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