Aim. Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below knee amputation; particularly in cases of severe soft tissue destruction. This study assesses the outcomes of combined ortho-plastics treatment of complex calcaneal osteomyelitis. Method. A retrospective review was performed of all patients who underwent combined single stage ortho-plastics treatment of calcaneal osteomyelitis (2008- 2022). Primary outcome measures were osteomyelitis recurrence and BKA. Secondary outcome measures included flap failure, operative time, complications, length of stay. Results. 33 patients (16 female, 17 male, mean age = 54.4 years) underwent combined ortho-plastics surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (s.d. 24.3). 20 received a local flap, 13 received a free flap. Fracture-related infection (39%) and diabetic ulceration (33%) were the commonest causes. 54% of patients had already undergone at least one operation elsewhere. There were seven cases of recurrent osteomyelitis (21%); all in the local flap group. One patient required a BKA (3%). Recurrence was associated with increased mortality risk (OR 18.8 (95% CI 1.5–227.8), p=0.004) and reduced likelihood of walking independently (OR 0.14 (95% CI 0.02–0.86), p=0.042). Local flap reconstruction (OR 15 (95% CI 0.8–289.6), p=0.027) and peripheral vascular disease (OR 39.7 (95% CI 1.7–905.6), p=0.006) were associated with increased recurrence risk. Free flap reconstruction took significantly longer intra-operatively than local flaps (443 vs 174 minutes, p<0.001), but without significant differences in length of stay or frequency of out-patient appointments. Conclusions. Single stage ortho-plastic management was associated with 79% eradication of infection and 3% amputation in this complex and co-morbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. Whilst good outcomes can be achieved, this treatment requires high levels of in-patient and out-patient care

Aim. Calcaneal osteomyelitis is an uncommon and challenging condition. In this systemic review we aim to analyse the concomitant use of bone debridement and soft tissue management for patients diagnosed with calcaneal osteomyelitis. Method. A complete computerised and comprehensive literature search of Pubmed and Cochrane database was undertaken from January 2000 to October 2018. During the review, studies were screened for information about the surgical and antimicrobial treatment, the complications, the reinfection rate and the functional outcome of patients with calcaneal osteomyelitis. Results. Of the 20 studies included, seven (35%) described bone treatment only, six (30%) soft tissue treatment only, five (25%) soft tissue and bone treatment, and two (10%) focused on prognostic factors and differences in outcomes between diabetic and non-diabetic patients. In the studies with bone treatment only, infection recurrence ranged from 0 to 35% and the amputation rate from 0 to 29%. If soft tissue coverage was also needed, both the reinfection rate and amputation rate ranged from 0 to 24%. Studies presenting the functional status showed preservation or even improvement of the preoperative ambulatory status. Conclusions. Calcaneal osteomyelitis is difficult to treat. A multidisciplinary approach involving orthopaedic surgeons, plastic surgeons and infectious disease physicians is necessary for treatment success. Based on the localisation and size of the bone and soft tissue defect, decision for surgical treatment should be made

Chronic calcaneal osteomyelitis is a rare and not usually part of the initial differential diagnosis of pseudotumoral calcaneal lesions. Presentation of surgical and functional outcomes of a case of a total calcanectomy. This can be seen as a foot rescue alternative in patients with chronic calcaneal osteomyelitis. We present the case of a 60 year- old patient with complaints of diffuse and intermittent pain in the left heel with 3 years of evolution. Radiographically, lytic lesion image sclerotic edges that covers the entire calcaneus, with preservation of cortical. MRI shows holo-calcaneal lesions compatible with tumor, infectious or inflammatory lesion. A biopsy is inconclusive. Negative microbiology results. Regular analytical study. It was decided to conduct a total calcanectomy. Procedure took place without complications. Patient still skin healing phase, without any pain complaint. It presents iconographic material made if and procedure. The total calcanectomy is an alternative procedure to transtibial amputation in patients with chronic calcaneal osteomyelitis

Aim. To demonstrate the use of indium-111 white-cell labelled SPECT CT (In111-WC-SPECT-CT) in bone infection. Method. This novel imaging modality is useful in bone infection. We present three cases of complex osteomyelitis to illustrate this. All were imaged with conventional modalities, but conclusive diagnosis could not be achieved. In111-WC-SPECT-CT was used to provide the definitive imaging that allowed successful treatment. Results. Case 1- A 29 y/o Male with spina bifida presented with chronic calcaneal osteomyelitis. Previous treatment included debridement, but recurrent infection ensued. MRI showed widespread changes consistent with infection throughout the calcaneus and a below knee amputation was planned. In111-WC-SPECT-CT (Figure 1) showed a distinct localised nidus of infection. A targeted sequestrectomy was performed and the patient has been infection free for four years. He was spared the amputation. Case-2- A 73 y/o male presented with a radiation induced colo-cutaneous fistula and pelvic chronic osteomyelitis. Surgical treatment included multiple debridements and sequestrectomy. He re-presented pain with pain in his pelvis six months later. MRI was performed and oedema seen in the bone. This was presumed to be infection and further surgery was planned. An In111-WC-SPECT-CT was then performed and confirmed no residual bone infection. The patient was spared surgery. Case-3- A 38 y/o female was involved in an RTA 6 months prior to presentation. She underwent fixation of her tibia with skin grafting for an open fracture. There was clinical suspicion of deep infection. The metalwork made MRI difficult to interpret. An In111-WCC-SPECT-CT confirmed infection around the metal screw and this evidence instigated a prolonged course of antibiotics to suppress the infection. The screw will be removed after the fracture heals. Conclusions. In-111-WC-SPECT-CT is an emerging imaging modality. We present three cases of complex bone and joint infection; where this imaging has altered the course of treatment

The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used. From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation. 29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test. Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients. Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction