0198-0211/98/1912-0849$03.

00/0
FOOT & ANKLE INTERNATIONAL
Copyright © 1998 by the American Orthopaedic Foot and Ankle Society, Inc.

Total Calcanectomy for the Treatment of Chronic Calcaneal Osteomyelitis

Judith F. Baumhauer, M.D.,. Carlos J. Fraga, MD.,t John S. Gould, MD.,:j: and Jeffrey E. Johnson, M.D.§
Rochester, New York, Bayamon, Puerto Rico, Charlottesville, Virginia, Birmingham, Alabama, and St. Louis, Missouri

ABSTRACT tional ambulation level, and one patient decreased two

The purpose of this study is to present the surgical and levels. One patient underwent below-knee amputation
functional results of a total calcanectomy procedure as a and is currently ambulatory with a prothesis. Assess-
foot salvage alternative in patients with extensive ment of ankle strength and range of motion of the sur-
chronic osteomyelitis of the calcaneus. A retrospective gical limb demonstrated decreased dorsiflexion and
review identified eight patients treated with a total cal- plantarflexion strength and a variable range of motion
canectomy for a chronic non healing plantar ulcer of the compared to the contralateral limb. Total calcanectomy
heel and osteomyelitis of the calcaneus. The primary is an alternative procedure to transtibial amputation in
diagnosis was insulin-dependent diabetes mellitus (six patients with chronic osteomyelitis of the calcaneus.
patients), pneumococcal septicemia (one patient), and Eradication of infection and preservation of the func-
an open calcaneal fracture (one patient). The average tional ambulation is achieved.
age of the patients was 52 years. Prior procedures in-
cluded irrigation and debridement of the heel ulcer (sev- INTRODUCTION
en patients), partial calcanectomy (three patients), and
split thickness skin grafting (two patients). The vascular Osteomyelitis of the calcaneus is a difficult manage-
status of each limb was assessed preoperatively. Distal ment problem. Treatment is directed toward the erad-
extremity bypass surgery was performed on two pa- ication of infected bone with preservation of the
tients before calcanectomy. Osteomyelitis of the calca- weightbearing function of the foot. Patients who de-
neus was diagnosed by magnetic resonance imaging velop chronic osteomyelitis of the calcaneus often
alone in three patients, and by technetium/indium scans
have other significant medical problems such as insu-
and magnetic resonance imaging in five patients. The
lin-dependent diabetes mellitus and/or peripheral vas-
average follow-up duration was 27.3 months (range,
6-57 months). Infection at the plantar heel was con- cular disease. In a small number of reported series,
trolled in all patients. In all eight cases the incisions were partial calcanectomy has been used successfully in
closed primarily. During a prolonged time of total con- cases of infection with limited calcaneal involve-
tact casting to facilitate wound healing, one patient ment. 6,10,16,17,23-25 With failure of a partial resection or
developed an anterior tibial ulcer that progressed to the finding of total calcaneal involvement, below-knee
osteomyelitis and underwent below-knee amputation. amputation has been indicated. 6,17In this patient pop-
Talonavicular subluxation occurred as a late complica- ulation, total calcanectomy as a treatment for osteo-
tion in one patient. This was treated with a talonavicular myelitis has several advantages: preservation of the
arthrodesis and subsequent bracing for a nonunion. An heel pad for weightbearing, decreased oxygen de-
assessment of functional ambulation was performed on
mand and energy costs." and a simple orthosis is
all eight patients. Four patients maintained the same
used postoperattvety." The purpose of this article is
ambulation level postoperatively in a modified heel-con-
tainment orthosis. Two patients decreased one func-
to present the surgical and functional results of total
calcanectomy in eight patients with chronic osteomy-
elitis of the calcaneus.
* Assistant Professor, Department of Orthopaedic Surgery, Uni-
versity of Rochester Medical Center, Box 665, 601 Elmwood Ave.,
Rochester, NY 14642. To whom requests for reprints should be METHODS
addressed.
t San Pablo Orthopedic Foot and Ankle Clinic, Bayamon, Puerto A retrospective review was performed that identified
Rico. eight patients with chronic nonhealing plantar ulcers
:j: Clinical Professor of Orthopaedic Surgery, University of Vir-
of the heel and osteomyelitis of the calcaneus. Each
ginia, Charlottesville, Virginia, and Alabama Sports Medicine and
Orthopaedic Center, Birmingham, Alabama. patient had been managed with a total calcanectomy.
§ Associate Professor, Department of Orthopaedic Surgery, The primary diagnosis was insulin-dependent diabe-
Washington University School of Medicine, St. Louis, Missouri. tes mellitus in six patients, pneumococcal septicemia
849
850 BAUMHAUER ET AL. Foot & Ankle IntemationallVo/. 19, No. 12/December 1998

with disseminated intravascular coagulation in one pa- Flexor Flexor hallucis

digitorum longus tendon
tient, and an open calcaneal fracture in one patient. A
longus Achilles tendon
secondary diagnosis of peripheral vascular disease tendon
was present in three patients. The patients ranged in Tibial nerve ~_ _ Posterior tibial
age from 33 to 71 years (average, 52 years). There artery
were four men and four women. The patients had Ulcer and Calcaneus
sinus tract
ulcers present for 1.5 to 22 months (average, 8.1
Tibialis
months) before the diagnosis of osteomyelitis of the posterior
tendon Skin
calcaneus. Prior procedures included irrigation and incision
debridement of the heel ulcer (four patients)," partial Flexor
digitorum longus
calcanectomy (two patients)," and split thickness skin tendon
grafting (two patients)."
Doppler pulse pressures were obtained in patients
with nonpalpable dorsalis pedis and posterior tibial
artery pulses. A minimal acceptable value for ankle-
brachial indices for wound healing was 0.45. 2 1 A sim- Fig. 1. Modified Gaenslen incision used to excise the sinus tract
ilar value for toe pressures was determined to be and remove the calcaneus.
0.45. 3 Distal extremity vascular bypass surgery was
performed on two extremities before calcanectomy. tendon in the wound. Beginning with the posterior
Osteomyelitis of the calcaneus was diagnosed by tuberosity of the calcaneus and working circumferen-
magnetic resonance imaging (3 patients), and com- tially, the calcaneus was released from its soft tissue
bined magnetic resonance imaging and technetium/ attachments and removed (Fig. 3). Care was taken to
indium scans (5 patients). The last imaging study avoid injury to the neurovascular bundle medially as
before calcanectomy demonstrated osteomyelitis in- the site of the sustentaculum tali was approached.
volving the majority of the calcaneus in all patients. After removal of the calcaneus, the wound was in-
The criteria used to diagnose osteomyelitis radio- spected for necrotic or infected soft tissue. This tissue
graphically has been described prevlously.'" Intraop- was removed. Cultures were sent intraoperatively
erative cultures and/or histology confirmed the diag- from the calcaneus and surrounding soft tissue. A
nosis of osteomyelitis of the calcaneus in each patient. suction drain was used with wound closure. The re-
No Charcot changes were evident on plain radiograph maining Achilles tendon and plantar fascial soft tissue
or follow-up radiographic imaging. with its subsequent skin attachments are closed in a
A modified Gaenslen incision" was used for each single layer. The incision was closed primarily in five
patient. The modification included a curvilinear inci- patients, and a delayed primary closure was under-
sion beginning over the heel cord and extending either
medial or lateral to ellipse the ulcer or sinus tract. The
incision continued midplantar to the level of the cal-
Flexor digitorum Flexor hallucis
caneocuboid joint (Fig. 1). The incision was carried longus tendon \ longus tendon
straight to bone to avoid the development of devas-
Tibial
cularized soft tissue flaps. The Achilles tendon was nerve
divided longitudinally in an effort to maintain continuity
with the distal plantar tissues to prevent excessive Posterior
tibial artery Calcaneus
dorsiflexion (OF) of the ankle and provide active plan-
tarflexion (PF) (Fig. 2). Snow et at.'? reported: "In a
Tibialis
recent anatomic study of the Achilles tendon and plan- posterior
tar fascia, there was found to be some anatomic con- tendon Quadratus
plantae
tinuity between the fibers of the Achilles tendon and a
plantar fascia in a younger age population (range,
20-30 years). In the elderly population, there appears
to be an insertion of fibers of the Achilles into the
tuberosity while the calcaneus and the plantar fascia
attaches onto the plantar surface of the calcaneus
with a periosteal bridge in between." In one case, the Fig. 2. Plantar calcaneus demonstrating the longitudinal division
Achilles tendon was released from the posterior tuber- of the Achilles tendon and maintenance of its distal expansion into
osity and allowed to retract because of an exposed the plantar foot.
Foot & Ankle Internationai/Vol. 19, No. 12/December 1998 CHRONIC CALCANEAL OSTEOMYELITIS 851
TABLE 1
Grading of Ambulatory Status'
Grade Ambulatory status Description
VI Unlimited community ambulator Walks at least 5 blocks; uses a wheelchair for longer distances; may use a cane or
crutches; and is able to negotiate independently on stairs without rails, on curbs,
on rough terrain, and on public transportation.
V Limited community ambulator Walks 1 to 5 blocks; uses a wheelchair for longer distances; may use a cane or
crutches; and is able to negotiate independently on stairs without rails, on curbs,
on rough terrain, and on public transportation.
IV Unlimited household ambulator Walks at least 30.5 m (100 feet) in the house; uses a wheelchair for longer distances
outside the house; may use a cane, crutches, or a walker; and is able to negotiate
independently on stairs with rails, on carpets, and in and out of chairs.
III Limited household ambulator Walks less than 30.5 m (100 feet) in the house; uses a wheelchair for longer
distances outside the house; may use a cane, crutches, or a walker; and is able to
negotiate independently on stairs with rails, on carpets, and in and out of chairs.
II Supervised household ambulator Needs supervision during limited walking in the house.
I Wheelchair ambulator Uses a wheelchair at all times and is able to transfer to and propel the wheelchair.
o Bedridden Confined to bed or unable to transfer to or propel a wheelchair.
* Modified from Volpicelli et al.,'8 1983.

taken, with a second look procedure in three patients. status (Table 1). Modified criteria according to Woll
A rectus free flap was used for soft tissue coverage in and Beals2 5 were used to classify the results of the
one patient. Postoperative antibiotics were used for a procedure (Table 2). This classification evaluated am-
variable period of time (range, 1-8 weeks), based on bulatory status, pain, limp, and resolution of sepsis.
consultation with the infectious disease consult ser- DF and PF strength and range of motion of the ankle
vice at the Medical College of Wisconsin. The antibi- were assessed by a physical therapist postcalcanec-
otic duration was determined by the culture results tomy for six patients. Range of motion comparison
and the clinical impression of the wound and soft between limbs was not assessed on one patient with
tissues. a contralateral below-knee amputation and one pa-
The follow-up period ranged from 6 to 57 months tient with an ipsilateral below-knee amputation.
(average, 27.3 months). Early and late complications
related to the surgical procedure were identified. All
patients were functionally assessed using a modified RESULTS
Volpicelli scale"? to compare pre- and postambulatory
Demographic information and a summary of prior
procedures, type of wound healing, complications,
Tibial
artery
Achilles tendon and functional results are listed in Table 3. In all eight
(reflected for
illustration) cases, the wound was closed primarily. A rectus free
Tibial_-fJ!t-c-'----"
flap was used for soft tissue coverage in case 1. This
nerve patient presented with a traumatic avulsion of the heel
Talus pad and osteomyelitis of the os calcis. Case 3 had
Calcaneus persistent wound drainage and developed signs and
(dorsal view) symptoms suggestive of infection 2 weeks postcalca-
nectomy. Although the patient had no fever and the
wound appeared benign despite serous drainage, she
had an elevated white blood cell count and blood
Navicular Cuboid
glucose. The decision was made to return to the op-
erating room for a repeat irrigation and debridement. A
Flexor
hallucis
second look procedure was performed after 3 days.
longus tendon Cultures obtained from the operating room demon-
strated no growth. The wound was managed with
adjunctive hyperbaric oxygen treatments and dressing
Fig. 3. Posterior, lateral, dorsal, and plantar soft tissues have been
changes. During the next 8 months, this patient was
released extraperiosteally. The calcaneus has been rotated to ex-
pose the sustentaculum tali and medial neurovascular bundle for its
managed with total contact casting to promote wound
protection during release of the medial soft tissue attachments to healing. The patient developed an ulcer and eventual
the calcaneus. osteomyelitis of the distal one-third of the tibial crest.
852 BAUMHAUER ET AL. Foot & Ankle InternationallVol. 19, No. 12/December 1998
TABLE 2 ambulation which was believed to be secondary to
Classification of Results* prolonged nonweightbearing with delayed healing, re-
Rating Definition quiring a split thickness skin graft postoperatively.
Excellent Resolution of sepsis This patient also had a complete detachment of the
Return to previous ambulatory status tibialis anterior tendon upon initial presentation. Case
No pain 2 decreased one functional ambulation level. With an
No limp
ipsilateral trans metatarsal amputation and a contralat-
Good Resolution of sepsis plus ONE of the following:
NO return to previous ambulatory status eral below-knee amputation, the functional loss attrib-
Pain uted to the calcanectomy procedure alone in this pa-
Limp tient is difficult to ascertain. Case 7 decreased two
Fair Resolution of sepsis plus TWO of the following: levels of ambulation because of generalized weakness
NO return to previous ambulatory status
and balance difficulties after calcanectomy.
Pain
Limp
The results were graded according to a modified
Poor Recurrence of infection and/or THREE of the Woll and Beals classification scale 2 5 (Table 2). Scores
following: included three excellent, one good, two fair, and two
NO return to previous ambulatory status poor. At last follow-up, there was no evidence of re-
Pain current infection in the operative feet. In this primarily
Limp
diabetic population, pain is rarely a complaint. Only
* Modified from Woll and Beals,24 1991.
case 2 complained of pain, attributed to the nonunion
of the talonavicular arthrodesis. In the remainder of the
She underwent below-knee amputation at 1 year post- cases, the grading of good, fair, and poor results were
calcanectomy. caused by limitations in ambulatory status and/or a
Early complications from the calcanectomy proce- limp.
dure included two areas of superficial wound necrosis. Ankle range of motion and strength were deter-
Each was <4 cm in size. Case 5 was successfully mined bilaterally for five patients. Two patients were
treated with dressing changes. Case 6 required a lim- excluded because of contralateral (case 2) and ipsilat-
ited debridement and split thickness skin graft. Resid- eral (case 3) below-knee amputations. Strength and
ual Achilles tendon in the wound prevented granula- range of motion were compared to the uninvolved
tion tissue from forming. With debridement, release of limb. There was a wide range of findings, from in-
the tendon, and skin coverage, the wound healed and creased to decreased for both parameters. The raw
the patient progressed with physical therapy within 4 data scores are presented in Table 3. The active OF
weeks. and PF range of motion was expressed as a difference
Talonavicular subluxation was a late complication between the operative and contralateral ankles (range,
from total calcanectomy in one case (case 2) (Fig. 4). A OF 0 -10° difference; PF -15-5° difference). The OF
talonavicular arthrodesis was performed 3 months af- and PF strength was determined using manual muscle
ter the calcanectomy procedure and the patient de- testing. OF strength was found to be decreased in the
veloped a nonunion treated with bracing (Fig. 5). operative limb by an average of 1.75 grades, and PF
Using a modified ambulatory grading scale accord- strength decreased an average of 2.0 grades.
ing to Volpicelli et al.2 0 (Table 1), four of eight patients
maintained the same level of ambulation assessed DISCUSSION
before the development of osteomyelitis and postcal-
canectomy. Three patients used a heel containment Surgical management of chronic osteomyelitis of a
orthosis incorporated into an ankle-foot orthosis portion of the calcaneus has included local curet-
(AFO), four patients required only a heel containment tage 2 ,18 or partial calcaneal resection. 6, 10,16,17,23-25
orthosis and extra-depth shoe (Fig. 6). The decision With extensive involvement of the os calcis, below-
for the need of an AFO was determined on a case-by- knee amputation has been recommended.F" In the
case basis. Case 2 needed an AFO because of the diabetic and dysvascular patient population in whom
concurrent transmetatarsal amputation. Cases 6 and the majority of these problems occur, a limb salvage
7 reported a lack of stability with the heel containment procedure is particularly attractive. Long-term fol-
orthoses alone, and a brace was fabricated for sup- low-up studies report that approximately 50% of dia-
port. These cases also demonstrated muscular weak- betics with foot infections develop a contralateral limb
ness. Case 3 underwent below-knee amputation sec- infection within 18 months."? One-third of these cases
ondary to a total contact casting complication will require an amputation of the contralateral limb at
discussed previously. Case 6 decreased one level of some level. 13 As many as 50% of unilateral amputees
 dJ
0
.....
Qo
):.
TABLE 3 ::J
2S::
Demographic Information and Patient Summary CD

Duration of
:J
Case Age symptoms (prior
Follow-up
Abiiity to walk" CD
number (at presentation) Sex Diagnosis
to calcanectomy) Prior procedures postcalcanectomy
(months)
Wound healing Complications
preop/postop Result" ROM; strength :3
III
(months)
g.
1 (G.M.) 43 M Right grade III open calcaneus 18 I and 0 x four; partial 6; lost to flu Rectus free flap None VINI Excellent R L ::J
III
fracture calcanectomy OF 15 15 ::::::
PF 30 30 ~
:-
DF 5/5 5/5
......
PF 5/5 5/5 ,CO
2 (K.Z.) 33 F Right purpuric heel lesion 10 I and 0 x 1; associated 57 Deiayed primary Talonavicularsubluxationwith VlIV Poor Left: BKA;
secondary to pneumococcal
sepsis and OIC
right transmet amp closure attempted fusion and
nonunion
right: trans-
metatarsal
~
amputation ......
I\)
3 (S.B.) 37 F 100M. ieft mal perforans heel 22 I and D and partial 13 Secondary intention Persistent wound drainage; VI/below-knee Poor R L
ulcer calcanectomy x 2 before below- I and D x 2; hyperbaric amputation DF 15 BKA Q
knee amputation oxygen tx; below-knee PF 30 CD
o
amputation DF 5/5 CD
PF 5/5 :3
0-
4 (D.P.) 63 M IDOM, PVD right mal perforans
heel ulcer
3 Extremity arterial bypass 47 Primary closure None III/III Excellent R L ..,
CD
......
DF 5 5 CO
25
CO
PF 10 Q)
OF 5/5 5/5
PF 3/5 5/5
5 (L.S.) 71 M IDDM, PVO right mal perforans 2 Extremity arterial bypass 20.5 Primary closure Superficial wound necrosis; tx VN Excellent R L
heel ulcer with dressing changes OF -5 5
PF 20 25
DF 2/5 5/5
PF 3/5 5/5
6 (I.S.) 67 F 100M, PVO right mal perforans 1.5 I and 0; STSG x2 15; died of Primary closure Superficial wound necrosis VlIV Fair R L
o
I
heel ulcer unrelated cause posterior heel; STSG DF -5 5 JJ
applied PF 40 40 0
DF 1/5 5/5 Z
PF 1/5 4/5 0
7 (K.P.) 55 F 100M, left mal perforans heel 1.5 None 23; died of Delayed primary None VI/IV Fair R L o
ulcer unrelated cause closure OF 10 5 ~
r
PF 40 30 o
DF 5/5 4/5 ~
Z
PF 5/5 3/5 m
8 (S.P.) 47 M 100M, right mal perforans heel 1.5 None 37 Primary closure None VINI Good R L ~
ulcer DF 5 5
r
PF 30 40 0
(J)
DF 5/5 5/5 --I
PF 5/5 5/5 m
0
ROM, range of motion; I and 0, irrigation and debridement; OF, dorsiflexion; PF, plantarflexion; OIG, disseminated intravascular coagulation; BKA, below-knee amputation; 100M, s:
insulin-dependent diabetes mellitus; PVO, peripheral vascular disease; STSG, split thickness skin grafting.
-<
m
a see Table 1.
r
=l
b see Table 2. en

Q)
CJ1
c.v
854 BAUMHAUER ET AL. Foot & Ankle Internat/onallVol. 19, No. 12/December 1998

Fig. 4. Lateral foot radiograph demonstrating the late complication Fig. 5. Lateral foot radiograph demonstrating the treatment of a
of a talonavicular subluxation (case 4). talonavicular subluxation with an attempted talonavicular arthrode-
sis and the development of a nonunion.

will undergo a contralateral amputation within 2 ambulatory in a modified AFO. The patients lost an
years." Successful rehabilitation rates range from 30% average of 10° of OF, and a variable range of PF was
to 66% for unilateral amputees and 11% to 30% for noted postoperatively. The patients decreased an av-
bilateral involvement." Preservation of function with erage of 1 to 2 manual muscle grades in OF and PF in
lower energy costs through decreased oxygen de- the operative limb as compared to the contralateral
mands has been demonstrated with foot salvage sur- limb.
gery.22 A limitation of the current study is in its retrospective
Few case series have been reported in the literature analysis without the advantage of a preoperative as-
evaluating total calcanectomy for chronic osteomyeli- sessment of strength and range of motion of the op-
tis of the calcaneus." .6.8,16 The data from these series erative limb. A comparison is made, therefore, to the
are difficult to interpret. Results were combined for the contralateral limb. The contralateral limb in the neuro-
partial and total calcanectomy procedures.Y'" length pathic patient is not normal. Because of this factor, the
of follow-up was not stated," no objective criteria were assessment of baseline for the operative limb is diffi-
used to establish the results,6,16 and complications cult to determine. In an attempt to address this prob-
related to the procedure were not reported.!" These lem, a functional assessment was performed evaluat-
studies were performed before the use of current re- ing ambulatory status. This was believed to be a more
vascularization techniques and standards known to important predictor of outcome than manual strength
improve the rates of limb salvage surgery.9,12,14,1S and range of motion testing.
This article presents the results of total calcanec- In the current study, the average length of follow-up
to my for the treatment of extensive chronic osteomy- was 27.3 months. Crandall and Wagner 6 found that
elitis of the calcaneus. Adjunctive revascularization midtarsal subluxation occurred 5 years postcalcanec-
procedures and soft tissue coverage were used to
improve the outcome of this procedure in three pa-
tients. Soft tissue coverage procedures with calcane-
ctomy have been shown to provide good function with
an adequate weightbearing surface.' Of eight patients
in this series, seven healed their surgical wounds and
are currently ambulatory. At most recent follow-up,
there is no recurrence of infection in the plantar heel in
any patient. One patient underwent below-knee am-
putation secondary to a total-contact casting compli-
cation and the development of osteomyelitis of the
anterior tibial crest. One late complication of talona-
vicular subluxation underwent a talonavicular arthro-
desis and developed a nonunion. The ipsilateral trans-
metatarsal amputation may have increased the Fig. 6. Picture of a heel containment orthosis used postcalcan-
likelihood of this complication. This patient is currently ectomy.
Foot & Ankle Internationai/Vol. 19, No. 12/December 1998 CHRONIC CALCANEAL OSTEOMYELITIS 855
to my in one patient. Continued follow-up in this pa- sure of resistant large ulcers of the heel, with or without osteo-
myelitis of the os calcis. Clin. Orthop., 84:149-153, 1972.
tient population is needed to monitor for this and other
11. Johnson, J.E., Janisse, D.J., Valdez, R.R., Hanel, D.P., and
potential late complications. The length of time for Gould, J.S.: Pedorthic management of bone and soft tissue
wound healing postcalcanectomy was not specifically defects of the heel. AOFAS Annual Summer Meeting, Napa,
addressed in the clinic records for each patient. Al- California, July 17, 1992.
though it was the largest reported series, the number 12. Karmody, A.M., Leather, A.P., Shah, D.M., Corson, J.D., and
of patients included in this review was too small for Naraynsingh, V.: Peroneal artery bypass: a reappraisal of its
value in limb surgery. J. Vase. Surg., 1:809-816, 1984.
statistical analysis. Previously published reports
13. Kucan, J.O., and Robson, M.C.: Diabetic foot infections: fate
lacked objective criteria for analysis and therefore, a of the contralateral foot. Plast. Reconstr. Surg., 77:439-441,
meta-analysis combining these series can not be per- 1986.
formed. 16. Martini, M., Martini-Benkeddache, Y., Bekhechi, T., and
Total calcanectomy is a successful alternative to Daoud, A.: Treatment of chronic osteomyelitis of the calcaneus
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14. Leather, R.P., Shah, D.M, and Karmody, A.M.: Infrapopliteal
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bulators at an equal or slightly decreased level post- 1981.
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1619,1984.
lar status of the limb and the surrounding soft tissue
17. Smith, D.G., Stuck, R.M., Ketner, L., Sage, R.M., and Pinzur,
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