Single-stage, combined, ortho-plastics treatment of severe calcaneal osteomyelitis with large soft tissue defects – long term follow up

B. Down, S.-T. Jerry Tsang, A. Hotchen, J. Ferguson, D. Stubbs, C. Loizou, A. Ramsden, M. McNally, A. Kendal

Background: Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below knee amputation; particularly in cases of severe soft tissue destruction. Aim: Assess the outcomes of combined ortho-plastics treatment of complex calcaneal osteomyelitis.

Methods: A retrospective review was performed of all patients who underwent combined single stage ortho-plastics treatment of calcaneal osteomyelitis (2008- 2022). Primary outcome measures were osteomyelitis recurrence and BKA. Secondary outcome measures included flap failure, operative time, complications, length of stay.

Results: 33 patients (16 female, 17 male, mean age = 54.4 years) underwent combined ortho-plastics surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (s.d. 24.3). 20 received a local flap, 13 received a free flap. Fracture-related infection (39%) and diabetic ulceration (33%) were the commonest causes. 54% of patients had already undergone at least one operation elsewhere. There were seven cases of recurrent osteomyelitis (21%); all in the local flap group. One patient required a BKA (3%). Recurrence was associated with increased mortality risk (OR 18.8 (95% CI 1.5-227.8), p=0.004) and reduced likelihood of walking independently (OR 0.14 (95% CI 0.02-0.86), p=0.042). Local flap reconstruction (OR 15 (95% CI 0.8-289.6), p=0.027) and peripheral vascular disease (OR 39.7 (95% CI 1.7- 905.6), p=0.006) were associated with increased recurrence risk. Free flap reconstruction took significantly longer intra-operatively than local flaps (443 vs 174 minutes, p<0.001), but without significant differences in length of stay or frequency of out-patient appointments.

Conclusion: Single stage ortho-plastic management was associated with 79% eradication of infection and 3% amputation in this complex and co-morbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. Whilst good outcomes can be achieved, this treatment requires high levels of in-patient and out-patient care.