Abstract
Chronic calcaneal osteomyelitis represents a complex surgical challenge due to poor soft-tissue coverage, limited vascularity, and the weight-bearing function of the heel. While below-knee amputation has traditionally been considered the definitive treatment, calcanectomy offers a limb-salvage alternative in selected patients. Bilateral total calcanectomy is exceedingly rare, and functional outcomes remain uncertain. We report a case of bilateral total calcanectomy performed for chronic polymicrobial calcaneal osteomyelitis in a 66-year-old woman. At 24-month follow-up, infection eradication, complete pain relief, and independent ambulation with custom orthopedic footwear were achieved. Our case highlights that bilateral total calcanectomy may result in satisfactory functional outcomes in selected patients.
Introduction
Chronic calcaneal osteomyelitis accounts for approximately 3–10 % of all osteomyelitis cases. The most common causes are posttraumatic and diabetic foot conditions, with ulcers and sinus tracts being the predominant clinical findings. Treatment is particularly challenging due to the calcaneus’ limited vascularity, poor soft-tissue envelope, and repetitive stress due to weight-bearing. ,, Furthermore, the skin is tightly adherent to the bone, prompting infection to erode through the skin rather than forming subcutaneous abscesses.
While below-knee amputation (BKA) has historically been regarded as the gold standard for definitive infection control, ,, partial and total calcanectomy have emerged as limb-salvage alternatives. Systematic reviews report infection control rates of approximately 80 % after calcanectomy, with secondary BKA required in around 17 % of cases. Reports of bilateral calcanectomy are exceedingly rare with no detailed reports on clinical function. , We present a successful case of a bilateral total calcanectomy with satisfactory postoperative functional outcome.
Case description
A 66-year-old woman presented to the dermatologic department with chronic non-healing ulcers of both heels (left > 1 year, right 3 months). Her medical history included morbid obesity (BMI 38.5), type II diabetes mellitus, hypertension, and hypercholesterolemia. On admission, she showed signs of acute infection with bilateral lower-leg erysipelas. Initial wound cultures revealed Escherichia coli (3-MRGN), β-hemolytic Streptococcus species, and Prevotella bivia; blood cultures grew Streptococcus mitis/oralis. Following six weeks of intravenous meropenem (2 g three times daily) systemic infection resolved, but both heel ulcers persisted.
Subsequent wound assessment revealed ulcers probing to bone bilaterally. On the right side, a subcutaneous abscess cavity extended medially toward the forefoot. Radiographs and magnetic resonance imaging demonstrated extensive osteolysis and cortical destruction of both calcanei, confirming bilateral calcaneal osteomyelitis ( Fig. 1 ). Peripheral arterial disease was ruled out by vascular surgery evaluation using ankle–brachial index assessment and pelvic–leg CT angiography.
Preoperative Radiologic Imaging.
Given the confirmed osseous infection, the patient was transferred to the orthopedic service for surgical management. Initially, the subcutaneous abscess cavity on the right side was drained to relieve soft tissues. Given the refractory infection and progressive bony collapse, bone debridement was indicated. Because of bilateral involvement, the surgical goal was to preserve leg length through partial calcanectomy and insertion of an antibiotic carrier. However, if intraoperative findings showed more extensive destruction, conversion to total calcanectomy was agreed upon with the patient.
Surgical procedure
Under general anesthesia, the patient was positioned prone, and a longitudinal approach as described by Gaenslen was utilized. Both calcanei were found to be completely necrotic, friable, and non-viable. Consequently, bilateral total calcanectomy was performed. The Achilles tendons were sutured to the plantar soft-tissues to preserve residual plantarflexion strength and hindfoot contour. Primary wound closure was achieved without flap reconstruction.
Intraoperative bone cultures grew Staphylococcus haemolyticus, Enterococcus casseliflavus, Klebsiella pneumoniae , and Cutibacterium acnes . Histopathological examination confirmed chronic osteomyelitis.
Postoperative course
Intravenous meropenem (3 g twice daily) was continued until discharge after three weeks, followed by five doses of intravenous dalbavancin (1 g every two weeks) and oral trimethoprim–sulfamethoxazole (80/400 mg twice daily) for eight weeks.
The left heel healed uneventfully. The right side developed a superficial wound-healing disturbance that resolved after ten months without further surgical intervention.
Strict non-weight-bearing was maintained for seven weeks, followed by a gradual increase in weight-bearing using a heel-offloading orthosis until full weight-bearing was achieved at three months. At seven months postoperatively, the patient was provided with a custom-made, non-articulating off-loading ankle–foot orthosis in collaboration with a specialized prosthetic and orthotic service. The orthosis consisted of a rigid posterior thermoplastic shell with a shaft height of approximately 25 cm, combined with a soft midsole, a rocker bottom, and a cushioned heel. It incorporated a removable insole allowing for continuous modification during the postoperative course ( Fig. 2 ). At ten months, the patient was independently mobile, requiring walking aids only for longer distances.
custom made shoe.
At 24-month follow-up, she remained infection-free, reported complete pain relief, and was independently ambulatory in custom-made footwear, although with unsteady gait (Video 1). Active ankle range of motion was possible (Video 2). She was fully socially reintegrated, has resumed caring for foster children and selling produce at a local market.
Functional outcome measures showed an AOFAS score of 65 preoperatively and 70 at ten months postoperatively. At 24 months, the FAAM activities-of-daily-living score was 61.9 %. SF-36 assessments at 24 months demonstrated fair physical function (45/100 points) but no role limitations due to physical or emotional problems (both 100/100 points) and good social functioning (87/100 points).
Follow-up radiographs showed progressive calcification within the former calcaneal region and increasing dorsal subluxation of the Chopart joint line ( Fig. 3 ). Owing to satisfactory function, elevated surgical risk, and patient preference, no secondary stabilizing procedure was undertaken.
