Pilon fractures Pat Yoon, MD Minneapolis Veterans Affairs Medical Center Associate Professor, University of Minnesota
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
Palazzo FF, BMJ 1999
Palazzo FF, BMJ 1999
Definition High-energy fracture of distal tibial metaphysis Usually compressive injury / axial load Soft-tissue compromise Severe injury - Educate the patient early!
How do these occur?
Soft tissue compromise
Do not treat pilons like an ankle Immediate ORIF + Large plates =
Initial treatment Tetanus Antibiotics Sterile dressing Immobilization Associated injuries!
Next step: debridement Open injuries common Thin medial tissues Medial spike
Next step: debridement Open injuries common Thin medial tissues Medial spike
Debridement Deliver the bone ends!
Deliver bone ends Extend wounds longitudinally
Deliver bone ends Extend wounds longitudinally
Often more soft tissue injury than initially apparent
Often more soft tissue injury than initially apparent
Remove all foreign debris and devitalized soft tissue & bone
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?
Check: Skin Subcutaneous tissue Muscle / tendon Fascia Periosteum Bone Major articular segments save?
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
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!
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
Very difficult to preop plan Much easier!
Ligamentotaxis Anterior inferior tib-fib ligament
Anterior inferior tib-fib ligament
Calcaneal pin Medial to lateral
Length Alignment Rotation
Length Alignment Rotation
Length Alignment Rotation
Bump of towels to adjust sagittal alignment
Posteriorly directed vector
Posterior translation!
Posterior translation!
Foot pins 1 st metatarsal
Foot pins Cuneiforms
Foot pins Talus
Foot pins Calcaneus
Why calcaneal pins? Pressure from splint
Why calcaneal pins? Pressure from heel on bed
Keep heel off bed! 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 (4-6 weeks) Significant comorbidities for ORIF Patient doesn t want further surgery
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
Does articular reduction matter? Ranked #1, 5, and 4 Ranked #24 DeCoster TA, FAI 1999
Does articular reduction matter? AOFAS 77 AOFAS 73 DeCoster TA, FAI 1999
Does articular reduction matter? AOFAS 77 AOFAS 73 Neither injury nor reduction correlated with outcome DeCoster TA, FAI 1999
Does articular reduction matter? DeCoster TA, FAI 1999
Does articular reduction matter? AOFAS 84 Injury severity correlated with arthrosis But arthrosis was not correlated with outcome! DeCoster TA, FAI 1999
Does articular reduction matter? Probably not as much as we think! DeCoster TA, FAI 1999
Spanning fixation as definitive treatment
Spanning fixation as definitive treatment
Spanning fixation as definitive treatment
Spanning fixation as definitive treatment 5 months in frame
Spanning fixation as definitive treatment 2 year follow-up
Usually wait approximately 2 weeks prior to ORIF
Swelling 6h 6d Time
Wrinkle sign ready for ORIF!
Preop planning
AM AL P F
P AM AL AM AL P
AM
AL
AM AL P
Approaches Anteromedial Anterocentral TA EHL EDL PT Anterolateral FHL PB PL Posteromedial Achilles Posterolateral
Plating options Anterior plate better fixation Medial plate Poor fixation of posterior fragment!
Plating options Combined plates Medial plate as adjunct
Plating options Combined plates Posterior plate helps to trap the talus
Trap the talus
Posterolateral PL PB GS FHL Sol PT EHL EDL TA TP FDL
Posterolateral FHL FHL PL Klammer FAI 2013
Anterolateral PT EDL EHL TA PB PL FHL Achilles
Anterolateral
Anterocentral PT EDL EHL TA PB PL FHL Achilles
Anterocentral EHL Tib Ant
Anteromedial PT EDL EHL TA PB PL FHL Achilles
Anteromedial Assal M JOT 2007
Open the fracture Cobb or lamina spreader Reduce major articular fragments
Work back to front
Work back to front Posterolateral constant fragment
Work back to front Close the book
Central comminution
Central comminution Push articular pieces down
Check reduction C-arm Distract foot, look from below Palpate with elevator
Bone graft metaphyseal void
Close anterior cortex Close anteromedial and anterolateral fragments together K-wire temporary fixation
Anterolateral plate Anterior plate
Rim plate
Simplifying the puzzle Establish articular block first Connect articular block to diaphysis
+/- Medial plate Medial plate mainly as an adjunct
+/- Medial plate or as an anti-varus plate
If you do use a medial plate use small incisions and handle soft tissues carefully
Small medial incisions!
Don t do this
Don t do this
α
α α
Summary Meticulous debridement Thoughtfully placed external fixator Careful preop planning Alignment
to Dr. Lew Zirkle, Jeanne Dillner, SIGN staff, & all of you Thank You! patyoon@gmail.com
Position of the foot at time of impact can create variants Dorsiflexed Inverted
Next steps Sponge and suction drain Antibiotic beads Sterile dressings Loose primary closure? Repeat debridements q 48-72h as needed
Ligamentotaxis Posterior syndesmotic ligaments
Anterior-inferior tibiofibular ligament Ligamentotaxis
Anterior inferior tib-fib ligament
Tibial pins Draw out later incisions Keep pins away from the lines Avoid this!
Nailing distial tibia fractures Selected cases 4-5 cm of intact distal bone Watch out tend to into valgus Align fracture BEFORE reaming
Primary fusion? Nonreconstructible joint surface Ipsilateral severe talus / calcaneus fracture Neglected cases
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
When do you ex-fix? For Shortening Impaction Subluxation / gross displacement Soft Tissue Problems