External Fixation & Surgical Staging

Transcription

1 External Fixation & Surgical Staging Pat Yoon, MD Minneapolis, MN Hennepin County Medical Center University of Minnesota VuMedi Webinar Pilon Fractures 02/24/2015 Disclosures Orthofix (consultant) Arthrex, Inc. (consultant) JAAOS (reviewer) FAI (reviewer) Initial management Debridement Fix the fibula? External fixator Planning for ORIF Outline 1

2 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! Pilon versus Ankle Do not treat pilons like an ankle Immediate ORIF Large plates 37-40% major complications 2

3 Pilon fractures High energy Axial load Standard orif doesn t work well AVOID early ORIF with large incisions and bulky implants Therefore: 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 hours Deep infection rate 3% One BKA SF-36: PCS 40.3, MCS 54.0 Boraiah et al JBJS 90:346-52,

4 Tetanus Antibiotics Sterile dressing Evaluate for associated injuries Initial workup Thinner soft tissues medially Initial presentation Obliquity usually produces a medial spike on the proximal fragment 4

5 Debridement Deliver the bone ends! Debridement Open wounds usually transverse Extend longitudinally Extend incisions If you can t deliver the bone ends, extend the traumatic wounds 5

6 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! 6

7 Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save? Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save? Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save? 7

8 Check: Skin Subcutaneous tissue 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 8

9 Do you fix the fibula initially? Yes if: It can be anatomically restored, and It will not compromise later ORIF Do you fix the fibula initially? No if: It can t be anatomically restored, or It compromises later ORIF Do you fix the fibula initially? No if: It can t be anatomically restored, or It compromises later ORIF 9

10 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! 10

11 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 11

12 When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems 12

13 When do you ex-fix? For Shortening Impaction Subluxation / gross 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 of Much easier! 13

14 Ligamentotaxis Posterior syndesmotic ligaments Ligamentotaxis AITFL 14

15 Anterior inferior tib-fib ligament 2 pins in diaphysis far from fx Usually 5mm Predrill Blunt pins Insert by hand Tibial pins Lateral Ant Post Medial Tibial pins Draw out later incisions Keep pins away from the lines Avoid this! 15

16 Calcaneal pin Medial to lateral 16

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18 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 18

19 Length Alignment Rotation Length Alignment Rotation Bump of towels to adjust sagittal alignment 19

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21 Posteriorly directed vector Posterior translation! 21

22 Posterior translation! Optional foot pin Helps maintain alignment Prevent equinus 3-4 mm Yeah, but what about just adding a posterior splint? Foot pin helps prevent pressure on sole of foot 22

23 Medial pin alone may supinate the foot 5 th met pin to balance foot More even! Danger of 1 st metatarsal pin 50% injury to deep plantar branch of dorsalis pedis 18mm danger zone Barrett MO JBJS 90: 560-4,

24 Alternatives Alternatives Dorsal to plantar 1 st metatarsal pin Alternatives Medial / intercuneiform pin 24

25 Alternatives Talar neck/head pin 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 25

26 Spanning fixation as definitive treatment Spanning fixation as definitive treatment Spanning fixation as definitive treatment 26

27 5 months in frame 2 year follow-up Conversion of spanning delta frame to a spanning circular fixator 27

28 Conversion of spanning delta frame to a spanning circular fixator Conversion of spanning delta frame to a spanning circular fixator Conversion of spanning delta frame to a spanning circular fixator 28

29 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 29

30 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! 30

31 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 Cole PA et al OTA

32 AM P AL F Cole PA et al OTA 2004 P AM AL AM AL P Anteromedial fragment AM 32

33 Anterolateral fragment AL Posterior fragment P AM AL P 33

34 Approaches: Anteromedial Anterocentral TA EHL EDL PT Anterolateral FHL PB PL Posteromedial Achilles Posterolateral 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? Anterocentral Anterolateral Anterolateral or anterocentral approach is best to remove central fragments 34

35 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 35

36 Medial plate Lateral plate How long do you wait? Wrinkle sign Wounds clean Blisters resolved Usually 1-2 weeks but can be longer 36

37 Swelling 6h Time 6d 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 37

38 Thank You! 38

39 2/16/2015 Tibial Pilon Fractures Surgical Approaches S. Andrew Sems, M.D. Department of Orthopaedic Surgery, Mayo Clinic Disclosure Royalties- Depuy/Biomet- Affixus Nail AO-OTA A: Nonarticular Classification B: Simple articular C: Complex articular 1

40 2/16/2015 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% malunion McFerran, JOT 6: 195,

41 2/16/2015 Results of Staged Approach 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 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 Dec;24(12): /95 patients underwent ORIF within 48 hrs. of admission 6% wound dehiscence/infection 90% anatomic reductions 78% mild arthritis or worse at 1 year 3

42 2/16/2015 Initial Management before ORIF External Fixation 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 Feb;13(2): Patterson MJ, Cole JD. Twostaged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma Feb;13(2): Initial Management before ORIF Soft Tissue Management Leave intact; if ruptured, leave roof intact Most complications occur with blood filled blisters Takes 3 wks to reepithelialize Giordano CP, Fracture Blisters, CORR. (307):214-21, 1994 Oct Initial Management before ORIF Soft 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 Feb;92(2):

43 2/16/2015 Timing of ORIF 12 days (closed) 14 days (open) 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 Feb;13(2): days Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma Feb;13(2): Timing of ORIF DVT Prophylaxis LMWH Duplex US 2.1% rate of DVT 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 Apr;66(4): 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 5

44 2/16/2015 Length Beware Comminution of fibula Complicates posterolateral approach Initial Management Fibular Fixation Technique of ORIF Choosing 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 6

45 2/16/2015 Technique of ORIF Posterolateral Approach Technique of ORIF Anterolateral Approach Options for Internal Fixation Anterolateral Plate 7

46 2/16/2015 Technique of ORIF Anteromedial Approach Technique of ORIF Locking Plates 8

47 2/16/2015 Staged Posterior Tibial Plating for the Treatment of Orthopaedic Trauma Association 43C2 and 43C3 Tibial Pilon Fractures. Ketz J, Sanders R. J Orthop Trauma Jan 20. Improved: AOFAS Maryland Foot and Ankle Score Articular Reduction Less: Arthrosis 9

48 2/16/2015 Postoperative Management 10

49 2/16/2015 Summary Immediate external fixation Delayed internal fixation Posterolateral approach Trap the talus Avoid medial plates if possible 11

50 2/16/2015 Posterior Approaches Paul M. Lafferty, MD Assistant Professor University of Minnesota Orthopaedic Trauma Regions Hospital St. Paul, MN Disclosures None 1

51 2/16/2015 Posterior Column Posterior Pilon Variant Posterior Pilon Variant 2

52 2/16/2015 Comminuted Pilon Large Posterior Fragment Comminuted Pilon Large Posterior Fragment Comminuted Pilon Large Posterior Fragment 3

53 2/16/2015 Posterolateral Approach (PL) Prone Lateral 4

54 2/16/2015 PM PL Transverse Intermuscular Septum MPM Tibial Nerve 5

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56 2/16/2015 Posteromedial Approach (PM) Prone Supine 7

57 2/16/2015 PM PL Transverse Intermuscular Septum MPM Tibial Nerve 8

58 2/16/2015 9

59 2/16/2015 Modified Posteromedial Approach (MPM) Prone Supine 10

60 2/16/2015 PM PL Transverse Intermuscular Septum MPM Tibial Nerve 11

61 2/16/

62 2/16/2015 Thank You Paul M. Lafferty, MD Assistant Professor University of Minnesota Orthopaedic Trauma Regions Hospital St. Paul, MN 13

63 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 1

64 Mechanical Mechanical Biological 2

65 Axial Loading 3

66 Rotational ankle fractures are different slow load, less energy few complications 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? Anatomical reduction critical?? 4

67 What do we know about patient outcome! b) Pain and decreased function common a) Complications create disasters! Complications have decreased! Absolutely determine outcome 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 5

68 Red Blisters The Soft Tissue Injury!! Clear Blisters Open Fracture The Injury/Management of the Soft Tissue Envelope is the Key Relative Success vs Dismal Failure Surgical delay enhanced using Spanning fixation! A- Frame Restore length and alignment 6

69 Plating through limited approaches Plating through limited approaches 7

70 The use of definitive external fixation 8

71 CT Spinning Frame off at 5 months Healed 9

72 Frame off at 5 months Healed Xrays at 2 years Definitive Spanning Fixator 36 yo male fell out of deer stand Closed soft tissue swelling, no blisters Limited or percutaneous approaches and use of reduction aids 10

73 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. 11

74 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 12

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