Open fractures of the calcaneus: a review of treatment and outcome

OBJECTIVES: The aim of this study was to evaluate the functional and clinical outcome of patients with open calcaneus fractures and to determine what factors were associated with these outcomes. DESIGN: Retrospective review of 2 level 1 prospective databases. SETTING/PATIENTS/PARTICIPANTS: All patients admitted with an open calcaneal fracture to 2 level 1 trauma units between January 1, 1987 and April 1, 1996 were identified. Data regarding demographics, injury characteristics, and treatment and complications were documented using a standardized data abstraction form. Radiographs were reviewed to document the fracture type according to Essex-Lopresti. For those patients who had computed tomography scans available, the Sanders et al classification was applied and documented. Patients were contacted and asked to return for follow-up evaluation including the American Orthopaedic Foot and Ankle Society ankle/hindfoot score, the Maryland Foot Score, and the Short Form 36 (SF-36). For patients not willing to return for examination, the questionnaires were completed over the telephone, and the objective scoring components were assigned to lowest score possible. RESULTS: Of 177 calcaneal fractures in patients treated as inpatients during the study period, we identified 30 open fractures in 29 patients. Twenty-seven patients had associated injuries. Two patients underwent amputation within 24 hours due to severe crush injury. Following urgent debridement, soft tissues were closed primarily (22 fractures) or with split thickness skin grafting (4 fractures) and free flap coverage (2 fractures); temporary spanning external fixation was used in 3 patients. Definitive fracture care was at the discretion of the treating surgeon and consisted of closed reduction without fixation (10 fractures), open reduction and bone grafting (1 fracture), minimal Kirschner wire (K wire) fixation (12 fractures), and formal lateral open reduction and internal fixation (5 fractures). There were no late amputations. There were no deep infections. Twenty-one of the 28 patients with salvaged limbs returned for follow-up evaluation, and 3 additional patients agreed to be interviewed by telephone. The average time to follow-up was 49 months with a range of 25 to 106 months. The overall American Orthopaedic Foot and Ankle Society ankle/hindfoot scores and Maryland Foot Scores were fair to poor. The average SF-36 results were within 1 standard deviation of published Canadian norms. Worse function was observed in patients with plantar wounds. Severely comminuted fractures had the worst function, whereas single joint depression injuries had the best functional outcome. CONCLUSION: Infection is uncommon following open calcaneus fractures treated with aggressive soft tissue management. Patients with plantar wounds and comminuted fractures are expected to have particularly poor functional results.