40-year old male sustained an open calcaneus fracture after a 20 foot fall. Initial surgery was an irrigation and debridement with definitive fixation 10 days after injury. 6 months later patient presented with an infected non-union and hardware failure. Cultures were positive for MRSA.
Treatment - stage 1
Hardware removal, debridement of grossly infected bone and soft tissues. STIMULAN
mixed with antibiotic was used to fill the resulting dead space and treat the bacterial infection. I.V. antibiotics for 8 weeks
Outcome - stage 1
Infection eradicated, soft tissues healed, infectious lab studies normal (1 month after I.V. antibiotics completed). Foot suitable for correction of proximal migration of calcaneus (soft tissue releases) and subtalar fusion.
Treatment - stage 2
Subtalar fusion procedure performed. STIMULAN was used again to fill the remaining dead space in and around the talus and calcaneus (image with STIMULAN at the fusion stage not included). Vancomycin and tobramycin were used to prevent infection recurrence. I.V. antibiotics restarted as prophylaxis.
2 months later hardware removed again due to positive blood cultures. Calcaneus cultures were negative however the PICC line catheter tip was culture positive. A new PICC line was placed followed by another 8 weeks of I.V. antibiotics.
Outcome - stage 2
This patient is now weight bearing as tolerated and clinically no signs of infection.
Infection in open calcaneus fractures is common and in some series amputation rates exceed 50%. For this patient a 2 stage approach was utilised to treat the infected non-union. Removal of hardware and aggressive debridement of the bone. The dead space was managed with STIMULAN.
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