External Fixation - Amazon Web Services metaphysis •Usually ... Conversion of spanning delta frame...

2/24/2015

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External

Fixation &

Surgical

Staging

VuMedi Webinar – Pilon Fractures – 02/24/2015

Pat Yoon, MDMinneapolis, MN

Hennepin County Medical Center

University of Minnesota

Disclosures

• Orthofix (consultant)

• Arthrex, Inc. (consultant)

• JAAOS (reviewer)

• FAI (reviewer)

Outline

• Introduction

• Initial management

• Debridement

• Fix the fibula?

• External fixator

• Planning for ORIF

http://www.umn.edu/sesqui/

http://www.umn.edu/sesqui/

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Definition of Plafond / Pilon

fractures

• High-energy fracture of distal

tibial metaphysis

• Usually compressive injury /

axial load

• Soft-tissue compromise

• Articular surface and fibula

usually (not always) fractured

• Severe injury - Educate the

patient early !

Introduction Fibula ? Ex-fix Preop PlanningDébridement

Pilon versus Ankle


Do not treat pilons like an ankle

• Immediate ORIF

• Large plates

• 37-40% major

complications


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Pilon fractures

• High energy

• Axial load

• Standard orif doesn’t work well


Therefore:

• AVOID early ORIF

with large incisions

and bulky implants

• Early percutaneous

treatment in selected

cases may be OK


Outcomes of open pilon fractures

• Staged protocol

• 59 consecutive open pilon fractures (most IIIA)

• Initial debridement, spanning ex-fix, sponge and

suction drains

• Repeat debridement q 48-72 hours

• Deep infection rate 3%

• One BKA

• SF-36: PCS 40.3, MCS 54.0

Boraiah et al JBJS 90:346-52, 2010


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Initial workup

• Tetanus

• Antibiotics

• Sterile dressing

• Evaluate for

associated injuries


Initial presentation

• Thinner soft

tissues medially

• Obliquity usually

produces a

medial spike on

the proximal

fragment



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Debridement

• Deliver the bone ends!

Fibula ? Ex-fix Preop PlanningDébridementIntroduction

Debridement

• Open wounds usually transverse

• Extend longitudinally


Extend incisions

• If you can’t deliver the bone ends, extend

the traumatic wounds


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Often more soft tissue injury than initially

apparent


Often more soft tissue injury than initially

apparent


Remove all

foreign debris

and

devitalized

bone

fragments

Can be very

proximal!


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Check:

• Skin

• Subcutaneous tissue

• Muscle / tendon

• Fascia

• Periosteum

• Bone

• Major articular

segments – save ?


Check:

• Skin


• Muscle / tendon

• Fascia

• Periosteum

• Bone

• Major articular

segments – save ?


Check:

• Skin


• Muscle / tendon

• Fascia

• Periosteum

• Bone

• Major articular

segments – save ?


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Check:

• Skin


• Muscle / tendon

• Fascia

• Periosteum

• Bone

• Major articular

segments – save ?


• Sponge and suction drain

• Sterile dressings

• +/- Loose primary closure ?

• Repeat debridements q 48-72h as needed



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Do you fix the fibula initially ?

Yes if:

• It can be anatomically

restored, and

• It will not compromise

later ORIF

Fibula ? Ex-fix Preop PlanningIntroduction Débridement


No if:

• It can’t be anatomically

restored, or

• It compromises later ORIF



No if:

• It can’t be anatomically

restored, or

• It compromises later ORIF


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Do you fix the fibula initially?

Anticipated anterolateral

approach

WAIT


When do you fix the fibula?

This one may need a

posterior incision –

fibula can be fixed

through that

WAIT


When do you fix the fibula?

• Anticipated

anteromedial

approach

• Unlikely to need a

posterior incision

Go ahead!


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Make it as posterior as possible!

Wide bridge



When in doubt – leave the

fibula for now

• I rarely fix it initially

• Definitive plan usually not known at

presentation (need CT with frame on)

• Fixing the fibula initially might compromise

your eventual plan


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When do you ex-fix?

• For

– Shortening

– Impaction

– Subluxation / gross

displacement

– Soft Tissue

Problems


When do you ex-fix?

• For

– Shortening

– Impaction


displacement

– Soft Tissue

Problems


When do you ex-fix?

• For

– Shortening

– Impaction


displacement

– Soft Tissue

Problems


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When do you ex-fix?

• For

– Shortening

– Impaction


displacement

– Soft Tissue

Problems


Benefits of spanning ex-fix

• Decreases pressure on skin – improves

soft tissues

• Makes later ORIF easier (fx out to length)

• Gives you time for preop planning

• Gives you time for transfer if needed


This is a very difficult xray to

plan off ofMuch easier!


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Ligamentotaxis

Posterior syndesmotic

ligaments


AITFL

Ligamentotaxis


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Anterior inferior tib-fib

ligament


Tibial pins

• 2 pins in diaphysis

far from fx

• Usually 5mm

• Predrill

• Blunt pins

• Insert by hand

Ant

Lateral

Medial

Post


• Draw out later

incisions

• Keep pins away

from the lines

Tibial pins

Avoid this !


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Calcaneal pin

Medial to lateral



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• If possible attach

each bar to both

pins

• “Delta frame”

• Keep clamps

loose for now!


• One person pulls

out to length

• Other person

tightens all clamps


• Length

• Alignment

• Rotation


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• Length

• Alignment

• Rotation


• Length

• Alignment

• Rotation


Bump of towels to adjust

sagittal alignment


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Posteriorly directed vector


Posterior translation!


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Posterior translation!


• Helps maintain

alignment

• Prevent equinus

• 3-4 mm

Optional foot pin


Foot pin helps

prevent pressure on

sole of foot

“Yeah, but what about

just adding a posterior

splint?”


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Medial pin alone may

supinate the foot


5th met pin to

balance foot

More even!


Danger of 1st

metatarsal pin

Barrett MO JBJS 90: 560-4, 2008

• 50% injury to deep plantar

branch of dorsalis pedis

• 18mm danger zone


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Alternatives


Dorsal to plantar 1st

metatarsal pin

Alternatives


Medial /

intercuneiform

pin

Alternatives


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Talar

neck/head

pin

Alternatives


For obtunded patients

Keep heel off bed!

Helps prevent pressure ulcers


When temporary spanning

fixation isn’t so temporary …

• Patient lost to follow-up

• Medically unstable

• Skin condition never allows safe ORIF in a

reasonable time frame

• Significant comorbidities for ORIF

• Patient doesn’t want further surgery


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Spanning fixation as

definitive treatment








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5 months in frame


2 year follow-up


Conversion of spanning delta frame to a

spanning circular fixator


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Next steps

• Antibiotics

• Elevate

• Nonweightbearing

• DVT prophylaxis

• Repeat debridement(s) as needed

• Soft tissue coverage



CT Scan

Plain films underestimate amount of articular involvement

CT scan affects operative plan majority of the time


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By bringing fx out to

length the true gap

is appreciated


Get the CT with the fixator on!


Get the CT with the fixator on!


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Now what?• At this point:

– Wounds are debrided

– Frame is in place

– Fibula may or may not be fixed

– You have your CT scan

• You have time to:

– Wait for soft tissues and fix it

– Transfer if you don’t feel comfortable fixing

– Or treat in frame!


Analyzing the CT scan

Cole PA et al OTA 2004




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AM

AL

P

F



AMAL

P

AMAL

P


AM

Anteromedial

fragment


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AL

Anterolateral

fragment



P

Posterior

fragment

AMAL

P


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Approaches:

PBPL

PT

EHLEDL

TA

FHL

Achilles

Anterocentral

PosterolateralPosteromedial

AnterolateralAnteromedial


Choosing the right approach

• Where is the major articular displacement?

• Where is there better soft tissue

coverage?

• Is there a large wound I can use?

• What stabilizes this fracture the best?


Where is the articular displacement?

Anterolateral or

anterocentral

approach is best to

remove central

fragments

Anterolateral

Anterocentral


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Where is there better soft tissue coverage?

• Open wounds are usually medial

• Anterolateral skin usually in better shape

• More soft tissue coverage laterally if skin

breaks down



Fracture obliquity

Posterior plate


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Medial plate


Lateral plate


How long do you wait?

• Wrinkle sign

• Wounds clean

• Blisters resolved

• Usually 1-2 weeks but

can be longer


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6h 6d

Swelling

Time



Now you’re

ready for

ORIF !

Summary

• Thorough, conscientious debridement

• Reduction and external fixator

– Carefully placed pins

– Remember the fixator might be definitive

• Fibula fixation only if definitive plan is known

• Staged ORIF once the patient and soft

tissue condition are ready

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Thank You !

2/16/2015

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Tibial Pilon Fractures –Surgical Approaches

S. Andrew Sems, M.D.

Department of Orthopaedic Surgery, Mayo Clinic

Disclosure

• Royalties- Depuy/Biomet- Affixus Nail

Classification

AO-OTA

• A: Non-articular

• B: Simple articular

• C: Complex articular

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Epidemiology

• 7% to 10 % of all tibia fractures

• Most occur secondary to high energy mechanisms

• Concomitant injuries are common and should be ruled out

Mechanism of Injury

• Axial Compression-significant comminution w/ articular impaction

• Shear-torsion injury, usually w/ two or more large fragments and minimal articular comminution

• Combined-high energy, often associated w/ other injuries

Results of ORIF

Historically many complications

•18% nonunion

•20% superficial infection / wound problems

•17% osteomyelitis

•27% arthrodesis / arthroplasty

•6% BKA

•54% PTA

•42% malunionMcFerran, JOT 6: 195, 1992

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• Fractures healed in an avg. 4.2 months

• 1 nonunion requiring bone grafting & 1 malunion requiring an osteotomy

• No infections & No wound healing problems were encountered

• Subjective & Objective measurements:

• 17 good/excellent, 3 fair, 2 poor results

Patterson MJ. Two-staged delayed open reduction and internal fixation of severe pilon fractures. Journal of Orthopaedic Trauma. 13(2):85-91, 1999

Results of Staged Approach

Results of Staged Approach

• Closed Fx

• 17%- partial skin necrosis

• 3.4%-osteomyelitis

• all wounds subsequently healed

• Open Fx:

• 10% deep wound infections

Sirkin M. A staged protocol for soft tissue management in the treatment of complex pilon fractures. Journal of Orthopaedic Trauma. 13(2):78-84, 1999 Feb

The results of early primary open reduction and internal fixation for

treatment of OTA 43.C-type tibial pilon fractures: a cohort study.

White TO, Guy P, Cooke CJ, Kennedy SA, Droll KP, Blachut PA, O'Brien

PJ.

J Orthop Trauma. 2010 Dec;24(12):757-63.

• 93/95 patients underwent ORIF within 48 hrs. of admission

• 6% wound dehiscence/infection

• 90% anatomic reductions

• 78% mild arthritis or worse at 1 year

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Initial Management before ORIFExternal Fixation

Patterson MJ, Cole JD. Two-

staged delayed open reduction

and internal fixation of severe

pilon fractures. J Orthop Trauma.

1999 Feb;13(2):85-91.

Sirkin M, Sanders R, DiPasquale

T, Herscovici D Jr. A staged

protocol for soft tissue

management in the treatment of

complex pilon fractures. J Orthop

Trauma. 1999 Feb;13(2):78-84.

• Leave intact; if ruptured, leave roof intact

• Most complications occur with blood filled blisters

• Takes 3 wks to re-epithelialize

Giordano CP, Fracture Blisters, CORR. (307):214-21, 1994 Oct

Initial Management before ORIFSoft Tissue Management

Initial Management before ORIFSoft Tissue Management

Boraiah S, Kemp TJ, Erwteman A, Lucas PA, Asprinio DE. Outcome following open reduction and internal fixation of open pilon fractures. J Bone Joint Surg Am. 2010 Feb;92(2):346-52.

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Timing of ORIF

• 12 days (closed)

• 14 days (open)

• 24 days

Sirkin M, Sanders R, DiPasquale T, Herscovici

D Jr. A staged protocol for soft tissue

management in the treatment of complex

pilon fractures. J Orthop Trauma. 1999

Feb;13(2):78-84.

Patterson MJ, Cole JD. Two-staged delayed

open reduction and internal fixation of

severe pilon fractures. J Orthop Trauma. 1999

Feb;13(2):85-91.

Timing of ORIFDVT Prophylaxis

Sems SA, Levy BA, Dajani K, Herrera DA, Templeman DC. Incidence of deep venous thrombosis

after temporary joint spanning external fixation for complex lower extremity injuries. J Trauma.

2009 Apr;66(4):1164-6.

LMWH

Duplex US

2.1% rate of DVT

Mechanism of Injury

• Fibula Fractures

• Fractured Fibula (85%)

• Leads to valgus deformity and lateral plafond impaction

• Intact Fibula (15%)

• Leads to varus deformity and medial plafond impaction

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Initial ManagementFibular Fixation

• Length

• Beware Comminution of fibula

• Complicates posterolateral approach

Technique of ORIFChoosing the Optimal Approach

Peter A. Cole, MD; Robert K. Mehrle, MD; Mohit Bhandari, MD;

Michael Zlowodzki, MD The Pilon Map: Assessment of Fracture Lines and Comminution

Zones in AO C3 Type Pilon Fractures. OTA 2004 Poster #5 Foot and Ankle

Anterolateral

Anteromedial

Posterolateral

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Technique of ORIFPosterolateral Approach

Technique of ORIFAnterolateral Approach

Options for Internal FixationAnterolateral Plate

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Technique of ORIFAnteromedial Approach

Technique of ORIF Locking Plates

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Staged Posterior Tibial Plating for the Treatment of

Orthopaedic Trauma Association 43C2 and 43C3 Tibial Pilon

Fractures.

Ketz J, Sanders R.

J Orthop Trauma. 2012 Jan 20.

Improved:

AOFAS

Maryland Foot and Ankle Score

Articular Reduction

Less:

Arthrosis

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Postoperative Management

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Summary

• Immediate external fixation

• Delayed internal fixation

• Posterolateral approach

• Trap the talus

• Avoid medial plates if possible

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Posterior Approaches

Paul M. Lafferty, MDAssistant Professor

University of MinnesotaOrthopaedic Trauma

Regions HospitalSt. Paul, MN

Disclosures

• None

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Posterior Column

Posterior Pilon Variant

Posterior Pilon Variant

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Comminuted PilonLarge Posterior Fragment



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Posterolateral Approach(PL)

Prone

Lateral

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Tibial Nerve

Transverse Intermuscular

Septum

PL

MPM

PM

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Posteromedial Approach(PM)

Prone

Supine

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Septum

Tibial NervePL

MPM

PM

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Modified Posteromedial Approach(MPM)

Prone

Supine

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Tibial Nerve


Septum

PL

MPM

PM

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Thank You

Paul M. Lafferty, MDAssistant Professor

University of MinnesotaOrthopaedic Trauma

Regions HospitalSt. Paul, MN

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Percutaneous Techniques for Tibial Pilon Fractues

Matthew D. Karam

University of Iowa Hospitals

Disclosures

• Grant funding from OTA, ABOS, AHRQ and NBME-Educational Research

• No relevant financial conflicts of interest

Tibial Pilon Fractures

• Factors that affect ultimate outcome

– Mechanical

– Biologic

– Clinical

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Mechanical

Mechanical

Biological

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Axial Loading

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Rotational ankle fracturesare different – slow load, less energy

few complications

Anatomical reduction critical??

What is the relative effect of the injury compared to our treatment?

Does an anatomical reduction of the displaced articular surface really guarantee a good outcome

in high energy fractures?

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What do we know about patient outcome!

b) Pain and decreased function common

a) Complications create disasters!

Absolutely determine outcome

Complications have decreased!

Factors leading to decreased complications –

plateau/pilon

Prioritize the soft tissue injury

Delay to definitive surgery

Use of temporary spanning fixation

Definitive external fixation

Low profile plates

Indirect reduction techniques

Percutaneous techniques for reduction and placement of implants

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The Soft Tissue Injury!!

Red Blisters

Clear Blisters

OpenFracture

The Injury/Management of the Soft Tissue

Envelope is the Key

Relative Success

Dismal Failure

vs

A- Frame – Restorelength and alignment

Surgical delay enhanced using

Spanning fixation!

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Plating through limited approaches

Plating through limited approaches

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The use of definitive external fixation

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CT Spinning

Frame off at 5 months – Healed

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Frame off at 5 months – HealedXrays at 2 years

36 yo male fell out of deer standClosed soft tissue swelling, no blisters

Definitive Spanning Fixator

Limited or percutaneous approachesand use of reduction aids

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Screw Fixation only supported by a spanning fixator

14 months – works full time

as a salesman,hunted one year after injury

2.5 years - continues to hunt.

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Summary

• Tibial Pilon Fractures are common

• Complex interplay of mechanical, biologic and clinical factors

• Complications can lead to disasters

• Some residual pain and dysfunction is common

• Limited approached when utilized appropriately can mitigate some risk of complications

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External Fixation - Amazon Web Services metaphysis •Usually ... Conversion of spanning delta frame...

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