Reconstructive microsurgery in the treatment of superficial calcaneal osteomyelitis
One of the most common complications associated with the treatment of calcaneal fractures is the marginal necrosis of the surgical wound resulting in chronic non-healing ulcers of the heel region and osteomyelitis of the calcaneus. In the structure of skeletal lesions the chronic osteomyelitis of the calcaneus occurs in 3.1-14.8% of cases, and among foot lesions it constitutes up to 51%. At the same time, the total incidence of deep soft tissue infections after open fractures is even higher than the incidence of superficial infections (12.2% vs. 9.6%). The traditional approach to the treatment of calcaneus osteomyelitis is often followed by poor outcome with recurrent osteomyelitis process and high rate of subsequent disability at working age.Objective: to identify the opportunities and evaluate the effectiveness of reconstructive microsurgery techniques for treatment of patients with superficial osteomyelitis of the calcaneus, accompanied by soft tissue defect.Materials and мethods. The authors analyzed treatment outcomes of 28 patients with superficial osteomyelitis of calcaneus, who underwent reconstructive plastic surgery with use of microsurgical techniques at Vreden Research Institute of Traumatology and Orthopaedics in the period from 2006 to 2013. Defects of covering soft tissues were located on the plantar (20 cases) and posterolateral surfaces (8 cases) of calcaneus. Procedure included the radical debridement of osteomyelitis focus, marginal resection of the affected bone and soft tissue grafting using a flap with axial blood supply.Results. In cases when tissue defect was located at non-supporting surface of heel region (9 cases) a radial fasciocutaneous free flap was used for grafting. For grafting of plantar defects (10 cases) preference was given to medial plantar flap. However, in presence of scarring and lesions of the medial plantar artery a two-step replacement of defect was performed using a prefabricated medial foot arch flap (9 cases). Complications were observed in 7% of cases (2 patients): in 1 patient following radial free flap grafting; and in 1 case following medial plantar flap grafting. Complications in both cases were associated with impaired blood supply to the flap resulting in necrosis of grafts. In the remaining cases (93%) full graft retention was achieved. Long-term results were followed up in 78,5% (n = 22) of patients in the period from 1 to 8 years after the treatment. In four cases, marginal wound defects were recorded that required secondary surgical procedure. Outcomes averaged 85 points on the AOFAS scale, which given the severity of the disease were regarded as a good result.Conclusions. The use of microsurgical techniques for treatment of patients with superficial osteomyelitis of the calcaneus, including cases with soft tissue defects, allows to achieve a sustained remission of osteomyelitis process and to restore support ability of the injured limb. Thus, it is expedient to use grafts including plantar skin for reconstruction of support surface of the calcaneal region.