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Table of Contents | Trauma to the Foot and Ankle: Keeping the Surgeon Stable (G) - Index

V. Tibial Pilon Fractures: ORIF and/or External Fixation

William C. McGarvey

I. Injury

A. Must dissect the anatomy of the traumatic event. 1. Estimate of energy imparted from mechanism to limb is most helpful in planning timing and type of surgery. 2. Soft tissue component of injury is as important if not more important than musculoskeletal component. a) Contusion versus abrasion b) Radiographs may give information regarding soft tissue damage by demonstrating comminution of fracture fragments (i) Spiral fracture pattern or minimal displacement = low energy (ii) Transverse oblique butterfly or greater than 50% displacement = moderate energy (iii) Multiple fragments, significant comminution = high energy 3. Extremity swelling a) Hematoma (i) Usually focal noted around region of joint or fracture b) Edema (i) Typically occurs anywhere from one to several hours from time of initial trauma (ii) Reduces oxygen tension to skin and subcutaneous tissues (iii) May be precursor to skin slough 4. Soft tissue classification (Tscherne, 1984) a) Grade 0 (i) minimal soft tissue injury (ii) indirect trauma, simple fracture pattern b) Grade I (i) Superficial soft tissue injury, i.e., abrasion/contusion (ii) Moderate fracture configuration, butterfly or impacted fragment attending the skin o c) Grade II (i) Deep abrasion, focal contusion extending to vessel imparted by direct trauma (ii) Severe fracture pattern with significant comminution or displacement greater than 50%

d) Grade III (i) Diffuse contusion to skin and muscle (ii) Subcutaneous avulsion, degloving, and/or compartment syndrome (iii) Major vascular injury (iv) Moderate to severe comminution fracture pattern o 5. Goals of management a) Provide stability to fractured skeletal fragments b) Preserve soft tissue sleeve c) Restore and maintain appropriate mechanical alignment and configuration d) Restore articular configuration (i) Controversial as to whether anatomic restoration of articular surface is necessary (ii) It is clear that restoring the articular surface at the expense of soft tissue stripping and devitalization of bony fragments is not desirable (iii) Risk/benefit ratio of anatomic restoration of skeleton versus devitalization of soft tissues leading to increased risk of loss of limb

II. Historical Perspective

A. Original principles: Reudi and Allgower 1. Restore fibular length 2. Anatomic reconstruct tibial articular surface 3. Compensatory autogenous bone graft 4. Metaphyseal bony defect 5. Medial tibial stabilization (buttress plate) B. Traditional results of open reduction and internal fixation 1. Reudi, Allgower 69 a) 74% good or excellent results with ORIF b) 47% sports related c) 6% infection, 5% arthrodesis d) 5 yr f/u suggested no decline in results 2. Heim, Naser 76 a) 90% good or excellent results with ORIF b) mostly skiing injuries 3. Etter, Ganz 91 a) 95% fair/good results with ORIF b) 10 yr f/u-anatomic result & good early results deteriorated over time 4. Bourne 83 a) 69% high energy pilon fxs. b) high rate of complications, 32% arthrodeses c) only 25% good results 5. Teeny and Wiss a) 50% poor result b) 37% infection rate c) arthrodesis in 10% low & 26% high energy injuries 6. Dillin, Slabaugh 86 a) 11 pts. surgeons without great experience

b) 3/11 healed without complications c) 55% osteomyelitis 7. McFerran 92 a) 40% high energy b) 20% infection rate c) 40% significant complications leading to an average of 1.5 additional surgeries per patient (77total procedures, not limited to high energy types) 8. Rommens 96 a) Moderate to high-grade fractures b) 36% fair to poor results c) Greater than 1 in 5 required additional procedures for soft tissue management

III. Operative planning

A. Soft tissue assessment (previously mentioned) B. Vascular assessment 1. Palpation of pulses 2. Doppler as necessary 3. Transcutaneous oxygen symmetry to assess viability of proposed skin flaps C. Patient profile 1. Nutrition 2. Smoking 3. Co-morbidities a) Diabetes b) Rheumatoid arthritis c) Medication usage D. Radiographic assessment 1. Fracture classification a) Helpful in preoperative planning to determine type of surgery 2. Plain radiographs frequency underestimate severity of fracture pattern a) Underestimate number of fragments b) No detail on impaction c) Poor detail on comminution 3. CT also helpful for placement of incision(s) a) Additional information almost always gained with CT scan

IV. Surgical Management Two stages

A. Initial immediate application of provisional external fixation traveling traction 1. Provisional external fixation provides ligamentotaxis 2. Restores length limitation and reduces angulation 3. Anecdotally reduces skin tension and has effect on reducing edema 4. Consideration should be given to immediate open reduction and reconstruction of fibula if possible a) Must assess viability of soft tissue envelope B. Delayed open reduction and internal fixation

1. Can wait anywhere from 10-21 days, sometimes longer 2. Incision should be placed according to major fracture lines determined by CT scan a) Incisions modified by presence of blisters, especially hemorrhagic b) Minimal 7-cm skin bridge should be maintained for viability of soft tissues c) Longer incisions better than short incisions with excessive retraction d) Keep wound edges moist e) Utilize traumatic wound if present in avoiding additional planes 3. Limited periosteal stripping 4. Use dental picks, small periosteal elevator to manipulate fragments and to place 5. Liberal use of C-arm and indirect reduction techniques with K wires as joystick 6. Liberal use of provisional stabilization with K wires or guide wires from cannulated screw set 7. Low profile plating systems a) Buttress plating systems b) Small plates may be combined with external fixators to buttress metaphysealdiaphyseal fragments c) Locked plating systems 1. Must remember that principles of fixation change with this type of fixation due to increased rigidity of construct a) single I-beam construct b) no moving parts between plate and bone - much more rigidity and resistance to motion 2. Cost also different so this must be considered because of tremendous disparity between locked and unlocked systems a) best indications: i. porotic (elderly/insufficient) bone ii. comminution iii. fracture gap iv. short segment (peri-articular) fractures v. buttress esp. to prevent varus 3. Can be used open or in percutaneous scenarios a) rigidity of construct makes this ideal for percutaneous fixation of metaphyseal fractures....internal fixators 4. Problems arise from trying to mix and match compression plating and locked plating principles a) locked plates usually less rigid as a unit (until locking screws applied) b) locking often keeps plate away from bone reducing friction of construct c) lag screws through locked plate interferes with biology of fracture healing i. may reduce fracture gap but may not reduce gap strain d) principles of external fixation apply - may make these systems too rigid which can lead to delayed or non-union C. Results 1. DiChristina, et. al. 96 a) 9 high energy pilon fractures treated by ex fix b) All healed c) 100% complications 2. Patterson, et al. 99

a) 22 high grade pilon fxs. W/ initial ex fix and fibular ORIF b) avg. 24 days to tibial ORIF c) 95% healed avg. 4 mos. d) Only 73% anatomic reductions; 77% good results e) no infections/ no wound slough 3. Tornetta, et al. 93 a) 26 pilon fxs. with calcaneal traction up to10 days b) avg. healing 4.5 mos. (11 supplementary bone graft procedures) c) 81% good results, 69% good in high energy d) 4 pin infections and 1 deep infection 4. Bone, et al. 93 a) 20 pilons severe or open; ex-fix and limited ORIF b) 75% good/excellent c) 2 pin infections, 2 fusions 5. Marsh, et. al. 95 a) Good results with appropriate fracture management b) Early motion with hinged monoplanar external fixator c) Anatomic reduction of fragments not necessary; 1 2 mm step-off acceptable as tradeoff for maintenance of soft tissue sleeve 6. Wyrsch, et al. 93 a) direct comparison of ORIF vs Ex-fix & mini ORIF b) 55% complications in ORIF alone c) 18% re-operations in ex-fix group Small wire hybrid external fixators gaining popularity, technically more difficult; small wires may be used instead of cannulated screw fixation for stabilization of articular fragments

a) Has advantage of minimal advantage b) Additional advantage of potential early weight-bearing in full circular fixator c) Foot plate or provisional foot fixation critical to prevent Aquinas contracture 5. Techniques and decision making still evolving; no black and white answers available at this point in time

V. Surgical Technique Application of Small Wire Ring External Fixator

A. Full circular frame versus hybrid frame 1. Surgeons preference 2. Differences in biomechanics a) Full ring fixator is biomechanically much more stable b) Hybrid frame does not have rotational control c) Hybrid frame does not have versatility d) No ability to compress or distract if necessary e) Hybrid frame has shorter lifespan cannot be maintained as long and cannot be revised as easily B. Fixator application

(The application technique described below is for a relatively standard full circular external fixator frame with small wires mixed with some half pin fixation. External fixator configuration may vary based on particular needs of the surgeon, particular demands of the fracture, anticipated shortening or lengthening, or presence of infection.) The external fixator can be prebuilt, nonsterile, based on preoperative planning. External fixation should be designed with anticipation of possible pin loosening, patient weight bearing, fracture fixation, fracture reduction. Consideration should be given to fracture pattern to anticipate need for extension across ankle joint (with a foot plate.) External fixator frame need not approach knee joint, may be mid calf length to ankle or heel. Initial wire may reference parallel to knee joint or perpendicular to tibial shaft. Anticipate placement of olive wires with three-point bend rule. This means that at the apex of angulation of your fracture, you should have one or two olives on side of angulation, and there should be at least one olive wire proximal and one olive wire distal to this point opposite the side of angulation just as you would place your fingers and thumbs to manipulate the fracture back into place. First transfixion wire should be inserted proximally and the second one distally. The second wire should parallel the articular surface of the ankle joint. A proximal wire and a distal wire that are parallel to one another and parallel to the joints indicate that a straight frame will provide a straight bone. In placement of the wires care must be taken to avoid the peripheral nervous structures as well as large musculotendinous units so as not to fix them into place by creating scar tissue. Wires may be placed horizontally, but typically are placed in angled directions so as to avoid skewering nerves, vascular structures, or musculotendinous units. A good rule of thumb is to assume that if you are in the plane of the tibia and fibula, that is, the syndesmotic membrane, then the neurovascular structures should be safe; similarly, the plane of the medial face of the tibia also provides safety as there should be no neurovascular or musculotendinous structures in harms way. Should you have to apply a horizontal wire, the technique should be a small stab wound through skin, spread down to bone, place the wire on bone, drill through both cortices. Once reaching the far cortex, a mallet should be used to drive the pin the rest of the way. This will reduce burning of cortical bone and reduce pin tract infections later. Once you have a proximal and a distal wire, your circular fixator can be applied. A straight circular external fixator applied with one proximal and one distal wire will provide a straight lower extremity. At this point, the goal is to reduce fracture fragments and stabilize the frame. Once the first two wires are fixed to the ring, they should be tightened and tensioned (using whatever tensioning device the surgeons preferred system recommends). Each ring in the system should have at least two points of fixation. These may be either thin wires under tension or one thin wire and one half pin, or two half pins at 90o angles to one another. All points of fixation ideally will be at 90o to one another. Realistically, the anatomy may preclude this pin configuration. However, the pins should be no less than 45o to one another or another form of fixation should be applied.

To increase the rigidity of the frame, half pins or wires may be dropped or raised from the individual rings with extender devices. Once each level of fixation has at least two points of fixation at appropriate angles to one another, stability of the frame should be achieved. Fracture reduction may take place and should be addressed before the entire frame is constructed. Fracture reduction is achieved once the proximal and distal wires are set and tensioned. Intermediate rings within the frame should be adjusted to allow for capture of individual fracture fragments as necessary and dictated by the fracture itself. Olive wires may be used as opposed to cannulated screws to obtain reduction and maintenance of fixation of individual fracture fragments if large enough. Alternatively, the traction and tension applied by applying the external fixator may align the fragments by ligamentotaxis and provide for a functional closed reduction and external splinting. Once overall alignment of the fracture is maintained, then rigid stabilization of the frame by applying points of fixation as previously describes proceeds. Verification of the fracture alignment, rotation, and angulation on multiple views including potentially a live fluoroscopic examination should provide enough information to suggest satisfactory reduction. Plain radiographs are helpful as fluoroscopy is inaccurate in overall limb alignment over the entire length of the tibia. Once the surgeon is satisfied with the angulation, rotation, and translation of the individual fragments in the overall limb, the length of the limb is reassessed. If the initial tension (especially if the procedure was done with a skeletal traction pin) has over distracted the fracture, then the external fixator frame can be compressed to reapproximate fracture fragments. The foot must be maintained in a right angle position. Even when there is a substantial distal fragment, the ankle and foot tend to be too painful to provide for initial range of motion and weight-bearing, and should be fixed rigidly with some sort of extension from the external fixator to prevent an equinus contracture. In very distal fractures, extension across the joint to include a foot plate and calcaneal fixation is strongly recommended. Application of calcaneal fixation is relatively simple. Counter opposing olive wires are placed from the foot plate at approximately 30o 45o angles from horizontal starting either posteromedial or posterolateral and proceeding through the calcaneus and across through the other side and fixed to the foot plate. The foot plate is attached to the proximal fixator. One transverse thin wire is placed through the metatarsals. It is not imperative to secure fixation on all metatarsals as long as one more medial and one more lateral are skewered by the thin wire to maintain the forefoot position. The forefoot equinus is a common problem even when external fixation expands the ankle joint and holds the hindfoot in a neutral position. Talar fixation is usually unnecessary, but is certainly a reasonable choice if necessary. There is usually little indication. Nearing the conclusion of the case, all nuts and bolts should be tightened thoroughly one last time.

It is imperative that all pin sites be released and have reasonable soft tissue glide for 1 2 mm on either side of the pin. Overall clinical limb alignment should be reassessed visually and radiographically (fluoroscopically).

VI. Postoperative Management

Twice daily pin care is the minimum recommendation. Pin care may need to increase based on amount of drainage or irritation around each pin. Patients are allowed to shower as long as pins are dried. Weight-bearing in certain frames is encouraged as soon as postoperative pain will allow this is manufacture and frame configuration dependent, and does not apply routinely to all external fixators. The patient should be followed frequently to evaluate for anticipated problems. Pin tract irritation or infection Loose nuts and bolts Soft tissue swelling creating impingement on a ring Foot plate if present should be removed 4 6 weeks from the time of the application depending on the stability of the fracture. A fracture with a large distal fragment may allow for earlier removal. It is better to be overcautious with pin management than to wish the problem away. Pin irritation/infection that does not respond to increased pin care and antibiotics should be either removed or replaced. Timing in the frame is dependent on the problem. Fracture fixation takes anywhere from 3 5 or 6 months. Fracture stabilization with lengthening may require an additional 3 9 months of time in the frame. Open fractures or fractures in the face of infection can require anywhere from three months to a year or more.

1. Bone L, et al.: External fixation of severely comminuted and open tibial pilon fractures. CORR 292:101-107, 1993. 2. Bourne RB, et al.: Intra-articular fractures of the distal tibia: the pilon fracture. J Trauma 23:591-596. 1983. 3. Dichristina, et al.:Pilon fractures treatedwith an articulated external fixator. Orthopedics 19:1019, 1996. Dillin L, Slabaugh P:Delayed wound healing, infection, and non-union following open reduction and internal fixation of tibial plafond fractures. J Trauma 26:1116-1119, 1986. 4. Etter C, Ganz R: Long term results of tibial plafond fractures treated with open reduction and internal fixation. Arch Orthop Trauma Surg 110:277-283, 1991.

5. Heim U, Naser M: Die operative behandlung der pilon tibial fraktur. Technik der osteosynthese und resultate bei 128 patienten. Arch orthop unfallchir 86:341-356, 1976. 6. McFerran MA, et al.:Complications encountered in the treatment of pilon fractures. J orthop trauma 6:195-200, 1992. 7. Reudi TP, Allgower M:Fractures of the lower end of the tibia into the ankle joint. Injury 1:9299, 1969. Teeny SM, WissDA:Open reduction and internal fixation of tibial plafond fractures:variables contributing to poor results and complications. CORR 292:108-117, 1993. 8. Tornetta P, et al.:Pilon fractures:treatment with combined internal and external fixation. J orthop trauma 7:489-496, 1993. 9. Wyrsch B, et al.: A randomized prospective study comparing the complications encountered in the management of pilon fractures. OTA annual mtg. New Orleans LA, 1993.