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Category: Ankle; Diabetes; Hindfoot; Trauma Introduction/Purpose: Management of hindfoot osteomyelitis involves eradication of infection, deformity correction, and bony stabilization in the setting of bone loss and poor bone quality. In this case series of 12 patients, we present a two-stage technique; debridement, deformity correction, joint surface preparation, and intramedullary reaming with placement of antibiotic rod and ring external fixation followed by a second stage of external fixator removal and exchange of antibiotic rod for definitive hindfoot rod. The purpose of this poster is to highlight techniques that can improve the success of obtaining stable fixation, remission of infection, and ultimately fusion. Techniques highlighted are ring fixator placement, preparation of the antibiotic rod, intramedullary canal preparation, rod exchange, and use of blocking screws to enhance compression and axial loading of the fusion. Methods: Twelve patients were treated with this two-stage protocol. The most common indication was post-traumatic osteomyelitis followed by neuropathic (Charcot) joint. All were treated in a staged manner with an initial debridement of nonviable tissue including osteomyelitic bone. The tibiotalar and talocalcaneal joints were resected and prepared for fusion at the initial debridement. Provisional stabilization and compression were obtained through the use of a ring external fixator. An intramedullary antibiotic impregnated cement coated rod was introduced through the calcaneus, talus, and the intramedullary space of the tibia. The patients were kept in the fixator until the skin was healed and all incisions were dry. At this point, the fixator was removed, and the antibiotic rod was exchanged for the definitive hindfoot fusion rod. Results: Cultures were positive for Staphylococcal or Streptococcal species in 58% of cases, fungal in 8%, and Gram negative organisms in 33%. On average patients spent 93 days in the fixator while wounds were healing, and they were receiving systemic antibiotics. One patient died while in the frame. There have been no amputations in the series. Of the patients that have completed the protocol, all have gone on to either bony fusion or stable fibrous union. All are able to walk unaided. And thus far, all are free of active infection. Secondary procedures are described. Conclusion: This technique of staged fusion for hindfoot osteomyelitis offers the following advantages. the first stage involves thorough debridement and deformity correction. Oftentimes there is extensive scarring and the soft tissue envelope is not conducive to internal fixation. This technique allows the soft tissues to heal before placing the definitive internal fixation. It also allows for graduated compression at the fusion site with the ring fixator. The antibiotic rod not only delivers high concentration of local antibiotics, but it prevents deformity recurrence during the compression phase. The definitive rod provides support of pathologic bone and maintains deformity correction.

Category: Ankle; Trauma; Other Introduction/Purpose: The novel coronavirus (COVID-19) pandemic has presented a unique challenge to orthopaedic trauma and operative fracture management throughout the United States. Various public health and safety measures imposed during the lockdown lead to cancelation or rescheduling of non-emergent or non-urgent surgery cases. In order to provide appropriate standard of care, certain operative cases were deemed urgent and managed on an inpatient basis. This change in practice had an impact on the management of acute ankle fractures which has previously reported excellent results and cost-savings with outpatient operative management. The goal of this study is to determine the impact of the COVID-19 lockdown and barriers to care in treating isolated operative ankle fractures in the inpatient setting. Methods: The current IRB approved study is a retrospective review of adult patients presenting to University of Cincinnati (UC) with isolated, operative ankle fractures. The study period consisted of patients who presented during the months of January 1st - July 1st 2020 to coincide with pre-, intra and post- COVID lockdown in Southwestern Ohio. Of note, the official mandated lockdown within the state of Ohio was March 23rd - May 1st with phased business re-openings after May 1st. Similarly, hospital operations including operative capacity was restricted until a return to full capacity on June 29, 2020. A total of 464 patient records were reviewed (159, 176, 129 ankle fractures for the respective years 2018-2020). A review of the data from years 2018, 2019 were analyzed for statistical comparison. Polytraumatized patients, open fractures and those with bilateral injuries were excluded. Results: The final cohort included 190 ankles (52, 71, 67, for 2018, 2019, 2020 respectively). This comprised of 71 males (38%), 119 females (62%). The average age of patients were 48+-19, 51+-18, 48+-20, respectively. There were no significant differences in BMI, smoking and diabetic status. There was a total of eight isolated ankle fractures during the immediate lockdown period of 2020, all managed with inpatient surgery. This was compared to the previous year 2019 (7/16 treated with inpatient management), versus 2018 (4/5 inpatient). Overall, among allcomers, 2020 had the lowest amount of acute fractures treated as outpatient, elective cases (34%) versus 45% -2019, 58%- 2018; however, this was not statistically significant. The length of stay for inpatients, time until surgical management, time to physical therapy clearance, postoperative follow up with index surgeon or midlevel providers were not significantly different among the 2020 cohort during and immediately after the state-wide lockdown. Conclusion: Little has been published about the effect of the coronavirus lockdown on acute fracture management. In this study of acute ankle fractures, strategic practice changes to predominantly inpatient management did not adversely affect patient care. However, there are disadvantages to inpatient versus outpatient management such as: (1) resource allocation (such as hospital beds during a pandemic) and (2) associated costs to both patients and hospital. Future efforts will be made to elucidate the cost analysis within our hospital system (not available at the time of this submission).