Radical surgical treatment of calcaneal osteomyelitis: clinical characteristics and treatment efficacy based on a synthesis analysis of 364 reported cases.

Abstract

Background: Calcaneal osteomyelitis (CO) poses substantial therapeutic challenges due to the distinctive anatomy and function of the calcaneus. Although multiple treatment modalities are available, severe cases frequently require radical surgical interventions, such as partial or total calcanectomy, and even amputation. Nevertheless, the clinical profile of these patients is not well characterized. Consequently, this study aimed to examine and elucidate clinical characteristics and treatment outcomes of CO patients who have undergone radical surgical interventions.

Methods: A systematic literature search was conducted by two independent authors across the PubMed, Embase, and Cochrane Library databases to identify English-language studies published between January 1, 2000, and December 31, 2021, focusing on patients with CO who had undergone partial or total calcanectomy, as well as limb amputation. Studies were selected based on pre-defined inclusion and exclusion criteria. Quality assessment was performed using the National Institutes of Health (NIH) assessment tool, and effective data were extracted and synthesized for analysis.

Results: Altogether 364 CO patients were enrolled, with a male-to-female ratio of 1.88:1 (188 males and 100 females). The median age at diagnosis was 58.5 years. Diabetic foot ulcers emerged as the predominant cause, and pathogen cultures indicated a high positivity rate of 97.2% (106/109). Staphylococcus aureus was the most commonly isolated strain at 33.3% (20/60), with polymicrobial infection accounting for 24.1% (19/79). The overall infection recurrence rate was 33.1% (105/317), with total calcanectomy and partial calcanectomy being 45% (18/40) and 30.4% (72/237), respectively. Among the 104 patients who underwent amputation procedures, 49 patients were subjected to primary amputations, with the remaining 55 patients receiving secondary amputations following partial or total calcanectomy. The majority of secondary amputations, specifically 78.2% (43/55), occurred after partial calcanectomy, whereas 21.8% (12/55) followed total calcanectomy. The overall mortality rate across all the 345 patients was 5.8%, with no fatalities being directly attributable to CO.

Conclusions: In this cohort of patients that received radical surgical interventions, the majority were middle-aged males, and the diabetic foot ulcer was the leading cause. Staphylococcus aureus continued to be the most frequently isolated pathogen. Even among patients who received partial and total calcanectomy, clinical efficacy remained unsatisfactory due to high rates of infection recurrence, leading to a high incidence of secondary limb amputation.