Pilon Fracture: Preventing Complications
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Abstract:
Fractures of the distal tibial plafond (ie, pilon) comprise a broad range of injury mechanisms, patient demographics, and soft-tissue and osseous lesions. Patients often present with considerably comminuted fracture patterns and notable soft-tissue compromise. Surgical intervention must be performed with respect for the exceedingly vulnerable soft-tissue envelope and with a properly executed technique. Even with proper timing, favorable host factors, and expert surgical technique, restoration of function and avoidance of complications are not always achievable. Recently validated techniques further diminish the risk of soft-tissue and osseous sepsis. These techniques include early (ie, "immediate") fixation, upgrading, primary arthrodesis, staged sequential posterior and anterior fixation, acute shortening, and transsyndesmotic fibular plating. Proper application of these recently adopted techniques may be instrumental in achieving aseptic union of pilon fractures.Keywords:
Pilon fracture
The results of treatment using a locally-designed external fixator in 20 patients are presented. Open fractures were the main indications for external fixation. Pin tract infection occurred in 8 patients. Only 2 patients had unstable fixation which required removal of the device. One third of patients developed malunion exceeding 15 degrees and two thirds had joint stiffness after conversion to plaster cast. This external fixator is adequate in the treatment of most open fractures of the tibia. However, improved techniques of pin insertion and cast application upon removal of the external fixator may help to reduce the incidence of pin tract infections and malunion.
Malunion
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Objective To analyze the data of external fixation instruments (including Ilizarov instruments) used by QIN Sihe orthopaedic surgical team in the treatment of limb deformities in the past 30 years, and to explore the indications for the application of modern external fixation techniques in the correction of limb deformities and individual device configuration selection strategy. Methods According to QIN Sihe orthopaedic surgical team, the use of external fixator between January 1988 and December 2017 was analyzed retrospectively. The total use of external fixation and the proportion of different external fixators were analyzed in gender, different operation time, different age, different parts, and different diseases. Results External fixators were used in 8 113 patients, 69 of them were used simultaneously in both lower extremity surgery, so 8 182 external fixators were used. Among them, there were 4 725 (57.74%) combined external fixators, 3 388 (41.41%) Ilizarov circle fixators, 64 (0.78%) single arm external fixators (including Orthofix), 5 (0.06%) Taylor space external fixators. There were 4 487 males (55.31%) and 3 626 females (44.69%). According to the analysis of different time periods, the number of external fixators increased year by year, and the number of applications increased after 2000. The main age of the patients was 11-30 years old, of which 1 819 sets (22.23%) were used at the age of 21-25 years. The use of the external fixator covered almost all parts of the limbs, with the ankle and toe areas being the most common, reaching 4 664 sets (57.00%), and the upper extremities the least, with 152 sets (1.86%). The 8 113 cases covered more than a dozen disciplines and more than 150 kinds of diseases. The top 5 diseases were poliomyelitis sequelae, cerebral palsy, deformity of lower extremity after spina bifida, traumatic sequelae, and congenital equinovarus foot. Conclusion Ilizarov technique has been widely used in extremity deformity, disability, and complicated orthopedic diseases caused by vascular, lymphoid, nerve, skin, endocrine, and other diseases. The indication of operation is far beyond the scope of orthopedics. The domestic external fixator and its mounting tools can basically meet the requirements of various treatments. The technique of external fixation has entered a new era of tension tissue regeneration under stress control, natural repair of tissue trauma and deformity, and reconstruction of limb function.
Ilizarov Technique
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The authors show 30 cases of recent tibial fractures treated by external fixation. They study the different types of fractures, the models of external fixation employed, the complications occurring during the treatment and the ultimate results obtained.
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Tibial pilon fractures are difficult to treat due to articular comminution and soft-tissue injuries caused by high-energy trauma. Open reduction and internal fixation is a commonly used method of treatment. However, it has a high risk of infection and soft-tissue complications due to the extensive detachment of soft tissue. We report on a case with a tibial pilon fracture and soft-tissue necrosis that we treated using limited internal fixation combined with a circular external fixator (LIFCEF) and reverse sural artery flap (RSAF) as part of an orthoplastic approach within the orthopedic surgery department alone, which obtained good results. A 51-year-old man was injured in a motorcycle accident and transported to a nearby hospital. X-rays at the time of injury showed tibial pilon fractures (AO Foundation/Orthopedic Trauma Association 43c3.3, Ruedi-Allgower: Type III). Soft-tissue necrosis with blisters on the medial side of the lower leg (AO soft-tissue classification: IC3-MT1-NV1) was observed. In addition, the patient was referred to our hospital on day 10 of the injury. LIFCEF was chosen for treating the fracture because plate fixation was accompanied by the risk of plate exposure, soft-tissue complications, and an increased skin defect area, and RSAF was chosen to reconstruct the soft tissue defect. Four years after the surgery, the American Orthopedic Foot and Ankle Score was 92 points. X-ray alignment evaluation showed mLDTA 93° and aADTA 91°. Stage 2 arthrosis was present according to the Takakura ankle osteoarthritis classification, but the patient was able to walk without pain. Tibial pilon fractures are difficult to treat due to articular comminution and soft-tissue injuries caused by high-energy trauma. The timing and choice of treatment are crucial concerning the soft tissue.
Pilon fracture
Soft tissue injury
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On a group of 30 patients authors present the results they have achieved in the treatment of fractures of distal radius by external fixation. They deal with indications to the treatment of this injury by external fixation and describe in detail the method of such treatment. They discuss the pitfalls of this treatment, potential complications and adequacy of individual types of external fixators. They point out the discrepancy in the evaluation of objective achievements and subjective evaluation of patients. In total they evaluate the results as good and recommend a more consistent diagnostic and therapeutic connsidera-tion of the treatment of these injuries in out-patient departments. Key words: fracture of distal radius, external fixator.
Distal radius fracture
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The purpose of this study was to evaluate the influence of intramedullary (IM) alignment used in combination with an Ilizarov external fixation on the healing index (HI) and lengthening index (LI) in the treatment of congenital leg length discrepancies (LLD). This study included 35patients aged from 3.5 to 19 (average age 10.73) who underwent thl egalisation procedure using an Ilizarov external fixator. We compared the duration of the external fixator application, LLD, HI and LI between two groups of children: children in Group I underwent limb lengthening by the conventional llizarov technique using an Ilizarov external fixator alone, and children in Group II underwent a combination of Ilizarov technique and intramedullary alignment with two Kirschner wires, introduced through two mini-incisions. We found significant differences between the two groups of patients for duration of external fixator application and HI. Patients with congeni- tal LLD treated with combined method of treatment had benefit from intramedullary alignment due to its better outcome.
Ilizarov Technique
Kirschner wire
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The management of closed intra-articular pilon fractures has a history of significant postoperative soft tissue complications when managed with open reduction and internal fixation. The classically described early open reduction of the tibia using an anterior approach was found to have an unacceptably high complication rate. It was observed that significant pilon fractures actually involved 2 injury paradigms: one involving bone and the other involving the soft tissue envelope. This led to significant changes in the protocol for managing closed pilon fractures effectively reducing the complication rates involving both soft tissue and bone. Recognition of the soft tissue trauma led to the staging of pilon fractures to allow time for soft tissue recovery from the initial trauma. Recognition of the diversity of the bony injury through the use of computed tomography scans has led to a variety of described approaches that allow the surgeon to choose how best to manage the fracture pattern.
Pilon fracture
Soft tissue injury
Distal tibia
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Orthopaedic trauma patients often require temporary stabilization prior to definitive treatment following the principles of damage control orthopaedics (DCO). DCO includes the use of temporary or supplemental implants including pelvic external fixators, large external fixators, small external fixators, ring external fixators, skeletal traction, cervical traction, and cervical halo fixation. Once provisional stabilization has been obtained, and the patient is optimized medically, further testing can be performed prior to definitive stabilization. Since MRI may be required before definitive fixation, it is necessary to understand MRI safety in patients with external fixation devices.
Hemipelvectomy
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Objective To investigate the clinical effect of treatment of severely comminuted Pilon's frac-tures with limited internal fixations and external fixators.Methods Since 2006,15 cases of severely comminuted Pilon's fractureswith limited internal fixations and external fixators were treated.They were all treated by Kirss-chnerwires or screws together with external fixators.External fixator were removed at 2～3 months after operation.Results All cases were followed up after operation.The following observation time was 4～18 months,average 13 months.No infections of wound and incision,no skin necrosis complication was found.According to Mazur ankle joint scoring system,The results demonstrated 6 excellent,7 good,2 fair,the excellent and good rate was 81.3%.Conclusion Limited internal fixation and external fixator is one of the effective way of treatment of severely comminuted Pilon's fracture because it can immobilize the sections of fracture and avoid infection of soft tissue and nonunion of fracture.
Pilon fracture
Soft tissue injury
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