To the Editor:

We appreciate the comments from Drs. Lawrence and Grau regarding our study of patients with open calcaneus fractures. While there have been recent articles on open calcaneus fractures, most have had a somewhat different set of injury patterns. (1,2,3). All of our patients were treated at a major level I trauma center. Additionally, all the patients were treated by experienced orthopedic trauma surgeons with extensive training in dealing with debridement techniques in open fractures. While Dr . Lawrence has noted a deep infection in one out of every five patients, we believe that one should resist the temptation to combine simple wounds with those that are complex (the proverbial apples and oranges), otherwise there would be no need for classification systems.

The purpose of our research was to evaluate which subsets of patients did poorly. Many of our patients had high energy wounds as noted by the high percentage of type III fractures (60%). We identified increased infection rates and poor outcomes in patients with penetrating injuries, lateral and extensive wounds, and type III open fractures. Because of our poor results with early internal fixation in these injuries we changed our protocol, subsequently improving our outcomes. While we agree with Dr. Lawrence’s statement that osteosynthesis should be delayed until the traumatic wound is covered, nowhere in our manuscript have we advocated leaving exposed implants in an open granulating wound. A review of our data reveals that other than an occasional lag screw inserted for an unstable fragment, all implants were placed after soft tissue coverage was performed.

Our recommended treatment protocol is presented at the conclusion of the Discussion section. All wounds are still debrided initially and as frequently as needed until they are clean. Type I and II open fractures, especially with medial wounds, can still be treated similar to closed fractures, with the initial debridement and ORIF at two to three weeks. Importantly, for the more severe fractures, which are very different injuries, we recommend either external fixation, or limited lag screw fixation, with attention to the state of the soft tissues.

The conclusion of our study must remain crystal clear: soft tissue injury determines outcome, and in the treatment of open calcaneal fractures, soft tissue damage coupled with the location and pattern of the wound should be the surgeon’s primary concern. Thank you for allowing us to expound on our thesis.

Keith Heier, M.D. Anthony Infante, D.O. Arthur Walling, M.D. Roy Sanders, M.D. Tampa, Florida.

To the Editor:

We wish to congratulate Dr. Heier and colleagues for their contribution, "Open Fractures of the Calcaneus: Soft tissue Injury Determines Outcome" (2003;85:2276-82). Their article, detailing the management of open calcaneus fractures, provides concise and much needed guidance on a daunting orthopedic problem. This injury has been largely ignored by our Orthopedic literature.

After reviewing the article, we were surprised by the report of a deep infection in nearly one in every five such injuries. Three recent publications have reported significantly lower rates of infection.1,2,3 Obviously, this difference may result from multiple variables, such as number or adequacy of debridement, antibiotic selection,or time to stabilization. Dr. Heier recommends a delay of definitive fixation until the wound is clean and soft-tissue swelling is minimal. In his series, fixation was undertaken at an average of 7.3 days and the wound "covered" at 10.6 days. This implies that, in some instances, fixation was performed in the presence of an open, granulating wound. In our experience, we have found that osteosynthesis should be delayed until the traumatic wound is covered. In general, this scenario is not typically present before the tenth day. Of course, each injury should be judged individually--no rigid timeframes should substitute for sound clinical judgement. Heir concludes that, as a result of their study, changes have been made in their treatment protocols. We would appreciate if Dr. Heir would share his comments on these modifications.

Again, the authors deserve congratulations on their concise, timely monograph which will undoubtedly serve as a foundation for the evaluation and management of these difficult open hindfoot injuries.

References

1. Aldridge JM, Easley M, Nunley JA. Open Calcaneal Fractures. J Orthop Trauma. 2004;18:7-11.

2. Lawrence SJ, Grau GF. Evaluation and Treatment of Open Calcaneal Fractures:A Retrospective Analysis. Orthopedics. 2003;26:621-6.

3. Benirschke SK, Kramer PA. Wound Healing Complications in Closed and Open Calcaneal Fractures. J Orthop Trauma. 2004;18;1-6.

Steven J. Lawrence, MD

Gregory F. Grau, MD