Pilon fractures. Pat Yoon, MD Minneapolis Veterans Affairs Medical Center Associate Professor, University of Minnesota
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1 Pilon fractures Pat Yoon, MD Minneapolis Veterans Affairs Medical Center Associate Professor, University of Minnesota
2 Disclosures Reviewer Foot and Ankle International Journal of the American Academy of Orthopaedic Surgeons Board of directors Surgical Implant Generation Network (SIGN) Committees OTA Humanitarian Committee AAOS Program Committee for Trauma AOFAS Health Policy Committee Consultant Orthofix Arthrex Inc. Paragon 28 Paid Talks International Congress for Joint Reconstruction
3
4 Palazzo FF, BMJ 1999
5 Palazzo FF, BMJ 1999
6 Definition High-energy fracture of distal tibial metaphysis Usually compressive injury / axial load Soft-tissue compromise Severe injury - Educate the patient early!
7 How do these occur?
8
9 Soft tissue compromise
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11 Do not treat pilons like an ankle Immediate ORIF + Large plates =
12 Initial treatment Tetanus Antibiotics Sterile dressing Immobilization Associated injuries!
13 Next step: debridement Open injuries common Thin medial tissues Medial spike
14 Next step: debridement Open injuries common Thin medial tissues Medial spike
15 Debridement Deliver the bone ends!
16 Deliver bone ends Extend wounds longitudinally
17 Deliver bone ends Extend wounds longitudinally
18 Often more soft tissue injury than initially apparent
19 Often more soft tissue injury than initially apparent
20 Remove all foreign debris and devitalized soft tissue & bone
21 Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save?
22 Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save?
23 Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save?
24 Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save?
25 Do you fix the fibula initially? Yes if: It can be anatomically restored, and It will not compromise later ORIF
26 Do you fix the fibula initially? No if: It can t be anatomically restored, or It compromises later ORIF
27 When in doubt leave the fibula alone Don t burn your bridges Definitive plan usually not known at presentation CT performed after ex-fix Leave it like this!
28 Next Step: 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
29 Very difficult to preop plan Much easier!
30
31 Ligamentotaxis Anterior inferior tib-fib ligament
32 Anterior inferior tib-fib ligament
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34 Calcaneal pin Medial to lateral
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41 Length Alignment Rotation
42 Length Alignment Rotation
43 Length Alignment Rotation
44 Bump of towels to adjust sagittal alignment
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49 Posteriorly directed vector
50 Posterior translation!
51 Posterior translation!
52 Foot pins 1 st metatarsal
53 Foot pins Cuneiforms
54 Foot pins Talus
55 Foot pins Calcaneus
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58 Why calcaneal pins? Pressure from splint
59 Why calcaneal pins? Pressure from heel on bed
60 Keep heel off bed! Prevent pressure ulcers!
61 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 (4-6 weeks) Significant comorbidities for ORIF Patient doesn t want further surgery
62 Does articular reduction matter? 3 independent examiners (Marsh, Nepola, DeCoster) Rank order list of 25 pilon fractures by severity Tried to correlate with arthrosis, outcomes DeCoster TA, FAI 1999
63 Does articular reduction matter? Ranked #1, 5, and 4 Ranked #24 DeCoster TA, FAI 1999
64 Does articular reduction matter? AOFAS 77 AOFAS 73 DeCoster TA, FAI 1999
65 Does articular reduction matter? AOFAS 77 AOFAS 73 Neither injury nor reduction correlated with outcome DeCoster TA, FAI 1999
66 Does articular reduction matter? DeCoster TA, FAI 1999
67 Does articular reduction matter? AOFAS 84 Injury severity correlated with arthrosis But arthrosis was not correlated with outcome! DeCoster TA, FAI 1999
68 Does articular reduction matter? Probably not as much as we think! DeCoster TA, FAI 1999
69 Spanning fixation as definitive treatment
70 Spanning fixation as definitive treatment
71 Spanning fixation as definitive treatment
72 Spanning fixation as definitive treatment 5 months in frame
73 Spanning fixation as definitive treatment 2 year follow-up
74 Usually wait approximately 2 weeks prior to ORIF
75 Swelling 6h 6d Time
76 Wrinkle sign ready for ORIF!
77 Preop planning
78 AM AL P F
79 P AM AL AM AL P
80 AM
81 AL
82 AM AL P
83 Approaches Anteromedial Anterocentral TA EHL EDL PT Anterolateral FHL PB PL Posteromedial Achilles Posterolateral
84 Plating options Anterior plate better fixation Medial plate Poor fixation of posterior fragment!
85 Plating options Combined plates Medial plate as adjunct
86 Plating options Combined plates Posterior plate helps to trap the talus
87
88
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90 Trap the talus
91 Posterolateral PL PB GS FHL Sol PT EHL EDL TA TP FDL
92 Posterolateral FHL FHL PL Klammer FAI 2013
93 Anterolateral PT EDL EHL TA PB PL FHL Achilles
94 Anterolateral
95
96 Anterocentral PT EDL EHL TA PB PL FHL Achilles
97 Anterocentral EHL Tib Ant
98 Anteromedial PT EDL EHL TA PB PL FHL Achilles
99 Anteromedial Assal M JOT 2007
100 Open the fracture Cobb or lamina spreader Reduce major articular fragments
101
102 Work back to front
103 Work back to front Posterolateral constant fragment
104 Work back to front Close the book
105 Central comminution
106 Central comminution Push articular pieces down
107 Check reduction C-arm Distract foot, look from below Palpate with elevator
108 Bone graft metaphyseal void
109 Close anterior cortex Close anteromedial and anterolateral fragments together K-wire temporary fixation
110 Anterolateral plate Anterior plate
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116 Rim plate
117 Simplifying the puzzle Establish articular block first Connect articular block to diaphysis
118
119
120 +/- Medial plate Medial plate mainly as an adjunct
121 +/- Medial plate or as an anti-varus plate
122 If you do use a medial plate use small incisions and handle soft tissues carefully
123 Small medial incisions!
124 Don t do this
125 Don t do this
126
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129
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131 α
132 α α
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136 Summary Meticulous debridement Thoughtfully placed external fixator Careful preop planning Alignment
137
138 to Dr. Lew Zirkle, Jeanne Dillner, SIGN staff, & all of you Thank You!
139
140
141 Position of the foot at time of impact can create variants Dorsiflexed Inverted
142 Next steps Sponge and suction drain Antibiotic beads Sterile dressings Loose primary closure? Repeat debridements q 48-72h as needed
143
144 Ligamentotaxis Posterior syndesmotic ligaments
145 Anterior-inferior tibiofibular ligament Ligamentotaxis
146 Anterior inferior tib-fib ligament
147 Tibial pins Draw out later incisions Keep pins away from the lines Avoid this!
148 Nailing distial tibia fractures Selected cases 4-5 cm of intact distal bone Watch out tend to into valgus Align fracture BEFORE reaming
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155 Primary fusion? Nonreconstructible joint surface Ipsilateral severe talus / calcaneus fracture Neglected cases
156 When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems
157 When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems
158 When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems
159 When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems
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