Kendal Adrian, Loizou Constantinos, Down Billy, McNally Martin
Nuffield Orthopaedic Centre, Oxford, UK.
Botnar Research Centre, The Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK.
Foot Ankle Orthop. 2022 Oct 30;7(4):24730114221133391. doi: 10.1177/24730114221133391. eCollection 2022 Oct.
The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis.
Twenty-eight patients (mean age 54.6 years, range 20-94) with Cierny-Mader stage IIIB chronic calcaneal osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids.
All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot.
Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities.
Level III, case series.
由于糖尿病的高患病率以及跟骨骨折的手术固定，慢性跟骨骨髓炎的治疗是一个具有挑战性且日益突出的问题。1931年，根斯伦报道了通过足底正中矢状切口进行手术切除治疗血源性跟骨骨髓炎。我们改进了这种方法，以使一系列患有血源性、糖尿病性和术后骨髓炎的复杂现代患者能够成功愈合并早期活动。
对28例（平均年龄54.6岁，范围20 - 94岁）Cierny - Mader IIIB期慢性跟骨骨髓炎患者采用矢状切口和跟骨截骨术，切除感染骨并闭合伤口。所有患者均接受至少6周的抗生素治疗，20例患者的骨缺损用抗生素载体填充。患者平均随访31个月（标准差25.4）。主要结局指标为跟骨骨髓炎复发和膝下截肢。次要结局指标包括术后30天死亡率和并发症、术后住院时间、鞋类适配、活动能力以及助行器使用情况。
所有28例患者既往的药物和手术治疗均失败。18例患者（64%）有明显的合并症。感染的最常见原因是糖尿病±溃疡（11例患者）、骨折相关感染（4例患者）、压疮、血行播散和穿透性软组织创伤。在随访期间，跟骨骨髓炎的总体复发率为18%（5例患者），其中2例患者（7%）需要膝下截肢。18例患者（64%）的足部通过定制鞋垫能舒适地穿进正常鞋子。另外6例患者（21%）需要定制鞋，只有3例患者需要定制靴子。
我们的结果表明，改良的根斯伦跟骨切除术在治疗一组具有明显局部和全身合并症的患者的这种疑难病症时简单、安全且有效。
III级，病例系列。
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