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.