Response to Letter to the Editor

Abstract

We appreciate your comments regarding our publication. It appears you are in agreement with our report; osteomyelitis of the calcaneus with pathologic fracture, especially in compromised patients, is a significant and underexamined complication. Certainly, standard good-quality wound care and a multidisciplinary approach that addresses management of comorbidities (vascular status, diabetes control, etc) are critical; however, we would argue that even in this setting, pathologic fracture of the calcaneus can occur. As demonstrated by the cases we presented, surgical planning of this complication must take into consideration the importance and viability of the Achilles insertion, adequate bone infection resection, maintaining a plantigrade foot, and stimulating wound healing. Our treatment methods varied from fracture excision, external fixation, percutaneous fixation, Achilles repair/attachment with bone anchor fixation, and Achilles tendon lengthening. With only 1 of 4 cases going on to heal, excluding the deceased patient, this speaks to the morbidity of this complication. Our publication hoped to shed light on this issue and provide considerations for its managment. Given the grim prognosis of the issue, we do not believe that the outcome was reliably predicted by the treatment method, but instead should be attributed to the significance of this complication and the urgency with which heel wounds must be treated, including significant offloading and aggressive osteomyelitis management before catastrophic failure of both the wound and bone. We commend your work, as much more research needs to be completed in our profession on this particular issue.