A Retrospective Assessment of Partial Calcanectomies and Factors Influencing Postoperative Course

A Retrospective Assessment of PartialCalcanectomies and Factors InfluencingPostoperative Course

Jeremy Cook, DPM,1 Emily Cook, DPM,2 Adam S. Landsman, DPM, PhD,3

Philip Basile, DPM,4 Thanh Dinh, DPM,5 Thomas Lyons, DPM,6 Barry Rosenblum, DPM,7

and John Giurini, DPM8

Partial calcanectomies are a common procedure for the treatment of chronic heel ulcers. We reviewed50 cases from patients who had partial calcanectomies to determine what factors, if any, affect the rateof healing. Each case was followed up for 1 to 6 years after surgery. We found that calcanectomy woundswere difficult to heal, regardless of the etiology. We examined a multitude of factors to determine whichones affected the rate of closure, including body mass index, vascular status, preoperative albuminlevels, wound grade, presence of methacillin-resistant Staphylococcus aureus, and other factors. Wefound that the average total closure rate for patients undergoing partial calcanectomy was between 51%and 83% after 1 year, depending on various preoperative conditions. Our data suggest that even thoughthe procedure itself is fairly straightforward, the course of recovery is complex, with a fairly high rate offailure after 1 year. We found that preoperative infections with methacillin-resistant Staphylococcusaureus, vascular disease, albumin levels, and preoperative ulcer grade had a significant bearing on theoutcomes. We also identified other factors that did not seem to affect surgical outcomes. Based on thesefindings, the authors suggest some factors that should be considered when performing partial calcane-ctomies. (The Journal of Foot & Ankle Surgery 46(4):248–255, 2007)

Key words: partial calcanectomy, limb salvage, heel ulcers, osteomyelitis, MRSA

It is estimated that there are 17.7 million patients withdiabetes in the United States, and it has been projected thatthis number will double by the year 2030 (1). In 1996, thelifetime risk of a patient with diabetes developing a foot

Address correspondence to: Adam Landsman, DPM, PhD, FACFAS,Beth Israel Deaconess Medical Center, Department of Surgery, HarvardMedical School, One Deaconess Road, Boston, MA 02215. E-mail:[email protected].

1Chief Resident, Beth Israel Deaconess Medical Center, Department ofSurgery, Harvard Medical School, Boston, MA.

2Chief Resident, Beth Israel Deaconess Medical Center, Department ofSurgery, Harvard Medical School, Boston, MA.

3Beth Israel Deaconess Medical Center, Assistant Professor, Depart-ment of Surgery, Harvard Medical School, Boston, MA.

4Beth Israel Deaconess Medical Center, Clinical Instructor in Surgery,Department of Surgery, Harvard Medical School, Boston, MA.

5Beth Israel Deaconess Medical Center, Clinical Instructor in Sur-gery, Department of Surgery, Harvard Medical School, Boston, MA.

6Beth Israel Deaconess Medical Center, Clinical Instructor in Surgery,Department of Surgery, Harvard Medical School, Boston, MA.

7Beth Israel Deaconess Medical Center, Assistant Professor andDirector of Resident Training, Department of Surgery, Harvard MedicalSchool, Boston, MA.

8Beth Israel Deaconess Medical Center, Associate Professor and Divi-sion Chief of Podiatric Surgery, Department of Surgery, Harvard MedicalSchool, Boston, MA.

Copyright © 2007 by the American College of Foot and Ankle Surgeons
1067-2516/07/4604-0008$32.00/0doi:10.1053/j.jfas.2007.03.016
248 THE JOURNAL OF FOOT & ANKLE SURGERY

ulceration was 15% and has now been estimated to be ashigh as 25% (2). Heel ulcers have been reported to be themost serious type of foot ulceration leading to a proximalamputation (3). The National Pressure Ulcer PrevalenceSurvey of 1995 found that of the 39,874 patients in 265hospitals, the incidence of heel ulcers ranged from 19% to32% (4). Nonhealing ulcers have been linked to 85% ofmajor amputations (5). Long-term survival rates of majoramputations in patients with concurrent diabetes or renaldisease have been found to be dismal, with a 70% 1-yearsurvival rate and only 30% 5-year survival rate in a recentoutcomes series (6). Therefore, limb salvage is of para-mount importance for surgeons who treat this affliction.

Originally presented in 1931 (7) but described as early as1896 (8), the partial calcanectomy (PC) has been an estab-lished limb salvage procedure that offers patients an alter-native to amputation. Clinically, PCs are frequently chosenfor patients with substantial soft tissue loss, and may in-volve extensive bony exposure. Figure 1 demonstrates asevere ulceration of the heel, which required a PC. Figure 2demonstrates the marked loss of soft tissues, around thecalcaneus, apparent on this radiograph. Figures 3 and 4show the clinical and radiographic postoperative appearanceof the foot after PC.

The largest study published to date used PC in 29 patients

over a 10-year period for the treatment of heel ulceration. Inthis study, of the diabetic subgroup, which consisted of 18patients, only 22% of these patients went on to heal ascompared with 78% of the nondiabetic group. The finalhealing endpoint demonstrated a 65% failure rate in patientswith diabetes (9). Other studies have reported healing ratesof 40% to 100% (10–15), with the majority having a smallsample size or consisting only of case studies (16–21).Many studies do not define the amount of calcaneus re-sected (10, 13, 22) or presence of osteomyelitis (9, 11, 14),include pediatric patients (23, 24), or focus on traumatic(11, 25) or hematogenous etiology (23, 26).

The purpose of the current study was to evaluate theoutcomes of PCs in a large, consecutive series of nontrau-matic but limb-threatening heel ulcerations. This study alsosought to delineate associated preoperative conditions thatimpacted these outcomes. The complex nature of thesewounds, including their associated comorbidities, promptedour team to hypothesize that several factors may delay therate of healing after PCs. Among these elements with as-sumed predictive value were the presence of peripheralvascular disease (PVD), body mass index (BMI), poor nu-tritional status determined by albumin levels, wound classas described by the Wagner system (27), and the presence ofmethacillin-resistant Staphylococcus aureus (MRSA).

Materials and Methods

A total of 50 feet from 46 patients who underwent a PCbetween 2000 and 2004 at the Beth Israel Deaconess MedicalCenter, Boston, Massachusetts, were included in this retrospec-tive study. Fifteen of these patients were patients with type 1diabetes, 31 were patients with type 2 diabetes, and 1 was apatient without diabetes. In all cases, at least 1 year of fol-

FIGURE 1 This patient presented with extensive soft tissue lossand exposed calcaneus. PC, at the very least, would be necessaryto close this type of wound.

low-up was available, and, in some cases, as much as 6 years

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of follow-up was considered with a mean of 2.7 years offollow-up available. This study focused on the postoperativecourse of healing based on the preoperative health status of thepatient. As part of our assessment, we reviewed the charts togather the following information for analysis:

● Duration of ulcer before surgery● Age of patient● History of tobacco use● Preoperative ulcer grade● Albumin levels● Presence of MRSA versus other bacteria● BMI● Vascular disease and need for intervention

Using these data points, we evaluated what affect, if any,

FIGURE 2 This radiograph illustrates the extent of soft tissue lossas well as the condition of the calcaneus bone before surgicalintervention.

they had on the ability of a patient to heal his or her wounds,

LUME 46, NUMBER 4, JULY/AUGUST 2007 249

and the amount of time necessary to achieve closure. Wealso included the rate of postoperative dehiscence afterprimary closure in our review.

For the purposes of this study, a wound was consideredhealed if there was full epithelialization over the entire heelwithout further breakdown, and absence of drainage. Al-though we tracked wound sites for up to 6 years, the focusof our analysis was during the first year after PC surgery.Analysis was performed with the Student t test and analysis

FIGURE 3 This picture demonstrates a completely healed patientwound site.

FIGURE 4 This radiograph is of the same patient as in Figure 3 anddemonstrates the extent of bony resection that was necessary toachieve closure.

of variance for parametric data, and chi-square analysis was


used for nonparametric data. In addition, averages and stan-dard deviations (SD) were used to characterize progressionof healing in some cases.

Preoperative grading of the ulcer was based on the Wag-ner classification system (27) and was recorded for eachparticipant. Serum albumin was collected during the asso-ciated admission before the calcanectomy and was considernutritionally deficient if levels were noted to be �3.0 g/dL.BMIs were prepared by using measurements of weight andheight performed in the hospital. Bacterial isolates wereidentified from intraoperative specimens submitted for mi-crobial culture and gram staining. Patient data points such asage, history of tobacco, and duration of ulceration were selfreported.

Results

The data presented here were gathered retrospectivelyfrom our medical records. We analyzed data from 50 PCsperformed on 46 patients. The average age was 56.7 years(SD � 10.2 years), with 32 men and 14 women evaluated.Seven patients were lost to follow-up immediately aftersurgery, and 1 patient died 6 days after surgery from acerebrovascular accident.

In our study, we found that complete healing wasachieved in 71.4% during the first year, and this number

PC. The posterior defect is apparent, as is the total closure of the
after
increased to 76.2% when looking beyond the first year

follow-up period. The average time to full closure was201.2 days (SD � 282.7 days). Although many of thewounds were clinically closed at the time of surgery, ourcriteria for healing required removal of all sutures and nogaps or dehiscence noted along the incision lines. There wastremendous variation in the number of days required fortotal closure based on these criteria, with a range of 27 to1532 days observed.

Based on our criteria for vascular disease (nonpalpablepulses and ankle/brachial index � 0.7), 28 patients requiredsome form of vascular intervention before surgery. Inter-vention involved angioplasty, with or without insertion of astent, and/or distal bypass surgery. We found that the pa-tients with vascular disease who underwent an interven-tional procedure closed 65.2% (n � 23), whereas those whodid not have vascular disease closed 68.4.0% (n � 19) ofthe time, within 1 year. The average time to closure waslonger with the patients with vascular disease who required120.5 days (SD � 74.78 days) as compared with the pa-tients without vascular disease, who required 106.3 days toclose (SD � 89.7 days). Although a difference in healingtime was noted, it was not statistically significant (P � .33).This trend becomes slightly stronger when consideringlonger-term closure rates. We found that 73.9% of thewounds in patients with treated vascular disease closedeventually, whereas 84.2% closed in patients without vas-cular disease (P � .22).

Using the scale supported by the American Society forBariatric Surgery (28, 29), we found that the rate ofhealing was not measurably affected by the patient’s BMI(Table 1).

As with all open wounds, the risk of bacterial infection isquite high. In our study, 48 out of 50 (96%) of the woundsgrew out bacteria. Of these, 19 (38.8%) had MRSA isolates.The 35 patients who produced nonMRSA colonies werenoted to have a 71.4% closure rate as compared with 50.0%in the MRSA subgroup during the first-year period (P �.09). When we compared the time to healing between these2 categories, we found that the nonMRSA patients healed,on average, in 86.6 days (SD � 50.9 days), whereas thosewith MRSA isolates averaged 335.7 days (SD � 370.0days); the difference between these 2 averages proved to be

TABLE 1 BMI versus wound healing

BMI Wounds Healed by1 Year

Average Time toHeal (d)

�18.4 (underweight) 66.7% 139.018.5–24.9 (normal) 43.0% 112.025.0–29.9 (overweight) 66.7% 119.330–34.9 (obese, class 1) 66.7% 62.335.0–39.9 (obese, class 2) 66.7% 204.0�40.0 (morbidly obese) 75% 135.0

quite significant (P � .004).

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To assess the affect of nutritional status, preoperativeserum albumin levels were evaluated. Data were availablefor 32 of the patients in our study. We found that 56.3% ofthe patients with a low preoperative albumin level of 2.2 to3.0 g/dL (n � 16) healed during the first year, whereaspatients with an albumin level of �3.0 g/dL healed 68.8%of the time, during that same postoperative interval. Theaverage time to heal in the deficient group was 160.9 days(SD � 84.1 days), whereas the group with albumin levels�3.0 g/dL healed in 98.5 days (SD � 77.4 days) during thefirst year after surgery. This difference in healing time wasstatistically significant (P � .05).

Preoperative wound classification was one parameter thatstrongly influenced the rate of wound closure. Our studyincluded ulcers that ranged from Wagner grades 1 to 4, withthe vast majority of the wounds being grade 2 or grade 3.Analysis demonstrated that 83.3% of the grade 2 Wagnerwounds closed within 1 year, whereas only 51.5% of thegrade 3 Wagner wounds closed in the same time period.This difference in closure rate was statistically significant(P � .03). Wagner grade 2 ulcers typically required 97.5days (SD � 45.0 days) to close, as compared with grade 3ulcers, which required 142.6 days (SD � 85.8 days).

We also considered whether the length of time that theulcer was present before surgery (that is, wound age) hadany influence on the rate of healing and found that there wasno correlation between the age of the ulcer and the potentialfor healing. In fact, some of the oldest ulcers responded thequickest to surgical intervention (Fig 5).

Patients with a past medical history of smoking showedabout the same closure rate, but took a longer time to closetheir wounds as compared with nonsmokers. Nonsmokersrequired approximately 177.3 days (SD � 130.4 days),whereas smokers required 235.3 days (SD � 381.6 days) toachieve closure; however, the difference was not statisti-cally significant because of the large SD observed, particu-larly among smokers.

Another point of consideration was the impact of thepatient’s vascular status on the rate of dehiscence. Weconsidered whether our patients who were vascularly com-promised and underwent preoperative intervention (that is,angioplasty, stent, or bypass) were more likely to dehisceafter primary wound closure. Our results demonstrated that88.2% of the patients who were vascularly compromiseddehisced despite vascular intervention, whereas only 35.7%of those patients with adequate circulation developed thiscomplication. This difference was statistically significant(P � .001). We also found that 40% of the patients in ourstudy experienced a recurrent ulcer at some point, after totalwound closure.

Of the 46 patients monitored in our study, 8 ultimatelywent on to a below-the-knee amputation (BKA) secondaryto their initial ulceration, 2 underwent BKA for an unrelated
condition, and 2 had contralateral BKAs. One of the 8 BKA

e age

0.883

cases was performed bilaterally and is in addition to thecontralateral BKAs reported. Six patients were lost to fol-low-up. A Kaplan-Meier Life Table analysis (30) was per-formed (Table 2), and this reveals a probability of survivalof 0.883 during the first 4 years after surgery.

Discussion

In this study, we considered many different parametersthat could affect the outcome of PCs. Although the focus ofour analysis was closure of the wound, there are otherconsiderations as well, which are not measured here. Forexample, we did not consider whether our patients couldambulate after surgery, or what type of braces or shoe gearwould be required. Similarly, we plan to discuss the influ-ence of adjunctive treatments, such as skin grafting and thewound vacuum assisted closure, in future publications.

In our study, closure of a wound was the critical endpointin our analysis. All parameters were discussed in the context

FIGURE 5 This graph shows the correlation between th

TABLE 2 Kaplan-Meier Life Table analysis (number in trial � 4

Year Number Died Number Censored Surviva

1 3 62 13 14 0 0

of whether this endpoint was achieved. In fact, we found


that there were several factors that influenced a patient’sability to achieve closure, as well as the time necessary forsuch closure.

Several factors that had a clear bearing on this outcomewere identified. We found that the presence of MRSAappears to have a strong influence on the rate of woundclosure. Patients infected with MRSA required more time toachieve closure. In a study by Dang et al (31), at least 30.2%of the diabetic foot infections in their series of 93 patientswere MRSA isolates. Nearly all of our patients demon-strated preoperative bacterial infection, and 38.8% hadMRSA isolates. Although the prevalence of Staphylococcusaureus as a pathologic entity is well established (31), ourreview of the literature failed to produce any evidencethat MRSA is associated with prolonged surgical healing.Our results demonstrated a greater 1-year closure rate inthe nonMRSA arm (71.4%) versus only 50% in thosepatients with MRSA isolates (P � .004). Given ouraverage difference of 249.1 days in healing time between

of the ulcer and the time required for healing, after PC.

bability 95% Confidence Interval Number Surviving

1.009 to 0.851 400.998 to 0.815 390.985 to 0.781 380.985 to 0.781 38

9)

l Pro

0.930.9060.883

those with MRSA isolates and those with nonMRSA

isolates, it becomes apparent that, indeed, this organism,even with appropriate antibiotic coverage, still increaseshealing time.

Nutritional status has also been suggested to affect woundclosure as well (32). Our study demonstrated that low pre-operative albumin levels did lead to longer healing times.We found that patients with an albumin level of 3.0 g/dL orlower required an average of 62.4 days longer to heal thenthose patients with an albumin level greater than 3.0 g/dL(P � .05). In 1992, Smith et al (33) noted the importance oftrying to maintain albumin levels greater than 3.0 g/dL, andfelt that this affected the potential for closure of woundsafter PC. Bollinger et al (11) noted that although it is idealto maintain an albumin level �3.0 g/dL, one should not tryto first improve preoperative nutritional status and thusdelay a limb salvage procedure. Our results agree with thisas well. Patients with a lower albumin level had the samehealing rate, but the surgeon can expect the wounds to takelonger to heal postoperatively. Based on our findings, wewould advise both serum albumin screening and nutritionalconsultations as needed.

At the outset of this study, we hypothesized that patientswho carried a diagnosis of peripheral vascular compromise andhad undergone invasive interventions to correct this issuewould display a healing rate comparable with those withoutthis diagnosis, after PC. Our results revealed no statisticaldifference between the 2 groups in terms of either percentagehealed or time to healing. However, the rate of postoperativedehiscence after PC proved to be very significant betweenthese 2 groups. Patients with preoperative vascular compro-mise had a significantly greater rate of wound dehiscence(88.2%) versus patients without preoperative vascular compro-mise (35.7%) (P � .001). Those patients without a history ofvascular compromise were nearly 3 times less likely to developdehiscence after primary wound closure. We hypothesize thatthis may be due, in part, to the presence of microvasculardisease, which remains even after macrovascular blood flowhas been enhanced. This may result in poor perfusion at thewound margins, which has the potential to affect the patient’sability to maintain a closed wound. Based on these observa-tions, our team recommends enhanced vigilance in those pa-tients with prior vascular intervention to minimize these risks.

Many studies have included patients with PVD but failedto isolate their results for comparison with those patientswithout a history of PVD (33–35). Smith (10) consideredpatients with diabetes mellitus (DM) and PVD, and dividedpatients into 3 groups: patients with diabetes, vasculopathicpatients, and a group with both disorders, and found thatthere was no appreciable difference among the groups inoverall wound healing. Most participants required no morethan a debridement, and only 20% (n � 10) were selectedfor PC. The 10 patients who underwent a PC were stratifiedinto the previously mentioned groups, 6 patients had both
PVD and DM, and 4 patients had DM without PVD. For the
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purpose of analysis, they were treated as one group anddemonstrated that 5 of the 10 patients required bypass graftsbefore a PC. With an average follow-up of 122 weeks, theirstudy demonstrated a 40% mortality rate and a 20% ampu-tation rate at the completion of the study period. A 40%healing rate was noted within 26.1 weeks before the study’send.

As expected, the greater the depth and extent of thewound preoperatively, the greater the length of time it tookto heal. Most of the patients who underwent a PC wereeither a Wagner grade 2 or 3. The Wagner grade 3 ulcerstook 45 days longer to close than grade 2 ulcers (P � .03).It was felt that several factors contributed to this. The grade3 ulcers typically had a larger amount of soft tissue loss,making primary closure difficult or not possible. Therefore,having to allow these wounds to granulate secondarily tooklonger than complete primary closure, which was achievedwith smaller wounds.

We were surprised to see that BMI made no significantdifference in either the time to heal or the number of woundsclosed. In part, we attribute this to the small sample size.Although we considered 50 feet, there were so many levels ofBMI that the power of the study in this category dropped offprecipitously. The question of BMI is an interesting one. Be-cause most patients in this study began with a heel decubitusulcer, we felt that patients with very low BMI would lack fattypadding around the heel, and obese patients would weigh a lotand apply significant pressure to the overlying skin. However,our data did not support this hypothesis.

Wound age (that is, the amount of time that the woundwas present before surgery) also appeared to have no bear-ing on the outcome. In our study, we demonstrated thatolder ulcers may achieve closure in a very short period oftime or in a very long period of time. This was also true fornewly acquired wounds.

Although we screened the data to determine which of ourpatients were smokers, this also appeared to have no bearingon the time required for wound closure or the rate of woundclosure. This does not agree with the literature, whichfrequently discusses the negative attributes associated withsmoking, including vasoconstriction and ischemic changes(36, 37). We believe that this fact is not reflected in our databecause of the way we classified smokers. We recorded apatient as a smoker if he or she was a smoker at any timebefore undergoing the PC. We did not distinguish betweenthose who once were smokers who quit, and those whocontinued to smoke during recovery, and so forth.

Based on the current study, it is clear that the PC proce-dure represents just the starting point in a long road torecovery and limb salvage. We found that the recovery timewas generally a drawn-out procedure, requiring careful at-tention to the condition of the wound margins. We alsofound that certain factors could predictably lengthen this
recovery period dramatically. Patients with more involved

wounds, such as grade 3 Wagner ulcers, those with pooralbumin levels, those infected with MRSA, and those withPVD have a substantially worse prognosis then their coun-terparts without these confounding factors. Some aspectssuch as albumin levels and bacterial loads can be “managedaway,” whereas others cannot.

When counseling patients on whether to proceed with a PCor a more proximal amputation, a realistic postoperative coursemust be discussed. Patient compliance and expectation are ofparamount importance postoperatively with the attendant pro-longed healing intervals; immobilization and nonweightbear-ing, both elements essential to successful healing of a PC, mustbe emphasized with the patient preoperatively. It should alsobe remembered that in many cases, the alternative treatment isa BKA. Future studies will compare the morbidity and mor-tality of this procedure with the PC as well.

Conclusion

This study illustrates the complex nature of the PC andseveral factors that influence outcomes. Patients with ahistory of vascular intervention, although demonstratingroughly equivalent closure rates and times, appear to be ata higher risk for postoperative complications. Despite ade-quate antibiotic selection, the impact of resistant organismsappears to delay wound healing significantly. Althoughnutritional status does influence healing, appropriate inter-vention in the urgent setting should not be delayed tooptimize the patient. We further endorse the multidisci-plinary approach to care in these cases, but would empha-size the critical nature of the postoperative period.

References

1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence ofdiabetes: estimates for the year 2000 and projections for 2030. Dia-betes Care 25:1047–1053, 2004.

2. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patientswith diabetes. JAMA 2:217–228, 2005.

3. Younes NA, Albsoul AM, Awad H. Diabetic heel ulcers: a major riskfactor for lower extremity amputation. Ostomy Wound Manage 50:50–60, 2004.

4. Barczak CA, Barnett RI, Childs EJ, Bosley LM. Fourth nationalpressure ulcer survey. Adv Wound Care 10:8–26, 2005.

5. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limbamputation. Basis for prevention Diabetes Care 13:513–521, 1990.

6. Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, SkillmanJJ, Campbell DR, Scovell SD, LoGerfo FW, Pomposelli FB Jr. Majorlower extremity amputation: outcome of a modern series. Arch Surg139:395–399, 2004.

7. Gaenslen FJ. Split-heel approach in osteomyelitis of os calcis. J BoneJoint Surg 13:759–772, 1931.

8. Landerer A. Medianer Fersenschnitt. Centralbl. F. Chir XXIII:857,1896.

9. Crandall RC, Wagner FW Jr. Partial and total calcanectomy: a reviewof thirty-one consecutive cases over a ten-year period. J Bone Joint
Surg Am 63:152–155, 1981.

10. Smith WJ, Jacobs RL, Fuchs MD. Salvage of the diabetic foot withexposed os calcis. Clin Orthop Relat Res (296):71–77, 1993.

11. Bollinger M, Thordarson DB. Partial calcanectomy: an alternative tobelow knee amputation. Foot Ankle Int 23:927–932, 2002.

12. Isenberg JS, Costigan WM, Thordarson DB. Subtotal calcanectomyfor osteomyelitis of the os calcis: a reasonable alternative to free tissuetransfer. Ann Plast Surg 35:660–663, 1995.

13. Woll TS, Beals RK. Partial calcanectomy for the treatment of osteo-myelitis of the calcaneus. Foot Ankle 12:31–34, 1991.

14. Horwitz T. Partial resection of the Os calcis and primary closure inthe treatment of resistant large ulcers of the heel, with or withoutosteomyelitis of the os calcis. Clin Orthop Relat Res 84:149 –153,1972.

15. Wiltse LL, Bateman JG, Kase S. Resection of major portion of thecalcaneus. Clin Orthop 13:271–278, 1959.

16. Perez ML, Wagner SS, Yun J. Subtotal calcanectomy for chronic heelulceration. J Foot Ankle Surg 33:572–579, 1994.

17. Gidumal R, Evanski P. Calcaneal osteomyelitis following steroidinjection: a case report. Foot Ankle 6:44–46, 1985.

18. Anderson RB, Foster MD, Gould JS, Hanel DP. Free tissue transferand calcanectomy as treatment of chronic osteomyelitis of the oscalcis: a case report. Foot Ankle 11:168–171, 1990.

19. Giacalone VF, Gregory JL, Krych SM. Calcanectomy for the treatmentof calcaneal osteomyelitis. A case report J Am Podiatr Med Assoc81:88–92, 1991.

20. Naftulin KA, Stone PA, McGarry JJ. Bilateral total calcanectomy forthe treatment of chronic refractory osteomyelitis. J Am Podiatr MedAssoc 87:141–143, 1997.

21. Lehmann S, Murphy RD, Hodor L. Partial calcanectomy in the treat-ment of chronic heel ulceration. J Am Podiatr Med Assoc 91:369–372,2001.

22. Baravarian B, Menendez MM, Weinheimer DJ, Lowery C, Kosanov-ich R, Vidt L. Subtotal calcanectomy for the treatment of large heelulceration and calcaneal osteomyelitis in the diabetic patient. J FootAnkle Surg 38:194–202, 1999.

23. Rasool MN. Hematogenous osteomyelitis of the calcaneus in children.J Pediatr Orthop 21:738–743, 2001.

24. Feigin RD, McAlister WH, Joaquin VH, Middelkamp JN. Osteomy-elitis of the calcaneus. Report of eight cases Am J Dis Child 119:61–65, 1970.

25. Pridie KH. A new method of treatment for severe fractures of the oscalcis. A preliminary report Gynecol Obstet 82:671–675, 1946.

26. Eid AM. Treatment of chronic haematogenous osteomyelitis of the oscalcis. Acta Orthop Scand 48:712–717, 1977.

27. Wagner FW Jr. The dysvascular foot: a system for diagnosis andtreatment. Foot Ankle 2:64–122, 1981.

28. American Society for Bariatric Surgery. Available at: http://www.asbs.org. Accessed July 15, 2006.

29. World Health Organization. Obesity: preventing and managing theglobal epidemic. Report of a WHO Consultation. WHO TechnicalReport Series 894. World Health Organization, Geneva, 2000.

30. Kaplan EL, Meier P. Nonparametric estimation from incomplete ob-servations. J Am Stat Assoc 53:457–481, 1958.

31. Dang CN, Prasad YDM, Boulton AJM, Jude EB. Methicillin-resistantStaphylococcus aureus in the diabetic foot clinic: a worsening prob-lem. Diabetic Med 20:159–161, 2003.

32. Raffoul W, Far MS, Cayeux MC, Berger MM. Nutritional status andfood intake in nine patients with chronic low-limb ulcers andpressure ulcers: importance of oral supplements. Nutrition 1:82– 88,2006.

33. Smith DG, Stuck RS, Ketner L, Sage RM, Pinzur MS. Partial calca-nectomy for the treatment of large ulcerations of the heel and calcaneal
osteomyelitis. J Bone Joint Surg Am 74:571–576, 1992.
http://www.asbs.org

http://www.asbs.org

34. Randall DB, Phillips J, Ianiro G. Partial calcanectomy for the treat-ment of recalcitrant heel ulcerations. J Am Podiatr Med Assoc 95:335–341, 2005.

35. Brooks KR, Sheldon SL, Wayne SB. Calcanectomy for treatment of
the infected os calcis. Tech Foot Ankle Surg 3:165–176, 2004.
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36. Freiman A, Bird G, Metelitsa AI, Barankin B, Lauzon GJ. Cutaneouseffects of smoking. J Cutan Med Surg 6:415–423, 2004.

37. Lind J, Kramhoft M, Bodtker S. The influence of smoking on com-plications after primary amputations of the lower extremity. Clin
Orthop Relat Res 267:211–217, 1991.

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A Retrospective Assessment of Partial Calcanectomies and Factors Influencing Postoperative Course