AOFAS Resident Review Course September 28, Justin Greisberg, MD Associate Professor of Orthopaedic Surgery Columbia University

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1 Course September 28, 2013 Justin Greisberg, MD Associate Professor of Orthopaedic Surgery Columbia University

2 Disclosures Consultant to Extremity Medical Receive royalties from Saunders/Mosby-Elsevier

3 History of Pilon Treatment 1905 Lambotte ORIF 1911 Destot - pilon Bonin - plafond 4 case series prior to 1963 consistently poor results

4 Reudi and Allgower, % good results at 9 years in 84 fractures Lower energy skiers in 75% Only 6% open

5 1970s and 1980s Multiple case series Teeny, Wiss 1993 Much less good results Wound problems one-third Large cloverleaf plate not biologically friendly Stimulus for Tornetta and others to propose limited ORIF with hybrid ex-fix

6 External Fixation with limited internal fixation Ex fix not anatomic, pin infections, slow return to work, lower clinical scores [Anglen, 1999] Higher malunion/nonunion [Pugh, 1999] Other studies suggest ex fix can be ok Outcome more correlated with soft tissue injury than anatomic reduction [Watson et al, 2000]

7 Staged ORIF Fix fibula and ex fix night of injury Delay tibial ORIF 1-2 weeks Smaller implants Skin not allowed to shrink Wound infection rates much lower

8 Literature on Pilons Almost entirely retrospective case series No clear winner when comparing ORIF to ex fix ORIF prob lower malunion, nonunion [Bacon et al 2008] Recent study showing similar outcome Lots of disability using outcome measures

9 Theoretical Benefit of ORIF Anatomic reduction possible Allows motion better than cast or ex-fix Better reduction and better motion more likely to lead to good result!? Assuming can be done with low rate of complications!! (infection)

10 Day 1 Restore length Ex fix No incisions do not fix fibula Does not need to be middle of night for closed injury

11 First Week Elevate Get to know patient Make him/her see things our way CT Scan, surgical plan Meanwhile skin swells, then shrinks

12 1-2 weeks later ORIF Expose joint Anterior or anterolateral Reduce and fix articular fragments Small plate and small screws Bridge joint to shaft Medial or anterolateral plate Minimal incisions/no dissection Fix fibula

13 Expose Joint Anteromedial Anterior Anterolateral Lateral

14 Anteromedial Medial to anterior tib

15 Anterior Between ant tib and EHL

16 Anterolateral and Lateral [Grose et al, 2007] Lateral to EDL Maybe fix fibula through same incision (lateral approach)

17 Skin Bridges 7cm rule not valid! 5-6 cm OK [Howard et al, 2008]

18 Reduce Joint Image courtesy of P.Cole, MD Medial fragment Anterolateral fragment Posterior fragment Central comminution Plantarflex talus to visualize joint Headlight helpful 2.7 screws with tubular plate

19 Bridge Metaphyseal Comminution Align joint relative to shaft Traction Ex fix Place plate Use joint incision or a separate small incision Submuscular, not subperiosteal Anterolateral or medial

20 Fix Fibula If having really hard time aligning fracture, may be tibial malreduction Maybe should fix fibula before tibia? If simple fracture pattern Remember syndesmosis Ligaments often intact through anterolateral fragment

21 Post Op 2 weeks in splint Then AAROM 1-2 week pre-op splinted, 2+ weeks post-op best case scenario is ankle motion beginning 3-4 weeks after injury! No wonder so many get stiff!

22 Partial articular fx Bridging ex fix day 1 or 2

23 1-2 weeks later 1. Anterior arthrotomy 2. Mini plate for joint pieces 3. Anterior buttress plate

24 Type C complete articular

25 Definitive Planning

26 10 days later Anterior arthrotomy Mini joint buttress Medial bridging plate

27 6 months later

28 Type C complete articular Probably no benefit to spanning fixator

29 When soft tissues ready Anterior arthrotomy Mini plates Medial and lateral buttress plates Metaphysis not exposed

30 Few months later

31 AVN anterior plafond

32 Posterior fragment