Session II - Foot and Ankle

Early Complications of Operative Treatment of Calcaneus Fractures

Jason W. Folk, MD; Adam J. Starr, MD; John S. Early, MD, University of Texas Southwestern Medical Center, Dallas, TX

Introduction: Operative stabilization of calcaneus fractures has become more common. Although surgical results have been good, a fairly high prevalence of wound complications has been reported. The purpose of this study was to discover any associations between preoperative variables and the occurrence of wound complications.

Materials and Methods: The records of all patients who underwent open reduction and internal fixation of a calcaneus fracture at our institution between July 1992 and July 1996 were reviewed. The patients' age, sex, pre-existing medical conditions, social history, mechanism of injury, and other injuries were recorded. Note was made of the status of the soft tissue injury, if any. The time from injury to surgical stabilization was recorded, as well as the duration of surgery, type of incision used, use of preoperative antibiotics, and type of wound closure. Times to wound and fracture healing were noted. The patients' records were reviewed for wound complications including infection, dehiscence, loss of reduction, and osteomyelitis. Statistical analysis was performed to determine which preoperative variables most reliably predicted the occurrence of a wound complication.

Results: Records from July 1992 to July 1996 revealed 144 patients who underwent operative stabilization of a calcaneus fracture. The average age was 35. Seven patients were diabetics. Ninety-one of the patients smoked cigarrettes. Fourteen of the fractures were open. All 14 patients with open fractures were treated with intravenous antibiotics and an initial irrigation and debridement (I & D). Repeat I & D's were done every 48 hours until the open wound was clean and could be closed. The average time elapsed from injury to surgery was 8 days. A standard, "L" -shaped lateral approach to the calcaneus was used in each case. Stabilization was achieved using standard techniques, with plates and screws. Autogenous bone graft was used in 4 cases, and hydroxyapatite crystals were used in 20 cases. In all cases, a 2-layer wound closure was used. All patients were placed in a short-leg plaster cast, and kept non-weight bearing for 3 months. Forty-two patients (29%) developed some form of wound complication. Thirty five (24%) of these required a surgical wound debridement. Out of this group of 35 patients managed surgically, 19 required hardware removal. Nine eventually required free myocutaneous flap coverage of the wound. Two went on to amputations. The average time to fracture union was 117 days. Logistic regression analysis identified diabetes (p=0.02), smoking (p=0.047), and open fractures (p<0.0001) as risk factors for a wound complication. Age and delay in surgical treatment were not associated with wound complications. The presence of more than one risk factor increased the risk of a wound complication requiring surgery. Patients with one risk factor had approximately a 30% chance of a complication requiring surgery, while patients with two risk factors had approximately a 60% chance. Those with three risk factors had approximately a 90% chance of developing a wound complication requiring surgery The relative severity of complications also increased with an increasing number of risk factors.

Discussion: While surgical stabilization of calcaneus fractures can yield excellent results, the rate of wound complications is high in certain patient groups. Smoking, diabetes, and open fractures all increase the risk of a significant wound complication. Cumulative risk factors increase the likelihood and severity of wound complications. Prior to surgical treatment of calcaneus fractures, patients who have the risk factors identified in this study should be counseled as to the possible complications which may arise after surgery. In patients with multiple risk factors, serious consideration should be given to non-surgical management.