Staged Subtalar Fusion for Severe Calcaneus Fractures with Bone Loss
A 19-year-old woman was transferred to our trauma center from another facility for treatment of injuries she sustained as the unrestrained driver in a motor vehicle accident. She was found to have an open right calcaneus fracture, in which a 2 cm x 3 cm bone fragment from the posterior calcaneal facet had been extruded out the medial-sided 6 cm skin laceration. A CT scan was obtained, which demonstrated a comminuted intra-articular calcaneus fracture.\nThe patient was taken to the operating room that night for irrigation and debridement, where it was determined that the extruded bony fragment contained approximately two-thirds of the posterior facet of the calcaneus. It reportedly had a thread of attached viable soft tissue, and thus it was reduced back to its anatomic position. The patient was taken back to the operating room for repeat irrigation and debridement. At this time, it was felt that the bony fragment was no longer viable, and it was therefore excised. Three Steinmann pins were used for fixation of the remaining fragments, and the void left behind from excision of the posterior facet fragment was filled with a strand of antibiotic beads consisting of polymethyl methacrylate (PMMA) mixed with tobramycin and strung on a wire. The skin was closed without tension.\nThe medial wound healed over the course of two months and the skin recovered. The patient was taken to the operating room at 12 weeks after her initial injury for hardware removal, removal of the beads, and subtalar bone block fusion using iliac crest bone graft and resorbable beads mixed with tobramycin. She was allowed to bear full weight on her right lower extremity seven weeks postoperatively. Radiographic evidence of solid fusion was noted 15 weeks postoperatively.\nThe patient was able to wear a regular shoe and return to full time employment as a factory worker.