. Open reduction and internal fixation via the extensile lateral approach is the appropriate surgical technique because it can restore calcaneal anatomy after substantial disruption and soft tissue trauma without exposing the patient to undue risk of complications. Surgical skill and patient compliance remain critical to success. As with closed calcaneal fractures and other fractures of the weight-bearing system, anatomic reduction, stable internal fixation, atraumatic surgical technique, and early mobilization comprise the treatment regimen of choice.