Risk Factors for Infection and Amputation Following Open, Combat-Related Calcaneal Fractures

Abstract

High-energy open calcaneal fractures are severe injuries complicated by high rates of infection, uncertain functional outcomes, and frequent need for later amputation. We conducted a retrospective review of 102 consecutive combat-related open calcaneal fractures. Patient demographics, injury mechanisms, fracture and wound characteristics, associated fractures, and methods of fracture fixation were reviewed to determine risk factors for eventual amputation or infection. Eighty-nine patients, with a mean age of twenty-six years, sustained 102 open calcaneal fractures (thirteen bilateral). After a mean follow-up of four years (range, five to ninety-two months), 42% (forty-three limbs) underwent amputation. A delayed amputation (more than twelve weeks from the time of injury) was performed in 15% (fifteen) of 102 open calcaneal fractures. In a multivariate Cox proportional-hazards survival model with time to amputation as the end point, the blast mechanism of injury, plantar wound location, larger size of open wound (in square centimeters), and escalating Gustilo and Anderson classification types (p < 0.05 for all) were predictive of eventual amputation. At the time of the final follow-up, patients who had undergone amputation had lower visual analogue scale scores for pain (2.1 compared with 4.0; p < 0.0001) and higher Tegner activity levels (5.4 compared with 3.5; p < 0.0001) than limb salvage patients. Lower-extremity amputation following open calcaneal fractures is predicted by the injury mechanism, wound location and size, and open fracture type and severity. After short-term follow-up, patients with open calcaneal fractures eventually requiring amputation exhibit improved pain and activity levels compared with patients with continued, ostensibly successful limb salvage.