Outcomes of partial and total calcanectomies for the treatment of diabetic heel ulcers complicated with osteomyelitis. A systematic review and meta-analysis.

BACKGROUND

Infected diabetic foot ulcers (DFU) complicated with calcaneal osteomyelitis are a real challenge for limb preservation. Very few alternatives to amputation are available, mainly the resection of a part or the totality of the calcaneal bone. Calcanectomies were advanced as limb-sparing procedures in patients with heel osteomyelitis. However, there is a lack of pooled quantitative evidence on their efficacy and complications.

OBJECTIVES

The present systematic review and meta-analysis was conducted to determine the primary outcome of healing rates following partial (PC) and total calcanectomies (TC) in treating calcaneal osteomyelitis due to diabetic heel ulcers. Additionally, secondary outcomes such as secondary TC following PC, secondary below knee amputation (BKA), mortality and the change in the ambulation status were analyzed.

METHODS

Medline, Scopus, Web of science, Cochrane Library and Google Scholar were searched since inception. All types of study design were included. Single case report studies and studies reporting osteomyelitis due to other etiologies than DFU were excluded.

RESULTS

Twenty studies met the inclusion criteria comprising 295 patients with 300 calcanectomies (270 PC and 30 TC). With a mean follow-up period of 29.3±17.7 months, the weighted results were as follows: a) the osteomyelitis healing rate was of 80% (95% CI=0.728 to 0.861, I2=48.3%), b) the rate of secondary total calcanectomy was of 5.4% (95% CI=0.022 to 0.097, I2=7.5%), c) the rate of secondary BKA was of 17.1% (95% CI=0.111 to 0.241, I2=50.6%) with no difference between subgroups of TC and PC, and d) the combined mortality rate of both calcanectomies was of 13.4% (95% CI=0.064 to 0.224, I2=73.6%); however, significant higher mortality was found following TC compared to PC (p<0.0001).

CONCLUSION

Partial and total calcanectomies were found to yield very good healing rates with acceptable complication frequencies. When compared to the reported outcomes of below and above-knee amputations in the literature, calcanectomies could be fairly considered as good alternatives to above ankle amputations.