Lecture 11 parekh pilon

Pilon Fractures

Selene G. Parekh, MD, MBAAssociate Professor

North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery

Adjunct Faculty Fuqua Business SchoolDuke University

Durham, NC919.471.9622

www.seleneparekhmd.com@seleneparekhmd

Principles

•Initial Evaluation•Initial Management•“Night 1” – Intervention•Imaging•Definitive Fixation•Aids

•Choosing your approach•Results

•Comparing Methodologies•Complications

Initial Radiographic Evaluation

• 3 views ankle

• Full length tibia

• Contralateral films

Therefore…• We know when it is bad!

• Is there another way to see if it is really bad?

Fibula Fracture ?

• If present• Valgus• Axial Load• Often higher energy

• If absent • Varus• Axial Load

Barei DP, et al: JOT 2006

What do we do with it?

“Night 1”

•Open?•Vascular injury?•Provisional ER reduction / Splint•Moist 4 x 4•Get it cleared!•Get it to the OR!

Initial GOAL

•Restore Mechanical axis

•Length•Alignment

•+ Fibula Plating•Relax soft tissues AT LENGTH

Temporizing Ex-fix

• Get length and alignment• Avoid Zone of injury• Stable construct• Maintain neutral foot

• Keeps tissue length• Avoids contracture• Decreases later problems

Why the staples on night 1?

Pins in zone of injury

Temporizing Ex-fix

• Get length and alignment• Avoid Zone of injury• Stable construct• Maintain neutral foot

• Keeps tissue length• Avoids contracture• Decreases later problems

Alignment?

Length?

Temporizing Ex-fix

• Get length and alignment• Avoid Zone of injury• Stable construct• Maintain neutral foot

• Keeps tissue length• Avoids contracture• Decreases later problems

Temporizing Ex-fix

•Ex-fix placement•Out of zone of injury•“Safe Zone”

•Proximal•Distal to tibial tubercle

•Distal•+ Talar neck•Calcaneus

•Posterior tuberostiy•Anti-equinus

Temporizing Ex-fix

•Structures at risk•Lateral plantar nerve•Most posterior lateral plantar nerve•Medial calcaneal nerve

•Posterior:•1/2 A-C•1/3 A-B

Medial Malleolus

Posterior- Inferior Medial Calcaneus

Temporizing Ex-fix

• Fix the fibula acutely?• Helps with alignment• Maintenance soft tissue

• Fix the fibula ever?• Definitive ORIF • Definitive Ex-fix

• Why fix the fibula?• Lateral column stability

CT Scans

Tornetta and Gorup, CORR, 1993

• MUST

• Operative plan changed in 14 (64%)

• Additional info gained in 18 (82%)

Articular Injury• Major Fragments

• Anterolateral Articular (Chaput)

• Medial Malleolus

• Posterior Articular (Volkmann’s)

Surgical Timing• Patience

• Timing critical

• Avoid 1-6 days

• Await soft tissue envelope (10-21 days)

It’s not the fractureIt’s the Soft Tissues

Blisters

•Cleavage of dermal / epidermal junction

•Caused by strain at time of initial energy absorption

•Clear•Occasional epidermal cells still in contact

•Blood-filled•Complete shear of epidermis•? Contamination•Longer re-epithelialization

•Varied treatments

Koval KJ, et al: 1994, 1995, 2006

What if ORIF definitively?

Rüedi and Allgöwer

• 60/84 low energy twisting• 74% good functional results• 90% return to work• Low complications

• 5% infection• 12% wound problem

Injury 1969, 1973

Low energy

“Boot-top” Injury

Delayed Surgery/Higher Energy

Mast 1988

Helfet 1994

Sirkin, Sanders 1999

“Wait until it is SAFE!!!”

• 5% skin slough• 5% infection• 0 amputations

• 28% infection• 33% wound breakdown• 16% Amputation

PlatingExternal Fixator

Wyrsch, JBJS 1996

Wait, what’s the problem with ORIF?

Staged Protocol Popularized

•34 closed fx’s•Avg 12.7 day delay

•5 minor wound issues tx’d non-op•1 osteomyelitis

•22 open fx’s•Avg 14 day delay

•2 minor wound issues tx’d non-op•1 ROH & IV Abx•1 amputation

Sirkin MS, et al: JOT 1999

When to do definitive surgery?

• Blisters epithelialized• “Wrinkle test”

• Without manipulationwrinkling of skin around Ankle

• Soft tissues determine energy of injury• Tscherne Classification

NIGHT 1

READY

It’s the right time…

What to do?

Principles

I. Restore length, fibulaII. Reconstruct jointIII. Bone graft defectIV. Buttress medially

Rüedi, injury 1969

ORIF - Overview

• Where to attack the injury from?• What are the approaches?• What is the fixation?• Supplements to fixation & grafting?• Wound management?

Early Limited Internal Fixation

•Night 1 •Meta-diaphyseal spikes

•May simplify definitive reconstruction•May protect soft tissues

Dunbar RP, et al: JOT 2008

Night 1: I&D open wounds, limited fixation

Post-op CT

Day 5: Repeat I&D w/ fibula plate

Day 12: The Real Deal

Day 12: The Real Deal

Day 12: The Real Deal

Day 12: The Real Deal

Limited “Night 1” fixation

“Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques.”

Blauth M, et al: JOT 2001• 3 treatments (51 pts, f/u ~68 months)

• Initial ORIF• Initial minimally invasive articular ORIF w/ definitive

spanning ex-fix• Initial minimally invasive articular ORIF w/ spanning ex-fix

and staged MIPPO ORIF• None of the 2-stage pts needed arthrodesis, they had

better ROM, less pain, higher RTW rate• No differences in wound complications

Choose surgical approach

• Choices• Anteromedial• Anterolateral• Direct Anterior• Posterolateral• Posteromedial

• Can Stage between approaches

• Rotation of posterolateral fragment

• Fix to posterolateral fragment

• Posteromedial to posterolateral

• Central impaction

• Anterolateral fragment

• Secure articular segment

• Span joint to diaphysis

Fixation Strategy

Fixation Strategy

• Work from back to front• Joint distraction

• Ex-fix• Femoral Distractor

Anteromedial Approach

•Traditional

•Access to majority of joint •Not optimal for complex anterolateral corner

•Access for anterior and medial hardware application

Anteromedial Approach

• ~5cm proximal to joint line just lateral to tibial crest

• Extends distal-medial crossing crest (following medial border of TA tendon) and extending around medial malleolus – or – continuing distally with TA tendon

• Do NOT violate TA tendon sheath

•Elevate anterior compartment from medial to TA tendon going laterally

•Excise anterior ankle capsule and intra-articular fat

•Preserve periosteum

Anteromedial Approach

TOES

• Supine

• Incision starts ~5cm proximal to tibio-talar joint line just lateral to tibial crest

• Extends distal-medial crossing crest (following medial border of TA tendon) and extending around medial malleolus – or – continuing distally with TA tendon - *Watch for saphenous vein

• Do NOT violate TA tendon sheath

• Elevate anterior compartment from medial to TA tendon going laterally

• Excise anterior ankle capsule and intra-articular fat

• Preserve periosteum

Anteromedial Approach•Supine

•Incision starts ~5cm proximal to tibio-talar joint line just lateral to tibial crest

•Extends distal-medial crossing crest (following medial border of TA tendon) and extending around medial malleolus – or – continuing distally with TA tendon - *Watch for saphenous vein

•Do NOT violate TA tendon sheath

•Elevate anterior compartment from medial to TA tendon going laterally

•Excise anterior ankle capsule and intra-articular fat

•Preserve periosteum

Anteromedial Approach

Anterolateral (Bohler’s) Approach

•Incision in line with the fourth metatarsal

•Centered at the ankle joint

•Protect SPN

•Incise the extensor retinaculum and the anterior compartment fascia

•Dissect the entire anterior compartment musculature from lateral to medial

•Joint arthrotomy

Anterolateral (Bohler’s) Approach

•Incision in line with the fourth metatarsal

•Centered at the ankle joint

•Protect SPN

•Incise the extensor retinaculum and the anterior compartment fascia

•Dissect the entire anterior compartment musculature from lateral to medial

•Joint arthrotomy

Anterolateral (Bohler’s) Approach

•Incision in line with the fourth metatarsal

•Centered at the ankle joint

•Protect SPN

•Incise the extensor retinaculum and the anterior compartment fascia

•Dissect the entire anterior compartment musculature from lateral to medial

•Joint arthrotomy

Anterolateral (Bohler’s) Approach

•Incision in line with the fourth metatarsal

•Centered at the ankle joint

•Protect SPN

•Incise the extensor retinaculum and the anterior compartment fascia

•Dissect the entire anterior compartment musculature from lateral to medial

•Joint arthrotomy

Anterior Approach

•Used for later fusion/TAR•Access to AM & AL joint•Extends distal to the lateral aspect of the talar neck•Watch SPN •Incise extensor retinaculum•Intervals

•EHL/TA •EHL/EDL •EDL/peroneous tertius

•Proximal to tibio-talar joint NV bundle between TA and EHL

•Distal to tibio-talar joint NV bundle beween EHL and EDL

•Excise anterior ankle capsule and intra-articular fat

Anterior Approach•Used for later fusion/TAR•Access to AM & AL joint•Extends distal to the lateral aspect of the talar neck•Watch SPN •Incise extensor retinaculum•Intervals

•EHL/TA •EHL/EDL •EDL/peroneous tertius

•Proximal to tibio-talar joint NV bundle between TA and EHL

•Distal to tibio-talar joint NV bundle beween EHL and EDL

•Excise anterior ankle capsule and intra-articular fat

Posterolateral Approach•Prone or lateral positioning

•Incision between the FHL and the peroneal tendons

•Protect sural nerve

•Exploit interval b/t peroneals & posterior compartment

•Dissect FHL muscle from posterior tibia

Posterolateral then Anterior

Posterolateral then Anterior

Posterolateral then Anterior

Posterolateral then Anterior

Posterolateral then Anterior

Posteromedial Approach•Prone or “figure 4” positioning

•Incision b/t Achilles & posteromedial tibia

•Identify NV bundle

•Exploit any of the intervals lateral to the posterior tibial tendon.

•Extra-articular reduction based on the cortical reads posteriorly

•Combination lag screws & anti-glide plate fixation(s)

•Allows visualization of joint through fracture only

Courtesy of Sean Nork, MD

Closure

• Facial closure

• Subcutaneous sutures

• Cutaneous sutures

• Consider VAC

RE ECT

the ankle

the foot