Bad Ankle with Soft Tissue Injuries: Fix them all Now! Don t Wait! BOB ZURA, MD OSET 2017 LAS VEGAS

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1 Bad Ankle with Soft Tissue Injuries: Fix them all Now! Don t Wait! BOB ZURA, MD OSET 2017 LAS VEGAS

2 Disclosures Consultant: Smith-Nephew Bioventus Cardinal Health

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10 This is really about soft tissue Yes you can wait, but. Easier if wound vac What if you closed the skin Wait until it heals? Re-open? What options does the soft tissue envelope/injury give you? The question is: Is it safe to the soft tissues to fix early? Assumption the open fracture is adequately clean and does not require redebridement.

11 Immediate internal fixation of open ankle fractures. J Orthop Trauma Wiss DA, Gilbert P, Merritt PO, Sarmiento A. 76 open ankles treated with immediate fixation Seventy-two percent of the patients had a satisfactory result Deep infection occurred in 5% of the patients We believe immediate internal fixation is the treatment of choice for displaced open ankle fractures, but this form of treatment does have a significant rate of complications.

12 Treatment of open ankle fractures. Immediate internal fixation versus closed immobilization and delayed fixation. Clin Orthop Relat Res Bray TJ, Endicott M, Capra SE. Thirty-one open ankle fractures 15 delayed 16 immediate One case in each group became infected Functional scores at follow-up examination were the same immediate showed less impairment of range of motion but had a greater incidence of chronic ankle swelling Significant shorter LOS for immediate Faster recovery with no more infection

13 Open ankle fractures. The indications for immediate open reduction and internal fixation.review article Clin Orthop Relat Res Johnson EE, Davlin LB. 22 open ankles treated with immediate fixation There were six Grade I (27%), 15 Grade II (68%), and one Grade III (5%) injuries. Excellent results were achieved in 14 patients (64%); good results in five (23%), and poor results in three (13%). There were no deep infections or nonunions. Immediate debridement, irrigation, reduction, and internal fixation of open ankle fractures is clearly indicated in Grade I and clean Grade II open injuries.

14 Does this apply to modern literature?

15 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. JOT pilons Primary ORIF was performed within 24 hours in 70% of cases and within 48 hours in 88%. Six patients developed a deep wound infection or dehiscence that required surgical débridement, four after open fractures (four of 21 [19%]) and two after closed fractures (two of 74 [2.7%]). Provided surgery is performed expeditiously by experienced orthopaedic trauma surgeons, most tibial pilon fractures can be stabilized by primary ORIF within a safe and effective operative window with relatively low rates of wound complications, a high quality of reduction, and functional outcomes that compare favorably with the published results for all other reported surgical treatments of these severe injuries.

16 Comparison of Early and Delayed Open Reduction and Internal Fixation for Treating Closed Tibial Pilon Fractures. Tang X1, Liu, Tu CQ, Li J, Li Q, Pei FX. If soft tissue conditions are acceptable, early ORIF for treating closed type C pilon fractures can be safe and effective, with: similar rates of wound complication fracture union good functional recovery but shorter operative time, union time, and hospital stay. These results favorably compare with delayed ORIF treatment.

17 Complications and early results after operative fixation of 68 pilon fractures of the distal tibia. Lomax, Singh, N Jane, C Senthil. Fixation of these complex fractures in subspecialist units can achieve overall low rates of wound complications, with definitive fixation of selected fractures within 48 h of initial presentation achieving comparable results to those fixed in a delayed fashion. However, this injury continues to have a significant overall complication rate with a high chance of developing early posttraumatic arthritis and of requiring further surgery.

18 Summary These are soft tissue injuries Must adequately debride and irrigate open fractures In open injuries ok (and I think preferable) to fix early No need to revisit incisions Personalize the treatment to each case It is SAFE to fix these early in experienced hands Complications will still occur as these are devastating injuries

19 Early is ok, ok with open fractures? Look to the tibia We know we can fix early if low grade and clean

20 Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes? Duyos, Oscar A. MD; Beaton-Comulada, David MD; Davila-Parrilla, Ariel MD; Perez-Lopez, Jose Carlos MD; Ortiz, Krystal BS; Foy-Parrilla, Christian MD; Lopez-Gonzalez, Francisco MD Open tibial shaft fractures should be débrided within 24 hours after injury. Primary reamed intramedullary nailing appears to be a reasonable option for the management of Gustilo-Anderson types 1 and 2 open tibial shaft fractures.

21 Thank You!