Techniques in Foot & Ankle Surgery 7(1):52–55, 2008 Ó 2008 Lippincott Williams & Wilkins, Philadelphia

| T E C H N I Q U E |

Total Calcanectomy for the Treatment

of Calcaneal Osteomyelitis
Gwynne Bragdon, MD
Brown University
Providence, RI

Judith Baumhauer, MD
Department of Orthopaedic Surgery
Division of Foot and Ankle Surgery
Strong Foot and Ankle Institute
University of Rochester Medical School
Rochester, NY

| ABSTRACT tion, total calcanectomy as a treatment for large heel

ulcers with or without osteomyelitis has several advan-
Total calcanectomy is a successful alternative to below-
knee amputation in patients with extensive chronic oste- tages: preservation of the heel pad for weight bearing, de-
creased oxygen demand, decreased energy costs,8 and a
omyelitis of the calcaneus or for primary wound closure
simple orthosis with or without a double upright brace
of large plantar heel ulcers. Most patients with chronic
used postoperatively. The purpose of this article was to
osteomyelitis of the calcaneus have underlying medical
present the technique utilized in total calcanectomy.
comorbidities, primarily diabetes and peripheral vascular
disease. By utilizing a foot salvage procedure over a
transtibial amputation, the patient’s energy and oxygen
| INDICATIONS AND
CONTRAINDICATIONS
demands are decreased. This becomes significant in
patients who have involvement of both lower extremi- Patients who are to undergo a total calcanectomy have to
ties. Total calcanectomy is an excellent alternative for have a diagnosis of extensive osteomyelitis of the calca-
the eradication of infection, primary wound closure, neus or a large heel ulcer greater than 50% of the heel
and preservation of functional ambulation. pad (Fig. 1). The diagnosis is often made by magnetic
Keywords: calcanectomy, osteomyelitis, heel ulcer, limb resonance imaging.
salvage, wound care The patients also must have an adequate vascular
supply for wound healing to occur. A minimal accept-
| HISTORICAL PERSPECTIVE able value for ankle-brachial indices is 0.45. A similar
value for toe pressures was determined to be 0.45.
Osteomyelitis of the calcaneus and large plantar heel
Some patients who may be appropriate candidates for
ulcers are difficult management problems. Treatment is
total calcanectomy based on the extensive calcaneal in-
directed toward the eradication of infected bone, primary
volvement may need to undergo a vascular bypass sur-
wound closure, and preservation of the weight-bearing
gery before total calcanectomy.
function of the foot. Patients who develop chronic oste-
Nutritional parameters play a role in soft-tissue heal-
omyelitis of the calcaneus often have other significant
ing. Nutritional parameters such as total albumin greater
medical problems such as diabetes mellitus and peripher-
than 3.5 g/dL, white blood cell count greater than 1500
al vascular disease. In a small number of reported series,
cells/mL, and total protein greater than 6.0 g/dL are in-
partial calcanectomy has been used successfully in cases
dicative of healing. Although renal failure also results in
of infection with limited calcaneal involvement.1Y7 With
low serum protein values, dialysis patients are afflicted
failure of a partial resection, persistent open heel wound,
with heel ulcers, and limb salvage through calcanectomy
or the finding of total calcaneal involvement, below-knee
has been a successful option in these patients.9
amputation has been indicated.1,4 In this patient popula-
Address correspondence and reprint requests to Judith Baumhauer, | PREOPERATIVE PLANNING
MD, Deparment of Orthopaedic Surgery, University of Rochester
School of Medicine, 601 Elmwood Ave, Box 665, Rochester, NY 1. Foot radiographsVanteroposterior, lateral, oblique,
14642. E-mail: [email protected]. and Harris view.

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 Calcanectomy for Calcaneal Osteomyelitis

FIGURE 1. An example of a large plantar heel ulcer commonly seen in patients with diabetes mellitus.

2. Magnetic resonance imaging to delineate the extent of with its subsequent skin attachments are closed in a
osteomyelitis. single layer. The incision is closed primarily (Fig. 5).
3. Noninvasive vascular studiesVtoe pressures, ankle/
brachial index, wave forms. | RESULTS
Eight patients underwent total calcanectomy for treat-
| TECHNIQUE ment of chronic osteomyelitis. In all 8 cases, the
A modified Gaenslen ‘‘heel splitting’’ incision is used. wound was closed primarily. A rectus free flap was
The modification included a curvilinear incision begin- used for soft-tissue coverage in one patient who had pre-
ning over the heel cord and extending either medial or sented with a traumatic avulsion of the heel pad and os-
lateral to completely ellipse the ulcer or sinus tract teomyelitis. One patient had persistent wound drainage
(Fig. 2). The incision is carried straight to bone to and developed signs suggestive of infection 2 weeks post-
avoid the development of devascularized soft-tissue operatively. The patient was found to have an elevated
flaps. The Achilles tendon is divided longitudinally in white blood cell count, and although the wound looked
an effort to maintain continuity with the distal plantar benign, the decision was made to return to the operating
tissues to prevent excessive dorsiflexion of the ankle room for irrigation and debridement. A second-look pro-
and provide active ankle plantar flexion. cedure occurred 3 days later, and cultures from the oper-
Beginning with the posterior tuberosity of the calca- ating room showed no growth. During the next 8 months,
neus and working circumferentially, the calcaneus is this patient was managed with total contact casting to
released from its soft-tissue attachments and excised promote wound healing. This patient developed an
(Fig. 3). Care is taken to avoid injury to the neurovascu- ulcer and eventual osteomyelitis of the distal one third
lar bundle medially as the site of the sustentaculum tali is of the tibia. She underwent below-knee amputation at
approached. After removal of the calcaneus, the wound 1 year after calcanectomy.
is inspected for necrotic or infected soft tissue (Fig. 4). Early complications included 2 areas of superficial
This tissue is removed. Cultures are sent intraoperatively wound necrosis, each less than 4 cm in size. One case
from the calcaneus and surrounding soft tissue. The was treated successfully with dressing changes, whereas
remaining Achilles tendon and plantar fascia soft tissue the other required a limited debridement and split-thickness

FIGURE 2. The ulcer is completely excised.

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 Bragdon and Baumhauer

FIGURE 3. Starting with the posterior tuberosity, the calcaneus is released from its soft-tissue attachments and excised.

skin graft. Both wounds healed well, and the patients pro- loss of ambulation attributed to the calcanectomy alone
gressed to physical therapy. is difficult to ascertain. One patient decreased 2 func-
Talonavicular subluxation was a late complication tional levels because of weakness and balance difficulties
from total calcanectomy in 1 case. This patient underwent after calcanectomy.
a talonavicular arthrodesis 3 months after calcanectomy
and developed a nonunion treated with bracing. | POSTOPERATIVE MANAGEMENT
Using a modified ambulatory grading scale accord-
Postoperative broad-spectrum antibiotics are used for a
ing to Volpicelli et al,10 4 of the 8 patients maintained
variable period based on consultation with infectious dis-
the same level of ambulation assessed before the devel- ease. The antibiotic duration is determined by the culture
opment of osteomyelitis and after calcanectomy. Three
results and the clinical impression of the wound and soft
patients used a heel containment orthosis and extra-
tissues. The usual course is for 3 weeks.
depth shoe. The decision for an ankle-foot orthosis
The patients required a heel containment orthosis post-
(AFO) was a case-by-case basis. One patient required
operatively. A heel containment orthosis is a custom-
an AFO because of a concurrent transmetatarsal amputa-
molded insert of Plastazote, fiberglass, and a viscoelastic
tion, whereas 2 other cases required an AFO for lack of
polymer, which is formed around the heel. It was designed
stability with heel containment orthosis alone. The final
to contain the soft tissue of the heel, reduce shear forces,
case had undergone below-knee amputation as discussed redistribute weight-bearing load, and accommodate for
previously. One patient decreased 1 level of ambulation
soft-tissue deficits on the heel.11 The heel containment or-
after a long duration of nonYweight bearing with delayed
thosis is incorporated into an ankle-foot orthosis or used
healing and skin grafting. A second patient decreased 1
alone in an extra-depth shoe. The decision for the need
functional level of ambulation believed to be related to
of an AFO was determined by the patients preoperative
an ipsilateral transmetatarsal amputation and contralateral
ambulatory status and need for walking aides.
below-knee amputation. In this patient, the functional
Postoperatively, the patients are placed nonYweight
bearing in a cast in neutral position until the wounds are

FIGURE 4. The wound is inspected for necrotic tissue

once the calcaneus is excised. FIGURE 5. The wound is then closed primarily.

54 Techniques in Foot & Ankle Surgery

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 Calcanectomy for Calcaneal Osteomyelitis

healed. After wound healing, the patients can begin | REFERENCES

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| COMPLICATIONS
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