Journal of Bone & Joint Surgery - American Volume:
Letters to the Editor
Corresponding author: Steven J. Lawrence, MD University of Kentucky Kentucky Clinic, K 401 740 South Limestone Lexington, KY 40536 firstname.lastname@example.org
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 calcaneal fractures, provides concise and much needed guidance on a daunting orthopaedic problem. This injury has been largely ignored in the orthopaedic 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 studies have described substantially lower rates of infection1-3. Obviously, this difference may result from multiple variables, such as the number of wound débridements or the adequacy of débridement, antibiotic selection, or time to stabilization.
Heier et al. recommend a delay of definitive fixation until the wound is clean and soft-tissue swelling is minimal. In their series, fixation was undertaken at an average of 7.3 days after presentation at the hospital and the wound was “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 time frames should substitute for sound clinical judgment. Heier et al. conclude that, as a result of their study, changes have been made in their treatment protocols. We would appreciate it if they would share their 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.
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
These letters originally appeared, in slightly different form, on jbjs.org. They are still available on the web site in conjunction with the article to which they refer.
1. , Easley M, Nunley JA. Open calcaneal fractures: results of operative treatment. J Orthop Trauma. 2004;18: 7-11.
2. , Grau GF. Evaluation and treatment of open calcaneal fractures: a retrospective analysis. Orthopedics. 2003;26: 621-6.
3. , Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18; 1-6.