Surgical Treatment and Outcomes of Calcaneal Osteomyelitis in Adults: A Systematic Review

The Concept of Treatment for Surgical Infection in the Hindfoot

Background

Chronic osteomyelitis of the calcaneus (OC) and open infected calcaneal fractures, especially when complicated by infected soft tissue defects, present significant surgical challenges. Accepted recommendations for the surgical treatment of this pathology are yet to be established.

Methods

Drawing from our experience and the consensus among experts, we have developed a concept for selecting optimal, well-known surgical approaches based on the specific pathologic presentation. This concept distinguishes 4 main forms of hindfoot infection: infected wounds, open infected fractures, OC, and their mixed forms. Patients with conditions that could confound the treatment outcomes, such as diabetes mellitus and neurotrophic diseases, were excluded from this analysis. We present a retrospective analysis of the treatment outcomes for 44 patients (4 women and 40 men) treated between 2009 and 2022 using some refined surgical techniques. Treatment success was evaluated based on the absence of disease recurrence within a 2-year follow-up, the avoidance of below-knee amputations, and the restoration of weightbearing function.

Results

The treatment results were considered through the prism of our proposed concept and according to the Cierny-Mader classification. There were 4 instances of disease recurrence, necessitating 6 additional surgeries, 2 of which (4.5% of the patient cohort) resulted in amputations. In the remaining cases, we were able to restore weightbearing function and eliminate the infection through reconstructive surgeries, employing skin grafts when necessary.

Conclusion

Surgical infections of the hindfoot area remain a significant challenge. The strategic concept we propose for surgical decision making, tailored to the specific pathology, represents a potential advancement in addressing this challenge. This framework could provide valuable guidance for orthopaedic surgeons in their clinical decision-making process.

Level of Evidence

Level IV, case series.

Addition of a Second Calcaneal Pin for Spanning Ankle External Fixation

Spanning ankle external fixation is a commonly used technique for the treatment of fractures of the lower extremity. Traditionally, a single pin is placed in the safe zone of the calcaneus to provide a point of traction for fracture reduction and stabilization. Complications include infection and pin loosening with subsequent loss of fracture reduction. We aim to highlight the benefits and techniques of adding a second calcaneal pin to reduce the likelihood of infection, pin loosening, and possible loss of fracture reduction. Using the standard medial-to-lateral placement technique, two centrally threaded Schanz pins were placed within the safe zone of the calcaneus approximately 2 cm apart and were connected by clamps and a short carbon fiber rod. The remainder of the external fixation apparatus is assembled using a standard technique after obtaining fracture reduction. There is an increased incidence of infection and pin loosening with decreased bone quality and a longer duration within an external fixator. The addition of a second calcaneal pin can be used to reduce the incidence of pin loosening and associated sequela, especially in patients with decreased bone quality, thus improving outcomes for patients undergoing spanning ankle external fixation.

Gentamicin-permeated cement to sustain mechanical support for the treatment of a chronic calcaneal abscess. A case report

INTRODUCTION AND IMPORTANCE

Chronic calcaneal osteomyelitis is a challenging condition associated with high relapse rates, requiring a multidisciplinary approach and various therapeutic options for effective management. We report a very rare case of a pyogenic osteomyelitis of the os calcis presented as a bone abscess.

CASE PRESENTATION

A diabetic male patient presented with chronic osteomyelitis of the calcaneus in the form of bone abscess with a cavity of 6*5 cm. After pus evacuation and debridement of the cavity, gentamycin-impregnated polymethylmethacrylate cement was used to locally assist in controlling the infection and to assure mechanical support. Antibiogram-based oral antibiotic was administrated for 6 weeks. At final follow-up, the patient could walk without any assistance and was able to raise his body on the operated heel, with no signs of infection.

CLINICAL DISCUSSION

This case illustrates successful conservative surgical treatment of calcaneal abscess using antibiotic-impregnated cement for mechanical support and local infection control.

CONCLUSION

Incorporating antibiotic-impregnated cement into conservative foot surgeries for deeply embedded calcaneal abscesses provides effective infection control, mechanical support, and functional preservation, leading to successful treatment outcomes.

Covering of wound infection in hip arthroplasty with local cutaneous flaps

Total hip arthroplasty is a very common procedure to treat osteoarthritis. One of the complication is the infection which occurs in about 1% of the cases. The manifestation of infection can be poor wound healing with dehiscence and exposition of bone or prosthetic components. Hip arthroplasty infections are difficult to treat. It required an associated multidisciplinary approach with infectiology, orthopedic and plastic surgeries. The study included five patients with hip wound dehiscence after total hip arthroplasty. Coverage after orthopedic surgery was provided by local cutaneous flap. These cutaneous flaps were either a deep inferior epigastric perforator flap (DIEP) or a transposition flap. The orthopedic and the plastic treatment were done at the same time. Two deep inferior epigastric flaps were performed for patients with a deep defect with bone or prosthesis exposure. Four transposition flaps were done in three patients with wound dehiscence but without direct contact with the prosthesis. Three transposition flaps were done from the abdominal wall and one from the posterior thigh. The mean follow up was 18 months, ranging from 10 to 24months. After healing, there was no recurrence of the infection. In all cases, the coverage was obtained. The prosthesis was salvage and the gait was possible. Cutaneous flaps are easy and safe to cover the hip. They are reliable flaps even in patients with multiple co-morbidities. They do not cause sequelae on the recipient site. This study is the first about cutaneous flap for covering hip defects in hip arthroplasty infections.

Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects

Background: Chronic osteomyelitis (OM) is a progressive but mostly low-grade infection of the bones. The management of this disease is highly challenging for physicians. Despite systematic treatment approaches, recurrence rates are high. Further, functional and patient-reported outcome data are lacking, especially after osseous defects are filled with bioresorbable antibiotic carriers. Objective: To assess functional and patient-reported outcome measures (PROM) following the administration of Cerament^® G or V due to corticomedullary defects in chronic OM. Methods: We conducted a retrospective study from 2015 to 2020, including all patients who received Cerament^® for the aforementioned reason. Patients were diagnosed and treated in accordance with globally valid recommendations, and corticomedullary defects were filled with Cerament^® G or V, depending on the expected germ spectrum. Patients were systematically followed up, and outcome measures were collected during outpatient clinic visits. Results: Twenty patients with Cierny and Mader type III OM were included in this study and followed up for 20.2 ± 17.2 months (95%CI 12.1–28.3). Ten of these patients needed at least one revision (2.0 ± 1.3 revisions per patient (95%CI 1.1–2.9) during the study period due to OM persistence or local wound complications. There were no statistically significant differences in functional scores or PROMs between groups. Conclusion: The use of Cerament^® G and V in chronic OM patients with corticomedullary defects appears to have good functional outcomes and satisfactory PROMs. However, the observed rate of local wound complications and the OM persistence rate may be higher when compared to previously published data.

Total calcanectomy in calcaneal osteomyelitis: An alternative to major amputation

BACKGROUND

Hindfoot ulcers associated with chronic calcaneus osteomyelitis are very difficult to manage and many patients need a limb amputation for resolution. Total calcanectomy can be a salvage procedure for these patients. The purpose of this study is to present our results of total calcanectomy.

METHODS

Retrospective analysis of six patients undergoing total calcanectomy at our institution between 2008 and 2019. Patient data and ambulatory status were analyzed.

RESULTS

In 4 of the 6 patients, infection control and wound closure was achieved with total calcanectomy with follow-up ranging from 1 to 12 years. The 4 patients maintain walking ability. Two major complications: an early death caused by a respiratory infection and a below the knee amputation due to recurrence of the foot infection.

CONCLUSION

Total calcanectomy is an useful procedure for limb salvage in foot ulcers with chronic calcaneus osteomyelitis.

Foot Wounds and the Reconstructive Ladder

Background:

Foot soft tissue coverage represents a challenge to reconstructive surgeons due to a lack of donor sites for this specialized skin. This glabrous tethered thick skin is designed to withstand weight bearing stress and is hard to replace. The limited arch of rotation of foot local flaps contributes to further difficulties. In this study, we share our experience in foot soft tissue loss coverage using techniques tailored to each wound presentation.

Methods:

This case series presents eight patients with wounds of the plantar and dorsal surfaces of the foot, heel, and ankle. Closure techniques were selected and planned based on wound presentation and comorbidity status.

Results:

Patients’ mean age at surgery was 61 years. Etiologies of wounds include trauma, frostbite, diabetic ulceration, malignancy, pressure ulcer with osteomyelitis, and necrotizing infection. Coverage techniques included split and full-thickness skin graft, medial plantar arch pinch graft, cultured epithelial autograft, Hyalomatrix wound device, EpiFix tissue matrix, pedicle flap, and free rectus flap. Complete soft tissue coverage was achieved in each case within reasonable postoperative periods, and ambulation was preserved and/or restored.

Conclusions:

Foot soft tissue reconstruction is challenging and should be planned carefully due to the required specialized skin replacement. Primary closure should be considered first and attempted if possible. Technique escalation in accordance with the reconstructive ladder should be undertaken based on wound etiology, presentation, amount and nature of tissue loss, available resources, and surgeon experience.

[A pedicled deep inferior epigastric flap to cover a hip arthroplasty infection]

The deep inferior epigastric perforator (DIEP) flap is a reliable flap mostly used in skin resurfacing after signifiant resection for sarcoma or correction contour deformities. This case is about a pedicled DIEP flap covering the trochanteric region after a total hip arthroplasty infection. A 62years old woman with a BMI at 42kg/m² presents an infected total hip arthroplasty with a cutaneous defect. The hip prosthesis is changed and covered with a pedicled DIEP flap. This original case reports the used of pedicled DIEP flap in hip coverage. This local fasciocutaneous flap covered the hip osteoarticular infection. The limb is salved and the patient can walked again. The success of this surgery is the collaboration between infectious disease specialist, orthopedic surgeon and plastic surgeon.

Cryptococcus neoformans osteomyelitis of the calcaneus: Case report and literature review

Cryptococcus neoformans is an encapsulated, yeast-like fungus that can cause a systemic mycosis, particularly in immunocompromised patients. Disseminated infections typically affect the central nervous system, and osseous lesions are infrequent. Only 5%–10% of disseminated cryptococcosis involves bones. A 69-year-old female presented pain, swelling, and a soft tissue mass in her right lateral hindfoot. Her medical history included a kidney transplant (10 years earlier) secondary to chronic disease due to IgA nephropathy. The patient underwent an excisional biopsy, surgical debridement, and secondarily negative pressure wound therapy to achieve skin closure. Biopsy revealed a rare Cryptococcus neoformans osteomyelitis of the calcaneus. The patient then received IV treatment with liposomal amphotericin B at 3 mg/kg/d for 25 days. In conclusion, we present a case of cryptococcal osteomyelitis which, although not a frequent disease, must be considered as one of the differential diagnoses of osteolytic osseous lesions in patients with chronic osteomyelitis. Cryptococcus neoformans may be a potential cause of below-knee infection, mainly in immunocompromised patients.

Gastrocnemius muscle flap with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone graft for the phase I treatment of localized osteomyelitis after tibial plateau fracture surgery

Purpose

To investigate the clinical effect of gastrocnemius muscle flaps combined with vancomycin/gentamicin-calcium sulfate combined and autologous iliac bone graft in the phase I treatment of traumatic focal osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery.

Methods

From July 2009 to January 2018, 35 patients with localized osteomyelitis (Cierny-Mader type III) who met the inclusion criteria were followed up and treated. All patients were infected after undergoing internal fracture fixation surgery. Among them, 18 cases were plate-exposed, 14 cases were due to sinus tracts, two were due to skin necrosis, and one was bone-exposed. We treated patients with several measures. All cases were then followed up. The follow-up indicators included Hospital for Special Surgery knee scores (HSS), the time of laying drainage pipe, bone healing time, infection control rate, and the incidence of nonunion and other complications.

Results

All patients were followed up for 24–60 months. None of them underwent amputation. For repairing soft tissue defects, 17 cases were covered with a muscle flap using the medial head of gastrocnemius alone, 15 cases were treated with the lateral head of gastrocnemius muscle, and three cases were covered with the combination of the two heads. Compared to the preoperative score, we found that the average HSS improved at the 1-year and 2-year follow-up (54 vs. 86 vs. 87).

Conclusion

Using a gastrocnemius muscle flap combined with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone was an effective method for the phase I treatment of osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery. In the primary treatment of focal traumatic osteomyelitis, it can decrease the treatment time, number of surgeries, pain of patients, time of bone healing, postoperative exudation, and infection recurrence rate and increase the healing bone’s strength.

MRI of the Achilles tendon - a comprehensive pictorial review. Part two

•

The abnormalities on MRI should be correlated with the clinical findings.

•

Higher signal of the Achilles tendon is a common postoperative finding.

•

The fluid signal within the Achilles tendon graft indicates a rupture.

•

Postoperative complications of Haglund’s syndrome should be assessed on MRI.

•

Elongation of the Achilles tendon is seen after surgical or conservative treatment.

The most common disorder affecting the Achilles tendon is midportion tendinopathy. A focal fluid signal indicates microtears, which may progress to partial and complete rupture. Assessment of Achilles tendon healing should be based on tendon morphology and tension rather than structural signal. After nonoperative management or surgical repair of the Achilles tendon, areas of fluid signal is pathologic because it indicates re-rupture. A higher signal in the postoperative Achilles tendon is a common finding and is present for a prolonged period following surgical intervention and needs to be interpreted alongside the clinical appearance.

Single-stage debridement with implantation of antibiotic-loaded calcium sulphate in 34 cases of localized calcaneal osteomyelitis

Background and purpose - The successful eradication of calcaneus infection with limb salvage remains a challenge. We describe the outcomes of cortical bone windowing followed by eggshell-like debridement and implantation of antibiotic-loaded calcium sulphate (CS) for localized (Cierny-Mader type III) calcaneal osteomyelitis (CO).Patients and methods - We report a retrospective study of 34 patients. Infection followed trauma or orthopedic surgery in 30 patients and hematogenous spread in 4 patients. 31 patients had a sinus tract, accompanied by a soft tissue defect in 3 patients. All patients received cortical bone windowing, debridement, multiple sampling, local implantation of vancomycin- and gentamicin-loaded CS, skin closure or flap coverage, and culture-specific systematic antibiotic treatment in a single-stage procedure. Patients were followed up for a median of 26 months.Results - Infection was eradicated in 29 patients after the single-stage surgery, and all of the 5 recurrent infections were cleared by repeated surgery without amputation. Other adverse events included 11 patients with aseptic wound leakage and 1 unrelated death. Compared with those before surgery, the median postoperative scores of the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale (65 vs. 86 vs. 89) and the visual analog scale (VAS) for pain (6 vs. 3 vs. 1) improved at the 1-year and 2-year follow-up.Interpretation - This single-stage protocol, cortical bone windowing, and eggshell-like debridement combined with local implantation of antibiotic-loaded CS is effective in treating type III CO. However, the incidence of aseptic wound leakage is high.