Table of Contents  
Year : 2017  |  Volume : 13  |  Issue : 1  |  Page : 28-32

Two-stage reconstruction of composite soft tissue and bone defects in open fracture of the calcaneus: Case report and literature review

1 Burns and Plastic Surgery Division, Department of Surgery, Lagos State, Nigeria
2 Department of Plastic & Reconstructive Surgery, E-da–Hospital, Kaoshuing, Taiwan, China
3 Division of Plastic Surgery, Ahmadu Bello University and Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
4 Division of Orthopedic Surgery, Department of Surgery, Lagos State University Teaching Hospital (LASUTH) Ikeja, Lagos State, Nigeria

Date of Web Publication16-Aug-2017

Correspondence Address:
Abdulwahab Ajani
Burns and Plastic Surgery Division, Department of Surgery, Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njps.njps_9_17

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The calcaneus has a fundamental role in weight bearing and gait. Open fractures of the calcaneus with complex soft tissue and bone defects represent a reconstructive challenge. Such fractures require specialized care and demand attention despite its low incidence. We report our experience in the management of a 50-year-old man with a Gustilo-Anderson type IIIB fracture of the right calcaneus complicated with extensive soft tissue defect and chronic osteomyelitis. He had a two-stage reconstruction. The soft tissue defect was reconstructed with an anterolateral thigh flap and the bone defect with a vascularized fibula osteocutaneous flap.

Keywords: Anterior lateral thigh free flap, calcaneus, gustilo-anderson type IIIB, vascularized fibula osteocutaneous flap

How to cite this article:
Ajani A, Shih HS, Takashashi K, Omosebi T, Ibrahim A, Solagberu B. Two-stage reconstruction of composite soft tissue and bone defects in open fracture of the calcaneus: Case report and literature review. Nigerian J Plast Surg 2017;13:28-32

How to cite this URL:
Ajani A, Shih HS, Takashashi K, Omosebi T, Ibrahim A, Solagberu B. Two-stage reconstruction of composite soft tissue and bone defects in open fracture of the calcaneus: Case report and literature review. Nigerian J Plast Surg [serial online] 2017 [cited 2023 Sep 24];13:28-32. Available from:

  Introduction Top

The calcaneus is the largest of the tarsal bones located in the hindfoot.[1],[2] The calcaneus and the surrounding soft tissue absorb the body weight when the heel strikes the ground during propulsion and, thus, has a fundamental role in weight bearing and gait.[1],[3],[4] Calcaneal fractures are the most common tarsal fractures and constitute 60% of all tarsal fractures.[5] However, open calcaneal fractures are a rare variant, representing 3–6% of all calcaneal fractures.[1],[6],[7]

Open fractures of the calcaneus are potentially devastating injuries typically caused by high-energy axial loading mechanisms with resultant disruption of the hindfoot soft tissue envelope.[3],[5],[7] Nonanatomic reduction, wound infection, and chronic osteomyelitis are the reported sequelae of open calcaneal fractures.[7],[8] In addition, most patients have to endure repeated surgical interventions with prolonged hospital stay and a high rate of late amputation.[1]

The advent of microvascular free tissue transfer in the last three decades has revolutionized lower limb reconstruction and dramatically improved outcome.[2],[3],[7],[9] The goals of microvascular reconstruction in open fractures of the calcaneus are (1) stable soft tissue coverage to promote wound healing and (2) restoration of bone alignment and maintaining anatomic reductions with internal and or external fixation techniques.[2],[3],[9] The authors report a case of open calcaneal fracture of the right foot with soft tissue and bone infection, which was successfully treated in a two-stage procedure with an anterolateral thigh (ALT) flap and a vascularized fibula osteocutaneous flap.

  Case report Top

A 50-year-old man sustained a Gustilo-Anderson type IIIB fracture of the right calcaneus after a fall from a height. He was referred to our hospital 1 month after having undergone an open reduction and internal fixation at a peripheral hospital. He presented with the complaint of a discharging wound on the right foot. A physical examination revealed an infected deep wound on the right foot, and radiological examinations showed evidence of chronic osteomyelitis. The patient had a preoperative angiography to reveal the vascular anatomy of the right lower limb. The posterior tibial artery, peroneal arteries, and anterior tibial arteries were all patent.

Multiple wound debridement and radical bone resection resulted in a large soft tissue defect measuring 10 cm × 8 cm and a total calcaneal bone defect [Figure 1]. He underwent a two-stage reconstruction: a free ALT flap in the first stage to reconstruct the soft tissue defect, and in the second stage, a free vascularized fibula osteocutaneous flap to reconstruct the calcaneal defect. The ALT free flap was performed 8 weeks after the initial injury [[Figure 2]a]. The recipient vessels were the anterior tibial artery and anterior tibial vein. The flap survived, and there were no donor site complications. An antibiotic bead pouch was inserted and changed twice fortnightly until there was no clinical and laboratory evidence of infection [[Figure 2]b].
Figure 1: Lateral X-ray view of the calcaneal defect in the right foot

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Figure 2: (a) Intraoperative picture with anterior lateral thigh flap in situ. (b) Introduction of antibiotic beads

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He underwent a free vascularized fibula osteocutaneous flap to reconstruct the calcaneal defect 6 weeks after the first stage. The shape and size of the calcaneus was evaluated by filling the defect with bone cement [[Figure 3]a]. The free fibula osteocutaneous flap was harvested from the contralateral leg and sectioned into two barrels using the bone cement as a template. The two barrels and a third barrel of fibular bone graft were fixed together with microplates [[Figure 3]b]. The anastomosis was performed in an end-to-end fashion between the peroneal vessel and the posterior tibia artery using the great saphenous vein as an interposition vein loop graft. The skin paddle was 2 cm in circumference and was used to cover the vascular pedicle. The fibula osteocutaneous flap was inset [[Figure 3]c and [Figure 3]d] with two Kirschner (K) wires. The skin defect of the donor site was closed primarily. The immediate postoperative period was uneventful.
Figure 3: (a) Intraoperative picture of the bone cement template of the calcaneal defect. (b) Double barrel fibula osteocutaneous flap. (c) Intraoperative picture with flap inset. (d) Postoperative X-ray view at 3 months

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Three months postoperatively, there was satisfactory healing of the primary and secondary defects [[Figure 4]a and [Figure 4]b]. An X-ray revealed bone union, and the K wires were removed. The patient was instructed to commence partial weight bearing. At 6-month follow-up [Figure 5], the patient had recovered full range of motion at the ankle joint, and he was able to ambulate with a normal gait.
Figure 4: (a) Postoperative picture of the primary defect at 3 months. (b) Postoperative picture of the secondary defect at 3 months

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Figure 5: Postoperative picture at 6 months

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  Discussion Top

The management of open fractures of the calcaneus remains a formidable challenge. It requires specialized care and demands attention despite its low incidence.[10] They are usually characterized by extensive soft tissue compromise and complex bony defects that cannot be reconstructed with local flaps and conventional bone grafts. Management is further complicated by the potential for wound infection.[2],[7]

Soft tissue and bone infection rates are higher in Gustilo-Anderson type IIIB fractures of the calcaneus, with an incidence of 37–60%.[3] Siebert et al.[11] studied open calcaneal fractures in 36 patients, including 13 patients with type IIIB fractures. The overall chronic infection rate in their study was 42%. Aldridge et al.[7] reported 19 patients with open fracture of the calcaneus. Five of the patients had type IIIB fracture, chronic osteomyelitis occurred in two of them, and one eventually underwent a below-knee amputation. Ulusal et al.[3] reported 25 open calcaneal fractures, with an infection rate of 12%. The authors opined that open calcaneal fractures complicated by soft tissue defects were associated with an increased rate of complications, such as chronic osteomyelitis.[3],[7],[11]

Several detailed reviews suggest that a two-staged procedure should be performed for open calcaneal fractures complicated by chronic osteomyelitis.[2],[3],[9] The first stage includes the removal of all implants and an aggressive debridement of necrotic soft tissues and devitalized bone. Bone curettage should be followed by a resection of the surrounding scar and granulation tissue to healthy bleeding soft tissue. This process is repeated every 48 h until the wound is clean and stable. The frequency of debridement is dictated by the degree of contamination and response to previous treatment.[2] The samples of all tissues should be sent for aerobic, anaerobic, fungal, and mycobacterial cultures. The wound is managed with culture-specific antibiotics and meticulous local wound care.[2],[3],[9] In this patient, the first stage of reconstruction was performed when wound cultures were negative and the wounds appeared grossly clean and healthy.

Adequate soft tissue coverage was achieved by the use of an ALT flap. Its popularity as a “work-horse” flap in the lower limb is often attributed to its multiple advantages, which can be divided into the following two: pedicle and flap design. It is remote from the primary defect, and has a long pedicle with a large caliber vessel allowing comfortable microanastomosis with recipient vessels.[3],[12] Flap design benefits include a large and pliable skin territory, the ability to modify flap thickness by elevating a thin fasciocutaneous flap, or providing bulk by incorporating a cuff of the vastus lateralis muscle.[13],[14] Muscle flaps have been shown to decrease bacterial count by obliterating dead space, improving the vascularity and oxygen delivery to the wound, and enhancing leukocyte function, thereby promoting bone and soft tissue healing. Furthermore, as a reconstructive advantage, the pliability of muscle provides proper obliteration of the defect.[3]

Since its first application by Taylor et al.,[15] free vascularized fibula graft has become a well-established method for bone reconstruction with good functional outcome. The aim of reconstruction in this patient was threefold: restoration of the overall shape of the calcaneus, anatomical reconstruction of the joint surfaces, and stable osteosynthesis to allow early mobilization.[3],[16] The structural characteristics of the fibula, which are sufficient length, mechanical strength, the facility of folding the graft into two or three segments, predictable vascular pedicle, and limited donor-site morbidity, make it suitable for reconstructing the bone defects.[9] Vascularized bone struts generally do not undergo resorption; rather, they readily respond to imposed stress, resist infection, and are associated with rapid remodeling and hypertrophy.[9] Internal fixation materials were considered as possible causes of contamination in the patient.[3] The use of implant material was thus kept to a minimum by using two K wires. We were content to use stable fixation rather than rigid fixation, and a solid bone union was achieved.

  Conclusion Top

Open fractures of the calcaneus are uncommon injuries that are characterized by extensive soft tissue compromise and complex bony defects. They are also associated with an increased incidence of chronic osteomyelitis. This case report demonstrates that acceptable functional results can be achieved with a treatment protocol consisting of meticulous soft tissue and bone debridement, followed by a two-stage reconstruction with an ALT free flap and a vascularized fibula osteocutaneous flap.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Zhang X, Liu Y, Peng A, Wang H, Zhang Y. Clinical efficacy and prognosis factors of open calcaneal fracture: A retrospective study. Int J Clin Exp Med 2015;8:3841-7.  Back to cited text no. 1
Lawrence SJ, Singhal M. Open hindfoot injuries. J Am Acad Orthop Surg 2007;15:367-76.  Back to cited text no. 2
Ulusal AE, Lin CH, Lin YT, Ulusal BG, Yazar S. The use of free flaps in the management of type IIIB open calcaneal fractures. Plast Reconstr Surg 2008;121:2010-9.  Back to cited text no. 3
Koski EA, Kuokkanen HO, Koskinen SK, Tukiainen EJ. Reconstruction of soft tissue after complicated calcaneal fractures. Scand J Plast Reconstr Surg Hand Surg 2004;38:284-7.  Back to cited text no. 4
Berry GK, Stevens DG, Kreder HJ, McKee M, Schemitsch E, Stephen DJ. Open fractures of the calcaneus: A review of treatment and outcome. J Orthop Trauma 2004;18:202-6.  Back to cited text no. 5
Ahn JH, Lee SK, Choy WS, Kim HJ. Distally based adipofascial flap for the treatment of hind foot soft-tissue defects combined with an open calcaneal fracture. J Plast Reconstr Aesthetic Surg 2009;62:675-7.  Back to cited text no. 6
Aldridge JM 3rd, Easley M, Nunley JA. Open calcaneal fractures: Results of operative treatment. J Orthop Trauma 2004;18:7-11.  Back to cited text no. 7
Beltran MJ, Collinge CA. Outcomes of high-grade open calcaneus fractures managed with open reduction via the medial wound and percutaneous screw fixation. J Orthop Trauma 2012;26:662-70.  Back to cited text no. 8
Yazar S, Lin C, Wei F. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004;114:1457-66.  Back to cited text no. 9
Kuwae MY, Costa EN, Silva RP, Albieri AD, Moraes FB. Resection osteotomy for calcaneus flattening after micro-surgical flap: Technical note. Rev Bras Ortop 2016;52:119-22.  Back to cited text no. 10
Siebert CH, Hansen M, Wolter D. Follow-up evaluation of open intra-articular fractures of the calcaneus. Arch Orthop Trauma Surg 1998;117:442-7.  Back to cited text no. 11
Tamimy MS, Rashid M, Ehtesham-ul-Haq, Aman S, Aslam A, Ahmed RS. Has the anterolateral thigh flap replaced the latissimus dorsi flap as the workhorse for lower limb reconstructions? J Pak Med Assoc 2010;60:76-81.  Back to cited text no. 12
Collins J, Ayeni O, Thoma A. A systematic review of anterolateral thigh flap donor site morbidity. Can J Plast Surg 2012;20:17-23.  Back to cited text no. 13
Hanasono MM, Skoracki RJ, Yu P.A prospective study of donor-site morbidity. Plast Reconstr Surg 2010;125:209-14.  Back to cited text no. 14
Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533-44.  Back to cited text no. 15
Rammelt S, Zwipp H. Calcaneus fractures: Facts, controversies and recent developments. Injury 2004;35:443-61.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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