Inpatient soft tissue protocol and wound complications in calcaneus fractures.

BACKGROUND: Operative treatment of calcaneus fractures is associated with the risk of early wound complications. Though accepted practice dictates surgery should be delayed until soft tissues recover from the initial traumatic insult, optimal timing of surgery has not been delineated. METHODS: A retrospective chart and radiographic review at a level I trauma center was performed to determine if an aggressive inpatient soft tissue management protocol designed to decrease the time delay from injury to surgery is effective at reducing complications. Ninety-seven patients (17 female, 80 male; mean age, 39.7±14.0 years) with 102 calcaneus fractures treated between October 1995 and January 2005 were identified. Differences in complication rates and quality of reduction between the inpatient and outpatient treatment groups were analyzed. Quality of reduction was determined by measuring postoperative Bohler's angle and posterior facet articular step-off. RESULTS: Mean time from injury to surgery was 6.2 days for the inpatient group and 10.8 days for the outpatient group (p<0.0001). The overall complication rate was over twice as high in the outpatient group (27 versus 12%, p=0.04) and the serious complication rate was 6.5 times higher when patients were managed as outpatients (9% versus 1%, p=0.09). With the numbers available, there were no significant differences in the quality of reduction obtained at surgery. CONCLUSION: This study suggests that this inpatient soft tissue management protocol of calcaneal fractures is a feasible treatment option when a patient is kept in the hospital that offers a reduction in postoperative wound complications while enabling surgery 4 days earlier on average.

Complications associated with open calcaneus fractures.

BACKGROUND: Literature on open calcaneus fractures is limited and inconsistent. This study's purpose was to report complications such as osteomyelitis, amputations, and soft tissue infections in open calcaneus fractures that were treated at a Level I Trauma Center. METHODS: From January 1995 through December 2007, 1,157 calcaneus fractures were identified with 127 fractures being open (11.0%). Average followup time was 9.1 (range, 2 to 53) months. All open fractures were treated by a similar protocol of intravenous (i.v.) antibiotics, emergent irrigation and debridement (I&D), initial fracture stabilization if possible, subsequent I&Ds as needed, and delayed definitive fixation. One hundred fifteen open calcaneus fractures in 112 patients had sufficient followup for study inclusion. For this study complications were classified into four categories: superficial infections, deep infections, osteomyelitis, and amputations. RESULTS: Medial based wounds occurred in 63 (54.8%) fractures. The overall complication rate was 23.5% with 16 fractures (13.9%) requiring a reoperation. Eleven (9.6%) fractures experienced superficial wound infection and 14 (12.2%) had deep wound infection. Six (5.2%) amputations were required with three being for either soft tissue infection or wound necrosis. Culture-positive osteomyelitis occurred in six (5.2%) patients. CONCLUSION: Utilizing a standardized protocol, open calcaneus fractures were found to have a lower complication rate than has been previously reported.

A rare trifocal presentation of Clostridium septicum myonecrosis.

Gas gangrene or clostridial myonecrosis is a rare, life threatening infection of the muscle that is typically associated with recent surgery or trauma. It usually affects older individuals who suffer from vascular insufficiency or who are immunocompromised. The typical pathogen is Clostridium perfringens. Atraumatic gas gangrene caused by Clostridium septicum is less common and has a unique association with colon cancer. This condition aggressively spreads through the muscular tissue and often culminates in septic shock. Fatality occurs within 48 hours if left untreated yet, despite emergent treatment the mortality rate is >50% without any comorbidities. Given the propensity to occur in the extremities the orthopedic surgeon must be familiar with its presentation, diagnosis, and treatment. This article presents a case of a 16-year-old girl who presented to the emergency room with an 18-hour history of malaise and progressive right arm discomfort and swelling. The identification and emergent treatment of necrotizing soft tissue infections is important and often falls on the orthopedic surgeon, especially when isolated to the extremities. Subtle initial presentation and rapid progression of the infection are classic findings of necrotizing soft tissue infections, particularly with clostridial myonecrosis and necrotizing fasciitis. Clostridium myonecrosis is a rare orthopedic condition with high mortality. Early diagnosis and debridement is imperative. A team approach to managing these patients postoperatively is necessary. The use of hyperbaric oxygen can be considered, however, it may not be readily available and its use is unproven in human studies. Due to its high mortality, one should err on the side of more aggressive resective/ablative surgery.