Session VII - Foot & Ankle

The Natural History and Treatment of Open Calcaneal Fractures

Keith A. Heier, MD, Dallas, TX; Anthony F. Infante, DO; Arthur K. Walling, MD; Roy W. Sanders, MD, Florida Orthopaedic Institute, Tampa, FL

Hypothesis: The purpose of this study is to determine the incidence and natural history of open calcaneal fractures from a large level one trauma center. A protocol was developed and applied to all patients with open calcaneal fractures. Our hypothesis was that aggressive debridement and fracture stabilization would minimize the rate of soft tissue infection and subsequent calcaneal osteomyelitis.

Methods: Between January 1, 1989 and June 30, 1997, 503 calcaneal fractures in 463 patients were treated at our institution; 43 fractures in 42 patients were open (8.5%). Thirty-four fractures were intra-articular and 9 fractures were extra-articular. Thirty-two patients were available for follow-up interview and radiographs with at least two year follow-up (78%). Open fractures were graded according to the classification of Gustillo et al. In our study, the fractures were classified as follows: type I (9), type II (8), type IIIA (12), type IIIB (13), and type IIIC (1). Pre-operative CT scans were obtained for all patients and the intra-articular calcaneal fractures were classified according to the CT classification of Sanders et al.: type 1 (2), type 2 (5), type 3 (9), and type 4 (18).Clinical evaluation was assessed via multiple outcome scores: AOFAS hindfoot score, Creighton-Nebraska calcaneal score, and Maryland foot score. Radiographic evaluation was assessed with 3 views of the calcaneus. The following parameters were measured: fracture healing, Bohler's angle, and the angle of Gissane. Degenerative changes were also measured in the adjacent joints to the calcaneus. All fractures were treated according to protocol which included: a) immediate intravenous antibiotic administration based on wound type in the emergency room, b) irrigation and debridement in the operating room with at least 9 liters of normal saline, c) temporary wound coverage with Epigard as needed, and d) stabilization of the limb by external fixation or bulky padded splint. Definitive fixation, if needed, was performed after the wound was deemed clean, and soft tissue swelling was minimal.

Results: Forty-three open calcaneal fractures were treated over the 8-year study period. Medical records were reviewed for all patients, and 33 of 42 patients (79%) returned for exam and radiographs with an average follow up of 55 months (range 24-121). Clinical evaluation was assessed via multiple outcome grading systems. The average AOFAS hindfoot score was 71. The average Creighton-Nebraska score was 64. The average Maryland foot score was 70. Patients with a BKA or AKA were not included in these scores since they couldn't adequately answer most questions. There were nine patients with type I open fractures. Seven of these patients had ORIF with no major complications and good to excellent overall results. There were eight type II open fractures. Three patients had internal fixation, and two of these patients developed an infection: superficial (1), osteomyelitis (1). One other patient with no fixation developed a deep infection. Thus, there were three infections in 8 patients (38%) with type II open fractures. There were 12 type IIIA open fractures. There was 1 superficial infection, 1 deep infection, and 1 case of osteomyelitis in these 12 patients (25%). There were 13 type IIIB open fractures. There was a high infection rate in these patients: superficial (2), deep (2), and osteomyelitis (6). The infection rate for type 3B fractures was 77%, with 6 of 13 patients developing osteomyelitis (46%). Forty-six percent of patients with type IIIB open fractures ended up with an amputation. Osteomyelitis developed in 19% (8) of open calcaneus fractures, and 28% (7) of type III open fractures. The overall infection rate was 37% (15) for all of the fractures, and 48% (12) when only the type III open fractures were considered.

Discussion: While the use of open reduction and internal fixation for the treatment of long bones with open fractures has been supported by multiple authors through many well designed studies, no such studies exist for the treatment of open calcaneal fractures. Reports of the treatment of calcaneal fractures include a few cases of open fractures, but their numbers are small, and they are not able to separate their results by location of wound, severity of soft tissue disruption, calcaneal fracture type, and definitive treatment . The results of this study show that open calcaneal fractures need to be treated differently than most other open fractures. These fractures need multiple surgical debridements and early soft tissue coverage when the wound is clean. The type I open fractures, especially the medial ones, can be treated with ORIF when the soft tissue swelling has resolved. The type III open fractures, notably the type IIIB, require extensive debridement and usually flap coverage. Internal fixation should be avoided in this subgroup due to the high rate of osteomyelitis and subsequent amputation.

Conclusion: Open calcaneus fractures are devastating injuries with high complication rates. Type 1 open medial fractures can be safely treated with ORIF. However, type IIIB open fractures are associated with soft tissue loss and bone infection and patients should be warned that amputation may be the only salvage procedure available. Early internal fixation must be avoided in this subgroup to avoid catastrophic results.