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
The purpose of this study is to present the surgical and
functional results of a total calcanectomy procedure as a
foot salvage alternative in patients with extensive
chronic osteomyelitis of the calcaneus. A retrospective
review identified eight patients treated with a total cal-
canectomy for a chronic non healing plantar ulcer of the
heel and osteomyelitis of the calcaneus. The primary
diagnosis was insulin-dependent diabetes mellitus (six
patients), pneumococcal septicemia (one patient), and
an open calcaneal fracture (one patient). The average
age of the patients was 52 years. Prior procedures in-
cluded irrigation and debridement of the heel ulcer (sev-
en patients), partial calcanectomy (three patients), and
split thickness skin grafting (two patients). The vascular
status of each limb was assessed preoperatively. Distal
extremity bypass surgery was performed on two pa-
tients before calcanectomy. Osteomyelitis of the calca-
neus was diagnosed by magnetic resonance imaging
alone in three patients, and by technetium/indium scans
and magnetic resonance imaging in five patients. The
average follow-up duration was 27.3 months (range,
6-57 months). Infection at the plantar heel was con-
trolled in all patients. In all eight cases the incisions were
closed primarily. During a prolonged time of total con-
tact casting to facilitate wound healing, one patient
developed an anterior tibial ulcer that progressed to
osteomyelitis and underwent below-knee amputation.
Talonavicular subluxation occurred as a late complica-
tion in one patient. This was treated with a talonavicular
arthrodesis and subsequent bracing for a nonunion. An
assessment of functional ambulation was performed on
all eight patients. Four patients maintained the same
ambulation level postoperatively in a modified heel-con-
tainment orthosis. Two patients decreased one func-
* 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
addressed.
t San Pablo Orthopedic Foot and Ankle Clinic, Bayamon, Puerto
Rico.
:j: Clinical Professor of Orthopaedic Surgery, University of Vir-
ginia, Charlottesville, Virginia, and Alabama Sports Medicine and
Orthopaedic Center, Birmingham, Alabama.
§ Associate Professor, Department of Orthopaedic Surgery,
Washington University School of Medicine, St. Louis, Missouri.
849
tional ambulation level, and one patient decreased two
levels. One patient underwent below-knee amputation
and is currently ambulatory with a prothesis. Assess-
ment of ankle strength and range of motion of the sur-
gical limb demonstrated decreased dorsiflexion and
plantarflexion strength and a variable range of motion
compared to the contralateral limb. Total calcanectomy
is an alternative procedure to transtibial amputation in
patients with chronic osteomyelitis of the calcaneus.
Eradication of infection and preservation of the func-
tional ambulation is achieved.
INTRODUCTION
Osteomyelitis of the calcaneus is a difficult manage-
ment problem. Treatment is directed toward the erad-
ication of infected bone with preservation of the
weightbearing function of the foot. Patients who de-
velop chronic osteomyelitis of the calcaneus often
have other significant medical problems such as insu-
lin-dependent diabetes mellitus and/or peripheral vas-
cular disease. In a small number of reported series,
partial calcanectomy has been used successfully in
cases of infection with limited calcaneal involve-
ment. 6,10,16,17,23-25 With failure of a partial resection or
the finding of total calcaneal involvement, below-knee
amputation has been indicated. 6,17In this patient pop-
ulation, total calcanectomy as a treatment for osteo-
myelitis has several advantages: preservation of the
heel pad for weightbearing, decreased oxygen de-
mand and energy costs." and a simple orthosis is
used postoperattvety." The purpose of this article is
to present the surgical and functional results of total
calcanectomy in eight patients with chronic osteomy-
elitis of the calcaneus.
METHODS
A retrospective review was performed that identified
eight patients with chronic nonhealing plantar ulcers
of the heel and osteomyelitis of the calcaneus. Each
patient had been managed with a total calcanectomy.
The primary diagnosis was insulin-dependent diabe-
tes mellitus in six patients, pneumococcal septicemia
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
Grade Ambulatory status
VI Unlimited community ambulator
V Limited community ambulator
IV Unlimited household ambulator
III Limited household ambulator
II Supervised household ambulator
I Wheelchair ambulator
o Bedridden
* Modified from Volpicelli et al.,'8 1983.
CHRONIC CALCANEAL OSTEOMYELITIS 851
TABLE 1
Grading of Ambulatory Status'
Description
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.
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.
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.
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.
Needs supervision during limited walking in the house.
Uses a wheelchair at all times and is able to transfer to and propel the wheelchair.
Confined to bed or unable to transfer to or propel a wheelchair.

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.
TABLE 2
Classification of Results*
Rating Definition
Excellent Resolution of sepsis
Return to previous ambulatory status
No pain
No limp
Good Resolution of sepsis plus ONE of the following:
NO return to previous ambulatory status
Pain
Limp
Fair Resolution of sepsis plus TWO of the following:
NO return to previous ambulatory status
Pain
Limp
Poor Recurrence of infection and/or THREE of the
following:
NO return to previous ambulatory status
Pain
Limp
* Modified from Woll and Beals,24 1991.
She underwent below-knee amputation at 1 year post-
calcanectomy.
Early complications from the calcanectomy proce-
dure included two areas of superficial wound necrosis.
Each was <4 cm in size. Case 5 was successfully
treated with dressing changes. Case 6 required a lim-
ited debridement and split thickness skin graft. Resid-
ual Achilles tendon in the wound prevented granula-
tion tissue from forming. With debridement, release of
the tendon, and skin coverage, the wound healed and
the patient progressed with physical therapy within 4
weeks.
Talonavicular subluxation was a late complication
from total calcanectomy in one case (case 2) (Fig. 4). A
talonavicular arthrodesis was performed 3 months af-
ter the calcanectomy procedure and the patient de-
veloped a nonunion treated with bracing (Fig. 5).
Using a modified ambulatory grading scale accord-
ing to Volpicelli et al.2 0 (Table 1), four of eight patients
maintained the same level of ambulation assessed
before the development of osteomyelitis and postcal-
canectomy. Three patients used a heel containment
orthosis incorporated into an ankle-foot orthosis
(AFO), four patients required only a heel containment
orthosis and extra-depth shoe (Fig. 6). The decision
for the need of an AFO was determined on a case-by-
case basis. Case 2 needed an AFO because of the
concurrent transmetatarsal amputation. Cases 6 and
7 reported a lack of stability with the heel containment
orthoses alone, and a brace was fabricated for sup-
port. These cases also demonstrated muscular weak-
ness. Case 3 underwent below-knee amputation sec-
ondary to a total contact casting complication
discussed previously. Case 6 decreased one level of
Foot & Ankle InternationallVol. 19, No. 12/December 1998
ambulation which was believed to be secondary to
prolonged nonweightbearing with delayed healing, re-
quiring a split thickness skin graft postoperatively.
This patient also had a complete detachment of the
tibialis anterior tendon upon initial presentation. Case
2 decreased one functional ambulation level. With an
ipsilateral trans metatarsal amputation and a contralat-
eral below-knee amputation, the functional loss attrib-
uted to the calcanectomy procedure alone in this pa-
tient is difficult to ascertain. Case 7 decreased two
levels of ambulation because of generalized weakness
and balance difficulties after calcanectomy.
The results were graded according to a modified
Woll and Beals classification scale 2 5 (Table 2). Scores
included three excellent, one good, two fair, and two
poor. At last follow-up, there was no evidence of re-
current infection in the operative feet. In this primarily
diabetic population, pain is rarely a complaint. Only
case 2 complained of pain, attributed to the nonunion
of the talonavicular arthrodesis. In the remainder of the
cases, the grading of good, fair, and poor results were
caused by limitations in ambulatory status and/or a
limp.
Ankle range of motion and strength were deter-
mined bilaterally for five patients. Two patients were
excluded because of contralateral (case 2) and ipsilat-
eral (case 3) below-knee amputations. Strength and
range of motion were compared to the uninvolved
limb. There was a wide range of findings, from in-
creased to decreased for both parameters. The raw
data scores are presented in Table 3. The active OF
and PF range of motion was expressed as a difference
between the operative and contralateral ankles (range,
OF 0 -10° difference; PF -15-5° difference). The OF
and PF strength was determined using manual muscle
testing. OF strength was found to be decreased in the
operative limb by an average of 1.75 grades, and PF
strength decreased an average of 2.0 grades.
DISCUSSION
Surgical management of chronic osteomyelitis of a
portion of the calcaneus has included local curet-
tage 2 ,18 or partial calcaneal resection. 6, 10,16,17,23-25
With extensive involvement of the os calcis, below-
knee amputation has been recommended.F" In the
diabetic and dysvascular patient population in whom
the majority of these problems occur, a limb salvage
procedure is particularly attractive. Long-term fol-
low-up studies report that approximately 50% of dia-
betics with foot infections develop a contralateral limb
infection within 18 months."? One-third of these cases
will require an amputation of the contralateral limb at
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.
Fig. 4. Lateral foot radiograph demonstrating the late complication
of a talonavicular subluxation (case 4).
will undergo a contralateral amputation within 2
years." Successful rehabilitation rates range from 30%
to 66% for unilateral amputees and 11% to 30% for
bilateral involvement." Preservation of function with
lower energy costs through decreased oxygen de-
mands has been demonstrated with foot salvage sur-
gery.22
Few case series have been reported in the literature
evaluating total calcanectomy for chronic osteomyeli-
tis of the calcaneus." .6.8,16 The data from these series
are difficult to interpret. Results were combined for the
partial and total calcanectomy procedures.Y'" length
of follow-up was not stated," no objective criteria were
used to establish the results,6,16 and complications
related to the procedure were not reported.!" These
studies were performed before the use of current re-
vascularization techniques and standards known to
improve the rates of limb salvage surgery.9,12,14,1S
This article presents the results of total calcanec-
to my for the treatment of extensive chronic osteomy-
elitis of the calcaneus. Adjunctive revascularization
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
likelihood of this complication. This patient is currently
Foot & Ankle Internat/onallVol. 19, No. 12/December 1998
Fig. 5. Lateral foot radiograph demonstrating the treatment of a
talonavicular subluxation with an attempted talonavicular arthrode-
sis and the development of a nonunion.
ambulatory in a modified AFO. The patients lost an
average of 10° of OF, and a variable range of PF was
noted postoperatively. The patients decreased an av-
erage of 1 to 2 manual muscle grades in OF and PF in
the operative limb as compared to the contralateral
limb.
A limitation of the current study is in its retrospective
analysis without the advantage of a preoperative as-
sessment of strength and range of motion of the op-
erative limb. A comparison is made, therefore, to the
contralateral limb. The contralateral limb in the neuro-
pathic patient is not normal. Because of this factor, the
assessment of baseline for the operative limb is diffi-
cult to determine. In an attempt to address this prob-
lem, a functional assessment was performed evaluat-
ing ambulatory status. This was believed to be a more
important predictor of outcome than manual strength
and range of motion testing.
In the current study, the average length of follow-up
was 27.3 months. Crandall and Wagner 6 found that
midtarsal subluxation occurred 5 years postcalcanec-
Fig. 6. Picture of a heel containment orthosis used postcalcan-
ectomy.
Foot & Ankle Internationai/Vol. 19, No. 12/December 1998
to my in one patient. Continued follow-up in this pa-
tient population is needed to monitor for this and other
potential late complications. The length of time for
wound healing postcalcanectomy was not specifically
addressed in the clinic records for each patient. Al-
though it was the largest reported series, the number
of patients included in this review was too small for
statistical analysis. Previously published reports
lacked objective criteria for analysis and therefore, a
meta-analysis combining these series can not be per-
formed.
Total calcanectomy is a successful alternative to
below-knee amputation in patients with extensive
chronic osteomyelitis of the calcaneus. The infection
can be eradicated with preservation of function. Pre-
operative ambulatory patients may be functional am-
bulators at an equal or slightly decreased level post-
calcanectomy. The procedure is safe with few
complications. Preoperative assessment of the vascu-
lar status of the limb and the surrounding soft tissue
envelope is important to evaluate the potential for
wound healing. Adjunctive vascular procedures to im-
prove blood flow and to promote healing may be
needed.
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