To The Editor:
We wish to congratulate Dr. Heier and colleagues for their contribution,
"Open Fractures of the Calcaneus: Soft-Tissue Injury Determines
Outcome"
(2003;85:2276-82). Their
article, detailing the management of open calcaneal fractures, provides
concise and much needed guidance on a daunting orthopaedic problem. This
injury has been largely ignored in the orthopaedic literature.
After reviewing the article, we were surprised by the report of a deep
infection in nearly one in every five such injuries. Three recent studies have
described substantially lower rates of infection1-3. Obviously,
this difference may result from multiple variables, such as the number of
wound débridements or the adequacy of débridement, antibiotic
selection, or time to stabilization.
Heier et al. recommend a delay of definitive fixation until the wound is
clean and soft-tissue swelling is minimal. In their series, fixation was
undertaken at an average of 7.3 days after presentation at the hospital and
the wound was "covered" at 10.6 days. This implies that, in some
instances, fixation was performed in the presence of an open, granulating
wound. In our experience, we have found that osteosynthesis should be delayed
until the traumatic wound is covered. In general, this scenario is not
typically present before the tenth day. Of course, each injury should be
judged individually—no rigid time frames should substitute for sound
clinical judgment. Heier et al. conclude that, as a result of their study,
changes have been made in their treatment protocols. We would appreciate it if
they would share their comments on these modifications.
Again, the authors deserve congratulations on their concise, timely
monograph, which will undoubtedly serve as a foundation for the evaluation and
management of these difficult open hindfoot injuries.
We appreciate the comments from Drs. Lawrence and Grau regarding our study
of patients with an open calcaneal fracture. While there have been recent
articles on open calcaneal fractures, most have had a somewhat different set
of injury patterns. All of our patients were treated at a major level-I trauma
center. Additionally, all of the patients were treated by experienced
orthopaedic trauma surgeons with extensive training in dealing with
débridement techniques in open fractures. While Drs. Lawrence and Grau
noted that we found a deep infection in one of every five patients, we believe
that one should resist the temptation to combine simple wounds with those that
are complex (the proverbial apples and oranges), otherwise there would be no
need for classification systems.
The purpose of our research was to evaluate which subsets of patients did
poorly. Many of our patients had high-energy wounds as noted by the high
percentage of type-III fractures (60%). We identified an increased infection
rate and poor outcome in patients with penetrating injuries, lateral and
extensive wounds, and type-III open fractures. Because of our poor results
with use of early internal fixation in these injuries, we changed our
protocol, subsequently improving our outcomes. While we agree with Dr.
Lawrence and Dr. Grau's statement that osteosynthesis should be delayed until
the traumatic wound is covered, nowhere in our manuscript did we advocate
leaving exposed implants in an open granulating wound. A review of our data
reveals that, other than an occasional lag screw inserted for an unstable
fragment, all implants were placed after soft-tissue coverage was
performed.
Our recommended treatment protocol is presented at the conclusion of the
Discussion section. All wounds are still débrided initially and as
frequently as needed until they are clean. Type-I and II open fractures,
especially with medial wounds, can still be treated in a manner similar to
that for closed fractures, with the initial débridement and a delayed
open reduction and internal fixation at two to three weeks. Importantly, for
the more severe fractures, which are very different injuries, we recommend
either external fixation or limited lag screw fixation, with attention to the
state of the soft tissues.
The conclusion of our study must remain crystal clear: soft-tissue injury
determines outcome and, in the treatment of open calcaneal fractures,
soft-tissue damage together with the location and pattern of the wound should
be the surgeon's primary concern. Thank you for allowing us to expound on our
thesis.
Aldridge JM 3rd, Easley M, Nunley
JA. Open calcaneal fractures: results of operative treatment. J
Orthop Trauma.2004;18:
7-11.187
2004
[CrossRef]
Lawrence SJ, Grau GF. Evaluation
and treatment of open calcaneal fractures: a retrospective analysis.
Orthopedics.
2003;26:
621-6.26621
2003
[PubMed]
Benirschke SK, Kramer PA. Wound
healing complications in closed and open calcaneal fractures. J
Orthop Trauma.2004;18;
1-6.181
2004
[CrossRef]