Staged treatment of open calcaneal fractures with medial wounds

Abstract

Objective To evaluate clinical outcomes of staged treatment of open calcaneal fractures with medial wounds.Methods Between February 2007 and July 2010,23 patients with open calcaneal fractures with medial wound (Gustilo type Ⅱ and Ⅲ A) were treated and fully followed up in our department.They were 16 men and 7 women,aged from 39 to 56 years (average,43.3 years).The left foot was affected in 9 cases and the right in 14.By the Sanders classification,there were 11 cases of type Ⅱ and 12 ones of type Ⅲ.By the Gustilo's classification,the open wounds were type Ⅱ in 11 cases and type ⅢA in 12 ones.The patients were treated in a staged fashion.Emergent debridement,irrigation and antibiotic prophylaxis were carried out as soon as possible.During the debridement,the height,length and axial alignment of the calcaneus were restored through the medial wound before temporary fixation with percutaneous Kirschner wires.Unstable wounds of Gustilo type ⅢA were covered with vacuum sealed drainage and managed with antibiotic prophylaxis and repeated debridement until the wounds grew stable.At the second stage,definitive open reduction and internal fixation were performed through the extensile lateral approach when soft tissues were amenable for surgery.The patients were followed up regularly with clinical and radiological examinations.The American Orthopaedic Foot and Ankle Society (AOFAS) score for hindfoot was recorded at the final follow-up for every patient.Results On average,the primary debridement was conducted at 6.8 hours (from 3 to 36 hours) after the injury.The necessary debridements averaged 2.6 times (from 1 to 4 times).The definitiveopen reduction and internal fixation were performed at an average of 10.9 days (from 7 to 21 days) after the injury.The mean follow-up was 23.6 months (from 19 to 32 months).All the wounds healed without infection or necrosis except for 2 wounds that were healed later after change of dressing for superficial infection.The final AOFAS score for hindfoot averaged 82.1 points (from 77 to 89 points),indicating the range of motion of the affected subtalar joint was somewhat limited compared with the healthy side in all the patients.Conclusions For open calcaneal fracture with medial wound,fairly good clinical outcomes can result from staged treatment if there is no obvious soft tissue defect.The emergency management should include not only thorough debridement but also reduction and provisional fixation of the fracture to restore the height,length and axial alignment of the calcaneus. Key words: Calcaneus; Fractures, open; Fracture fixation, internal; Staged treatment