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OTA 2002 - Session 5 Session V - Foot and Ankle Sat., 10/12/02 Foot & Ankle, Paper #34, 9:41 AM Chopart Joint Fracture Dislocations: Initial Open Reduction is Better than Closed Reduction Martinus Richter, MD ; Tobias Hüfner, MD; Ulf Schmidt, MD; Thomas Gosling, MD; Jens Geerling, MD; Christian Krettek, MD, FRACS; Trauma Department, Hannover Medical School, Hannover, Germany Purpose: Cause of injury and long-term results of patients with Chopart joint dislocations or fracture dislocations were evaluated with regard to injury pattern and treatment procedures to create a basis for optimization of treatment. Methods: Cause of injury, type and extent, treatment, and long-term results were assessed clinically and with use of pedobarography. Scores of patients with Chopart joint dislocations on the AOFAS-M (midfoot), HSS (Hannover Scoring System), and our own questionnaire were evaluated. Results: Between 1972 and 1997, 100 patients with Chopart joint dislocations were treated at our institution. Men ( N = 68) were affected twice as often as women ( N = 32). The mean age was 32 years (range, 17 to 85). Both sides were involved in an equal percentage (right, 46; left, 44; bilateral, 10). Pure Chopart joint dislocations were observed in 28 patients (25%), fracture dislocations in 60 patients (55%), and combined Chopart & Lisfranc joint fracture dislocations in 22 patients (20%). Injury causes included vehicular trauma in 90, car occupants, 55; motorcyclists, 31; falls, 8; and others 10. The primary treatment was operative in 91 (83%); 10 were closed procedures, 81 had open reduction, and 12 were initial amputations. Six arthrodeses were initially performed (3 fracture dislocations, 3 Chopart and Lisfranc joint fracture dislocations), and 28 fasciotomies at the foot. Nineteen (17%) feet (exclusively pure Chopart joint dislocations) were treated nonoperatively with a short leg cast. Altogether, a secondary arthrodesis was required eight times (7.3%; three after dislocation-fracture, five after Chopart and Lisfranc joint fracture dislocations). Sixty-five (65%) patients with 66 Chopart joint dislocations (one bilateral) had follow-up examinations after an average of 9 years (range, 1 to 25); 8 patients had died before examination, and 4 had undergone an amputation. The mean scores of the entire Chopart joint dislocation follow-up group were AOFAS-M, 75 (range, 35 to 100); HSS, 69 (range, 29 to 100), and our own questionnaire, 68 (range, 30 to 100). There were no significant differences in scores because of age, sex, injury cause, time, or type of treatment. There were no differences in scores between patients with pure Chopart dislocations (mean scores, AOFAS-M, 78; HSS, 79; our own questionnaire, 73) and those with fracture dislocations (AOFAS-M, 73; HSS, 77; our own questionnaire, 68) ( t -test, P >0.05). Patients with combined Chopart and Lisfranc joint fracture dislocations had significantly lower mean scores (AOFAS-M, 61; HSS, 57; our own questionnaire, 48) ( t -test, P = 0.05). For patients with all three injury pattern groups, an initial anatomic reduction was essential for good results. An open reduction showed better results than closed reduction in fracture dislocations and combined Chopart and Lisfranc joint fracture dislocations (mean scores for open reduction: AOFAS-M, 75; HSS, 78; and our own questionnaire, 72; closed reduction: AOFAS-M, 55; HSS, 52; and our own questionnaire, 45) ( t -test, P <0.05). For pure Chopart joint dislocations, closed and open reduction had similar results. Discussion: Chopart joint dislocations are uncommon. In our clinical study we found the same proportion of pure Chopart joint dislocations and fracture dislocations as described in the literature. The injuries mainly occurred in multiply injured automobile occupants. Diagnosis and treatment were found to be as difficult as previously described. The overall results of the different scoring systems in our study are comparable to those of other studies. In our patients, the reduction was problematic, especially in fracture dislocations. A closed reduction could usually not restore anatomic alignment. An open reduction was considered to be necessary in those patients. In pure dislocations, a closed reduction was more successful. However, for some pure dislocations an open procedure was necessary. Our long-term results showed that open reduction in fracture dislocations was superior to closed reduction. For pure dislocations, there were no significant differences between open and closed reduction. An internal fixation was frequently necessary to maintain the reduction. In extremely unstable conditions, an additional external fixation was useful. Conclusion: The long-term results of Chopart joint dislocations are characterized by high functional restrictions, which can most likely be minimized with initial open reduction, especially in fracture dislocations. A closed reduction is only acceptable in pure dislocations, when anatomic conditions can be restored.

OTA 2002 - Session 5 Session V - Foot and Ankle Sat., 10/12/02 Foot & Ankle, Paper #31, 9:16 AM Operative Management of Talar Neck Fractures: Outcomes and the Effect of Timing Heather A. Vallier, MD ; Sean E. Nork, MD; David P. Barei, MD; Stephen K. Benirschke, MD; Bruce J. Sangeorzan, MD; Harborview Medical Center, Seattle, Washington, USA Purpose: Talar neck fractures are typically the result of high-energy trauma and are frequently associated with osteonecrosis and posttraumatic peri-talar arthritis. Because of the poor blood supply to the talus, these injuries are frequently treated urgently to preserve any remaining blood supply. We evaluated the incidence of osteonecrosis and posttraumatic arthritis after fixation of these fractures, the impact of surgical delay on results, and the functional outcomes after talar neck fractures. Methods: Over a 67-month period, 100 consecutive patients with 102 talar neck fractures (OTA classification 72-A1) were treated surgically at a level-1 trauma center. Sixty men and forty women with an average age of 32.6 years (range, 13 to 77) and an average Injury Severity Score of 15.8 (range, 9 to 50) were identified. The fractures were divided into groups (Hawkins' classification as modified by Canale and Kelly): type I ( N = 4), type II ( N = 68), type III ( N = 25), and type IV ( N = 5). Twenty-four fractures were open. Twenty-three patients had contiguous talar body fractures, and 20 had associated lateral process fractures. All fractures were treated with open reduction and rigid internal fixation by using small fragment or mini-fragment implants or both. Dual anteromedial and anterolateral surgical approaches were used in 91 patients. Complications, secondary procedures, and the radiographic presence of osteonecrosis and posttraumatic arthritis were determined. Foot Function Index (FFI) and Musculoskeletal Functional Assessment (MFA) questionnaires were administered and the results tabulated. Results: Sixty fractures were evaluated at an average of 35.7 months >from injury (range, 12 to 74). Fixation was performed within the first 24 hours in 40 patients (67%). Delayed presentation and associated life-threatening injuries precluded urgent operative management in the remaining 20 patients. The average time from injury to fixation was 3.7 days (range, 4 hours to 48 days). Radiographic evidence of osteonecrosis was identified in 53% of patients. However, 37% of these patients demonstrated revascularization of the talar dome radiographically without collapse. Osteonecrosis was seen in 39% of Hawkins II fractures, with 56% of these progressing to collapse of the talar dome. In Hawkins III fractures, 64% developed osteonecrosis, and 67% of these progressed to collapse. Chi square analysis of fixation within 6 hours, 8 hours, 12 hours, or 24 hours, determined no correlation between surgical delay and the development of osteonecrosis. Time was also analyzed as a continuum using a Student's t -test, and no correlation was seen between the time to fixation and the development of osteonecrosis. The mean time to fixation for patients who developed osteonecrosis was 3.4 days (range, 4 hours to 20 days) compared with 5.0 days (range, 4 hours to 48 days) for patients who did not develop osteonecrosis. Further analysis of all cases with fixation within 24 hours revealed a 50% incidence of osteonecrosis; the mean time to fixation for both patients with and without osteonecrosis was 13 hours. Osteonecrosis was associated with comminution of the talar neck (58% incidence, P <0.03) and with open fractures (69% incidence, P <0.05). Fifty-four percent of patients developed posttraumatic arthritis of the tibiotalar or subtalar joints or both. Posttraumatic arthritis occurred more frequently after comminuted talar neck fractures (61% incidence, P <0.07) or after open fractures (69% incidence, P = 0.09). Patients with comminuted fractures or open injuries also had lower functional outcome scores on the FFI and MFA. Discussion and Conclusions: The impact of surgical delay on the outcome of talar neck fractures is unknown. It has been suggested that early operative intervention protects the already tenuous blood supply to the posterior portion of the talus after a fracture of the talar neck. Although the numbers in this series are small, no correlation was found between surgical delay and the development of osteonecrosis. Osteonecrosis and posttraumatic arthritis were associated with talar neck comminution and open fractures, confirming that higher-energy injuries have more complications and a worse prognosis. This finding is further strengthened by the poor FFI and MFA scores among patients with comminuted fractures or open injuries. We continue to recommend expeditious fracture fixation, with urgent management of open injuries and reduction of dislocations. Proceeding with definitive fixation in this setting, whenever possible, will provide rigid fracture stability and may promote early revascularization of fracture fragments.

OTA 2002 - Session 5 Session V - Foot and Ankle Sat., 10/12/02 Foot & Ankle, Paper #35, 9:54 AM Operative Treatment of Calcaneal Fractures for Elderly Patients Dolfi Herscovici, Jr., DO ; James Widmaier, MD; Julia M. Scaduto, ARNP; Anthony Infante, DO; Roy W. Sanders, MD; Thomas G. DiPasquale, DO; Tampa General Hospital, Tampa, Florida, USA

OTA 2002 - Session 5 Session V - Foot and Ankle Sat., 10/12/02 Foot & Ankle, Paper #32, 9:22 AM Surgical Treatment of Fractures of the Talar Body Heather A. Vallier, MD; Sean E. Nork, MD ; Stephen K. Benirschke, MD; Bruce J. Sangeorzan, MD; Harborview Medical Center, University of Washington, Seattle, Washington, USA

OTA 2002 - Session 5 Session V - Foot and Ankle Sat., 10/12/02 Foot & Ankle, Paper #33, 9:35 AM The Mangled Foot and Ankle: The Role of Soft Tissue Coverage Michael J. Bosse, MD 1 ; Renan C. Castillo, MPH; Dolfi Herscovici, Jr., DO 2 ; Thomas G. DiPasquale, DO 2 ; Ellen J. MacKenzie, PhD; 1 Carolinas Medical Center, Charlotte, North Carolina, USA 2 Tampa General Hospital, Tampa, Florida, USA (-NIH Grant) Purpose: Severe injuries to the foot and ankle require significant reconstructive surgery for salvage. Many authors feel that amputation in these circumstances result in a superior functional outcome. One determinate in the literature has been whether or not the patient will require a bulky free tissue transfer, as in many situations this will make shoe wear untenable. This study was undertaken to determine the functional outcome of the mangled foot and ankle undergoing salvage, with and without the need for free tissue transfer, and compare this cohort to a similar group undergoing below knee amputation. Materials and Methods: The study population consisted of 182 open and mangled lower extremities (130 foot, 11 ankle and 41 pilon). All injuries were irrigated and debrided and provisionally stabilized at the time of injury. Neurovascular assessment, soft tissue loss, bone loss, and other systemic factors were applied to a treatment algorithm intra-operatively, and decisions were then made regarding the need for an immediate or early amputation. Excluding the early amputees, there were 74 foot, 9 ankle and 33 pilon fractures that remained. Reconstructive salvage was then performed, including staged internal fixation, and delayed wound closure (with/or without STSGs), or free vascularized tissue transfers. All patients (amputees and salvage) were then followed for two years. Follow-up data recorded included: SIP scores, percent with walking speed >4 ft/sec, number of re-hospitalizations for complications, time to full weight bearing, visual pain scores and return to work rates. Regression analysis was used to determine, what effect, if any, the use of free tissue transfer had on the outcome of these patients. The impact of ankle fusion was also assessed. Results: All of the BKAs were closed employing typical skin flap designs. 37/66 had 2 year follow-up. In the reconstruction cohort, free flaps were needed as follows: foot salvage 10/60 2 yr follow-up (16.6%), pilon salvage 7/29 (24%), ankle salvage 1/5 (20%). The two year results can best be seen in table form: Two-Year SIP Outcomes   Overall   SIP   Physical SIP   Psychosocial SIP BKA (standard coverage)    13.20  10.73  12.08   Foot Salvages  11.92  10.00  11.02   Pilon Salvages  10.94  9.43  7.32   Ankle Salvages  15.22  13.11  13.79 Multivariate Regression Results at 24 Months   Overall SIP   p-value   Physical SIP   Psycho-social p-value   SIP  p-value   Foot Injury   -3.6  .14  -2.2  .30  -4.0  .20   Ankle/Pilon Injury  -3.7  .16   -1.8  .45  -6.7  .06   Free Flap  +6.7  .02  +2.6  .30  10.3  01   Ankle Fusion  +8.3  .02  +6.9  .02  7.7  .09 19.2% of the reconstruction patients required free tissue transfers. The regression analysis showed a significant negative effect of both free flaps and ankle fusions on the SIP score: a free flap added 6.7 points, a fusion =8.3. Further analysis showed that where a standard soft tissue coverage had a significantly better SIP score than a BKA, the addition of a free flap or a fusion reversed the result. All salvage patients had significantly more re-hospitalizations and longer times to full weight bearing. Return to work rates, walking speeds and pain were not different. Discussion: This information can be used to educate a patient and the patient's family during the limb salvage decision making process. Longer follow-up is required to see if the differences are stable over time.