OTA 2006 Posters

Scientific Poster #35 Foot and Ankle

The Early Outcomes and Management of Patients with Open Calcaneus Fractures Sustained by American Forces in Operation Iraqi Freedom
Joanna G. Branstetter, MD1 (n); Adam T. Groth, MD2 (n);
Scott B. Shawen, MD2 (n); James R. Ficke, MD1 (n);
1Brooke Army Medical Center (BAMC), Ft. Sam Houston, Texas, USA;
2Walter Reed Army Medical Center (WRAMC),
Washington, District of Columbia, USA

Purpose: Our objective was to review early outcomes and surgical management and define patient demographics, injury patterns, and complications associated with open calcaneal fractures due to injuries sustained during the current conflict.

Methods: We retrospectively reviewed the patient records, radiographs, and early clinical outcomes of 32 patients (17 WRAMC and 15 BAMC) who sustained severe open calcaneal fractures from March 2002 to the present during Operation Iraqi Freedom. There were 32 males and no females (average age 27.9) with 6 AO/OTA Type A fractures, 5 Type B, and 22 Type C, including two patients with bilateral trauma and 9 with segmental bone defects. Mechanisms of injury included landmine (8), other blast (improvised explosive device, mortar, grenade) (18), high-velocity gunshot (5), and vehicle maintenance accidents (2). All injuries were open, with 10 Gustilo and Anderson Type II, 11 Type III A, 8 Type III B, and 3 Type III C; and all patients underwent multiple debridement and irrigation procedures during the medical evacuation process before arriving at a tertiary Army Medical Center for definitive management.

Results: On average, patients were received at our facilities 7.6 days after injury (range, 4-23) and underwent 2.2 surgical procedures (range, 1-4) in theater, including provisional percutaneous or spanning external fixation in 11 soldiers. 22 (69%) patients had associated injuries, including 19 with ipsilateral foot/ankle fractures and 11 with neurologic deficit. All patients underwent debridement and irrigation upon arrival and averaged 4.8 total procedures(range, 1-12). Eight (25%) patients underwent early below-knee amputation due to severe bone and soft-tissue loss, while three were salvaged with flap coverage (sural). Definitive fracture management included closed reduction in 8 (25%), open reduction internal fixation in 6 (19%), percutaneous fixation in one, and subtalar fusion in two. Deep wound cultures were positive in 18 patients (56%) including all patients that required amputation. Two of these wounds were clinically treated as wound infections while the remainder were treated as presumptive osteomyelitis with a 6-week course of IV antibiotics. At early follow-up (average 18.8 mos, range 12-25 mos), there have been no recurrent infectious complications. The average AOFAS Hindfoot and Ankle score is 75/100.

Conclusion/Significance: High-energy open calcaneal fractures sustained in an austere combat environment carry a high risk for amputation and early infection. Surgical fixation options are limited due to the complex fracture patterns. Management of these injuries requires meticulous surgical debridement and recognition of associated injuries. Despite the devastating injury, patients have generally high functional outcomes at early follow-up.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.