Comparison of Bone Preserving and Radical Surgical Treatment in 32 Cases of Calcaneal Osteomyelitis

Abstract

Introduction. Radical procedures like calcanectomy and amputation performed for calcaneal osteomyelitis are regarded as effective in eradication of infection even though potentially functionally disabling. Bone sparing procedures offer better functional result at the expense of potentially worse infection control. The aim of the study has been to assess the influence of the surgical radicalism as much as the extent of bone infection on the final outcome in the surgical therapy of chronic calcaneal osteomyelitis (CO). Material and method. 32 patients with chronic CO have comprised the group under study: 8 with superficial type, 12 localised type and 12 with diffuse type according to Cierny-Mader classification. The aim of the treatment was to heal infection, preserve the heel shape and achieve good skin coverage over the calcaneus. The therapy consisted of 9 debridement surgeries with or without flaps, 8 drilling-operations of the calcaneus with application of collagen-gentamicin-sponge in bore holes, 15 partial and 2 total calcanectomies, and 4 below-the knee amputations. Results. The healing of infection and wound has been achieved after 7 of 9 debridements, 6 of 8 drilling-operations, 13 of 15 partial and all total calcanectomies. Conclusion. Bone preserving operations in chronic calcaneal osteomyelitis provided inferior infection control (76,47% vs 88,24%) and worse patient satisfaction (88,24% vs 100%) and almost camparable ambulation (100% vs 93,33%). Drilling of the calcaneus with application of collagen sponge containing gentamicin performed in chronic diffuse calcaneal osteomyelitis seems to offer a viable alternative to partial or radical calcanectomy. Level of evidence: V.

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

“…Of these, eight patients (25%) were treated with a drilling operation combined with insertion of collagen-gentamicin sponges, nine (28%) with debridement with or without fasciocutaneous flap, and 15 (47%) with a partial calcanectomy. Infection control and wound healing was achieved in 75% (n=6/8), 78% (n=7/9), and 73% (n=11/15), respectively 14. Patients treated with bone preservation showed lower infection control rates as well as lower patient satisfaction.…”

“…Nine studies described treatment in a single stage 9,10,13,14,16,18,21,23,24. Only 2 papers describe 2 stage procedures 11,20.…”

“…In the study by Babiak et al (2016), eight (25%) of 32 patients were treated with collagen-gentamicin sponges (CGS) as a local antimicrobial carrier after debridement and drilling of calcaneum 14. Two (25%) of these patients had a recurrence of infection and were finally treated with BKA, neither being able to walk after amputation.…”

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

“…Such changes might be associated with absolute infection eradication as well as preservation of calcaneus integrity. In a recent study, Babiak et al (2016) compared the efficacy between bone-preserving strategies (debridement or drilling and collagen-gentamicin sponge) and radical surgical protocols (partial or total calcanec- ogous bone graft surgery, whereas in our study we only performed 1-stage surgery, facilitated by CS being totally biodegradable and not requiring a second surgery. It should be noted that, in this study, we included only non-diabetic foot patients, which may be the primary reason for our much lower amputation rate compared with those of previous studies.…”

“…Of these, 10 were managed with wound dressing and 1 underwent a secondary debridement surgery to remove the residual CS; all of these patients recovered well. In addition, 1 patient died of a cause unrelated to amputation following limb-saving surgery in CO patients ranged from 4% to 20% (Baumhauer et al 1998, Schade 2012, Van Riet et al 2012, Walsh and Yates 2013, Babiak et al 2016. Even a recent study (Waibel et al 2019) showed that 50% of the CO patients had to undergo secondary below-knee amputation even if they had already received total calcanectomy.…”