Download Pilon Fractures

Introduce the Topic
Pilon Fracture Fixation:
Joseph Borrelli, Jr. MD
Professor and Chair
Department of Orthopaedic Surgery
University of Texas – Southwestern Medical Center
Dallas, TX
Objectives:
1- Briefly review radiographic and clinical findings
of high energy pilon fractures,
2- Describe the ‘Two-Stage Approach’ for the
treatment of high energy pilon fractures,
3- Review surgical options and approaches for these
fractures,
Rotational Type:
• Characteristics:
– spiral distal tibia fracture,
– little metaphyseal comminution,
– few articular fragments,
• mild/moderate displacement,
– w/wo fibula fracture,
– mild to moderate soft tissue
injury,
Axial Compression Type:
• Characteristics
– articular impaction,
– metaphyseal and articular comminution,
• moderate to major displacement,
– severe soft tissue injury/open
– associated with fibula fracture (85%),
Recognize the Difference !
• Timing of treatment,
– earlier vs delayed,
• Type of treatment,
– approach,
– ORIF vs limited IF and EF,
• Complications,
• Outcome,
Radiographic Evaluation:
• Plain radiographs:
AP
Mortice
Lateral
Radiographic Evaluation:
• Axial CT scans,
–
–
–
–
identifying fracture planes,
intra-articular fracture fragments,
pre-operative planning,
prognosis,
*
Radiographic Evaluation:
• CT scans: Coronal reconstructions,
Radiographic Evaluation:
• CT scans: Sagittal reconstructions,
Goals of Treatment
•
•
•
•
•
•
•
Biological exposure
Articular surface restoration (1)
Bone graft metaphyseal defect (2)
Buttress plate fixation (3)
Atraumatic closure
Early active ROM (4)
Protected weightbearing
RÜEDI - ALLGÖWER
‘Two Stage Protocol’
1st Stage:
– Ankle Spanning External Fixator,
• ORIF of the fibula,
– as soon as possible after presentation,
• maximize “ligamentotaxis”,
– stabilize the fracture while soft tissues
are recovery,
‘Two Stage Protocol’
Interim:
• ice, elevation, pre-operative plan,
• physical therapy,
• TIME to allow swelling to resolve,
Surgical Timing
• Patience
• Timing critical
• Avoid 1-6 days
• Await soft tissue envelope
(10-21 days)
Fibular Alignment Controls Talus
Fibular Alignment Controls Talus
“traveling traction”
Frame Configuration
“Traveling Traction”
Half Pins
Transfixation
Pin
Posterolateral fibular approach
Interim: Pre-operative Plan !!!
• Patient
– Ice, elevation,
– CT scan,
– Crutch training,
• Surgeon
– Pre-operative plan,
TIME to allow swelling to resolve,
Definitive Fixation: Plates/Screws
2nd Stage: Definitive Fixation
• ORIF tibia and fibula,
• removal of external fixator,
• ORIF Fibula,
– posterolateral approach,
– maximize skin bridge,
Definitive Fixation: Plates/Screws
Anteromedial Approach: Indications
• Anterior and medial comminution
• Planning a ant and/or medial plate
Approach
– ½ finger breath lateral to tibial crest,
– maintain 7 cm skin bridge,
– parallel to Anterior Tibialis tendon,
– towards the talonavicular joint,
Definitive Fixation: Plates/Screws
Anteromedial Approach:
medial
talonavicular joint
Definitive Fixation: Plates/Screws
Articular Reduction:
– largest, least displaced fragments first,
• posterior fragment,
– reduce fragments and hold,
• K-wires (1.6 mm),
• pointed reduction forceps,
– definitive fixation,
• lag screws, cannulated screws,
– reduce articular bloc to shaft,
• definitive fixation,
Definitive Fixation: Plates/Screws
DON’T make medial a incision !!!
– incision is directly over the bone/plate,
– difficult to close,
– increased wound complications,
• deep infection,
• soft tissue loss,
• free flap only bailout,
– burns bridges for later reconstruction,
NO !!
Definitive Fixation: Plates/Screws
Anterolateral Approach (Bohler):
• Indications:
– open medial wound,
– displaced Chaput fragment,
– lateral articular comminution,
• Advantage:
– good soft tissue coverage,
– uninjured skin,
– single incision for ORIF of the tibia and
fibula,
Wolinsky, P, & Lee, M J Ortho Trauma 2008
Anterolateral Approach
• Deep Dissection:
– through superior and inferior retinaculae,
– interval between toe extensors and fibula,
– elevate muscles off interosseous membrane,
• Caution:
– superficial peroneal nerve,
– 8 cm proximal to joint,
Anterolateral Approach
Wolinsky, P, & Lee, M J Ortho Trauma 2008
Definitive Fixation: Plates/Screws
Implants: Small Fragment Plates
– small fragment plates,
– 3.5 LC-DCP,
– precontoured medial LCP,
– anterolateral plates LCP,
• Screws
– 3.5 cortical/4.0 cancellous,
– cannulated: 4.0/4.5
Definitive Fixation: Plates/Screws
Implants: Small Fragment Plates
– small fragment plates,
– 3.5 LC-DCP,
– precontoured medial LCP,
– anterolateral plates LCP,
• Screws
– 3.5 cortical/4.0 cancellous,
– cannulated: 4.0/4.5
Definitive Fixation: Plates/Screws
Bone Graft: Theory
– support articular fragments,
– augment healing,
– fill cancellous defects,
• ICBG,
• Allograft,
• Synthetic
– Calcium putties,
Definitive Fixation: Plates/Screws
Meticulous Wound Closure
– Deep closure,
• 1-0 vicryl for capsule,
• 2-0 vicryl for subcutaneous
tissue,
– Skin closure
• 3-0 nylon,
AllgÖwer’s modification of the Donati stitch,
PL 45 y/o MVC
“Two Stage Protocol”
“Traveling Traction”
“Two Stage Protocol”
“Two Stage Protocol”
“Two Stage Protocol”
Ligamentotaxis
Definitive fixation
Summary
• Tibial Plafond Fractures are challenging injuries,
• Represent both a bony and soft tissue injury,
– AO principles have remained the same:
•
•
•
•
articular reduction,
stable fixation,
early mobilization of the patient and ankle,
meticulous soft tissue handling,
Summary
• “Two Stage Protocol”,
– spanning external fixation and +/- ORIF fibula,
– definitive management of the tibia,
• Approaches,
– Anteromedial approach,
– Anterolateral approach,
• Implants,
– Small fragment plates and screws,
– Pre-contoured plates (LCP),