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Murawski CD, Mittwede PN, Wawrose RA, Belayneh R, Tarkin IS. Management of High-Energy Tibial Pilon Fractures. J Bone Joint Surg Am 2023; 105:1123-1137. [PMID: 37235679 DOI: 10.2106/jbjs.21.01377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
➤ Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.➤ Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.➤ Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.➤ Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.➤ Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.➤ The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.
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Affiliation(s)
- Christopher D Murawski
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Corona PS, Pujol O, Vicente M, Ricou E, de Albert M, Maestre Cano D, Salcedo Cánovas C, Martínez Ros J. Outcomes of two circular external fixation systems in the definitive treatment of acute tibial fracture related infections. Injury 2022; 53:3438-3445. [PMID: 36028372 DOI: 10.1016/j.injury.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/22/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Acute tibial fracture-related infection (FRI) is one of the most feared and challenging complications after a tibial fracture. The most appropriate treatment in this scenario is far from a resolved topic. Circular external fixators (CEFs) offer multiplanar control and minimize soft tissue injury using temporary implants far from the infected area. This study aimed to investigate the outcomes of two different types of CEFs (Ilizarov and hexapod) in the treatment of a series of acute tibial FRIs. MATERIAL AND METHODS A retrospective study at two specialized limb reconstruction centres identified all patients with an acute tibial FRI (≤4 weeks after index procedure) definitively treated with a CEF from January 2015 to December 2020. PRIMARY OUTCOMES fracture healing and infection eradication rate with a minimum FU of 12 months after frame removal. SECONDARY OUTCOMES to investigate the differences between the two types of circular frames regarding final post-treatment deformity magnitude. RESULTS We included 31 patients with acute tibial FRIs: 18 treated with hexapod-type and 13 with Ilizarov-type CEFs. Average age was 45.5±16.56 years. Fracture healing and infection eradication were achieved in all patients (31/31) after a mean follow-up of 24.7 months (range 12.1-55.3). Patients treated with an Ilizarov-type fixator presented shorter time to fracture union (5.5±2.2 months vs. 9.2±6.0 months; p-value 0.021) and shorter duration of external fixation (p-value 0.001). Regarding residual post-treatment deformity, the hexapod system presented significantly less residual coronal translation deformity (p-value 0.034) and better callus quality. Fixator-related complications were similar when comparing the two groups. No significant differences were seen in pain (p-value 0.25), RTW rate (35% vs. 45%; p-value 0.7) or functionality (p-value 0.4). CONCLUSIONS Definitive circular external fixation is an excellent treatment for acute tibial FRI. Both Ilizarov and hexapod systems offer a very high rate of fracture healing and infection eradication. Although both presented very low radiological post-operative residual deformity, the hexapod system showed less residual coronal translation deformity and better callus quality.
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Affiliation(s)
- Pablo S Corona
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Cències Morfològiques). Barcelona, Spain; Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain; Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Oriol Pujol
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Cències Morfològiques). Barcelona, Spain; Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain.
| | - Matías Vicente
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Cències Morfològiques). Barcelona, Spain; Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain; Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Elisenda Ricou
- Orthopaedic Surgery Department, Hospital de Sant Joan Despi Moises Broggi, Barcelona, Spain
| | - Matías de Albert
- Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Domingo Maestre Cano
- Orthopaedic Surgery Department; Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia. Spain
| | - César Salcedo Cánovas
- Orthopaedic Surgery Department; Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia. Spain; Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department; Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia. Spain
| | - Javier Martínez Ros
- Orthopaedic Surgery Department; Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia. Spain; Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department; Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia. Spain
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Lu V, Zhang J, Zhou A, Thahir A, Lim JA, Krkovic M. Open versus closed pilon fractures: Comparison of management, outcomes, and complications. Injury 2022; 53:2259-2267. [PMID: 35300868 DOI: 10.1016/j.injury.2022.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups. METHODS This retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807). RESULTS Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p = 0.017, respectively), ORIF-treated 43C closed fractures had shorter time to union (p = 0.005). Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (24%), superficial infection (21%). All occurred more frequently in FWF-treated patients. CONCLUSION Most ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups, yet few were statistically significant. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.
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Affiliation(s)
- Victor Lu
- School of Clinical Medicine, University of Cambridge, CB2 0SP United Kingdom.
| | - James Zhang
- School of Clinical Medicine, University of Cambridge, CB2 0SP United Kingdom
| | - Andrew Zhou
- School of Clinical Medicine, University of Cambridge, CB2 0SP United Kingdom
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, CB2 0QQ United Kingdom
| | - Jiang An Lim
- School of Clinical Medicine, University of Cambridge, CB2 0SP United Kingdom
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, CB2 0QQ United Kingdom
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Liu Y, Wang F, Liu K, Cai F, Zhang X, Li H, Zhang T, Yusufu A. Staged correction trajectory with hexapod external fixator for the satisfactory reduction of long bone shaft fracture. BMC Musculoskelet Disord 2022; 23:224. [PMID: 35260138 PMCID: PMC8905859 DOI: 10.1186/s12891-022-05172-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
Backgroud When the reduction of long bone shaft fracture fragments is performed by a hexapod external fixator, the collision and interference between bony ends often results in an incomplete reduction and a time-consuming procedure. The purpose of this study was to present and determine the clinical effectiveness of staged correction trajectory with hexapod external fixator in the reduction of a long bone shaft fracture. Methods A total of 57 patients with tibial shaft fractures treated by hexapod external fixator were retrospectively analyzed from June 2016 to February 2020. Thirty-one cases (Group I) underwent a conventional one-step reduction trajectory from June 2016 to July 2018. Starting in September 2018, the other twenty-six patients (Group II) underwent staged correction trajectory (three key points reduction trajectory of “distraction-derotation-reduction”). The demographic data, residual deformities before and after correction, number of repeated X-rays after the first postoperative X-ray, duration of deformity correction process, and external fixation time were analyzed. Johner-Wruhs criteria were used to evaluate the final clinical outcomes. Results All the 57 patients achieved satisfactory fracture reduction and bone union. There were no significant differences between the two groups in demographic data, residual deformities before and after correction, external fixation time, and final clinical outcomes (p > 0.05). The average number of repeated X-rays after the first postoperative X-ray and mean duration of deformity correction process in Group II (1.3 times, 2.9 days) were all less than those in Group I (2.3 times, 5.1 days) (p < 0.05). Conclusion Compared with the conventional one-step reduction trajectory, there is no differences in final clinical outcomes, but the staged correction trajectory provides less repeated X-rays and shorter reduction process duration.
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Affiliation(s)
- Yanshi Liu
- Department of Trauma and Microreconstructive surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Fei Wang
- Department of Orthopaedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Kai Liu
- Department of Trauma and Microreconstructive surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Feiyu Cai
- Department of Trauma and Microreconstructive surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xingpeng Zhang
- Department of Orthopedics, Shanghai Pudong New Area People's Hospital, Shanghai, China
| | - Hong Li
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Tao Zhang
- Department of Orthopedics and Trauma, Tianjin Hospital, Tianjin, China.
| | - Aihemaitijiang Yusufu
- Department of Trauma and Microreconstructive surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
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Chen Y, Li Y, Ouyang X, Zhang H. Ankle joint salvage and reconstruction by limited ORIF combined with an Ilizarov external fixator for complex open tibial pilon fractures (AO 43-C3.3) with segmental bone defects. BMC Musculoskelet Disord 2022; 23:97. [PMID: 35090407 PMCID: PMC8800251 DOI: 10.1186/s12891-022-05060-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/24/2022] [Indexed: 11/28/2022] Open
Abstract
Background Open pilon fractures combined with sizeable segmental bone defects are rare, difficult to treat, and often result in the loss of ankle joint function. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures and sizeable segmental bone defects treated by limited ORIF combined with an Ilizarov external fixator. Methods We conducted a retrospective analysis of open pilon fractures with sizeable segmental bone defects treated by limited ORIF combined with the Ilizarov external fixator strategy between July 2014 and August 2019. All patients were included for assessments of fracture healing and infection rates. Ankle functional outcomes were assessed in all patients according to the Paley criteria and American Orthopedic Foot and Ankle Society Score (AOFAS) at least 24 months post-injury. Results All patients were followed up for a mean of 41.09 months. The mean bone defect size was 5.64 ± 1.21 cm. The average EFI and BTI were 1.56 ± 0.28 months/cm and 11.12 ± 0.74 days/cm, respectively. According to the Paley evaluation system, the success rate of ankle joint reconstruction was 64% (7/11). The mean score based on the AOFAS functional assessment was 77.73 ± 8.87. Five patients showed posttraumatic arthritis, one of whom required ankle arthrodesis. Three patients developed pin site infections, and one patient developed a deep infection after bone grafting. Conclusion The strategy of limited ORIF combined with an Ilizarov external fixator can restore ankle function in most patients with complex open tibial pilon fractures. Ankle stiffness, pin tract infection, and traumatic arthritis were the most common complications associated with this therapy.
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Mair O, Pflüger P, Hoffeld K, Braun KF, Kirchhoff C, Biberthaler P, Crönlein M. Management of Pilon Fractures-Current Concepts. Front Surg 2022; 8:764232. [PMID: 35004835 PMCID: PMC8732374 DOI: 10.3389/fsurg.2021.764232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/29/2021] [Indexed: 11/23/2022] Open
Abstract
Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.
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Affiliation(s)
- Olivia Mair
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Patrick Pflüger
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kai Hoffeld
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Center for Orthopedic and Trauma Surgery, University Medical Center, Cologne, Germany
| | - Karl F Braun
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Trauma Surgery, Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Tarkin IS, Murawski CD, Mittwede PN. Temporizing Care of Acute Traumatic Foot and Ankle Injuries. Orthop Clin North Am 2022; 53:95-103. [PMID: 34799027 DOI: 10.1016/j.ocl.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Temporizing care has become a critical part of the treatment armamentarium for select foot and ankle injuries. Indications for performing temporizing care are based on the specific injury pattern, the host, associated injuries, as well as surgeon resources. Foot and ankle injuries are often associated with severe adjacent injury to the soft tissue sleeve. An acute procedure performed through a traumatized soft tissue envelope will often lead to the failure of wound healing and/or infectious complications. Thus, delayed reconstruction of acute foot and ankle injuries is often advisable in these cases.
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Affiliation(s)
- Ivan S Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Suite 1010, Pittsburgh, PA 15213, USA.
| | | | - Peter N Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Intraoperative acute correction versus postoperative gradual correction for tibial shaft fractures with multiplanar posttraumatic deformities using the hexapod external fixator. BMC Musculoskelet Disord 2021; 22:803. [PMID: 34537029 PMCID: PMC8449448 DOI: 10.1186/s12891-021-04505-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine the differences in clinical outcomes, if any, between intraoperative acute correction and postoperative gradual correction for tibial shaft fractures with multiplanar posttraumatic deformities using the hexapod external fixator. METHODS We retrospectively analyzed 58 consecutive patients with tibial shaft fractures treated by the hexapod external fixator at our institution from January 2015 to April 2019. Twenty-three patients (Group I) underwent intraoperative acute correction, from January 2015 to October 2016. Starting in November 2016, the other 35 patients (Group II) all underwent postoperative gradual correction. The demographic data, operation duration, original residual deformities before correction, residual deformities after correction, and external fixation time were collected and analyzed. The clinical outcomes were evaluated by the Johner-Wruhs criteria at the last clinical visit. RESULTS All patients achieved complete bone union with a mean time of 28.7 ± 4.6 weeks (range 21 to 37 weeks) in Group I and 27.9 ± 4.8 weeks (range 19 to 38 weeks) in Group II (P > 0.05). The operation duration in Group I (88.9 ± 7.7 min) was longer than that in Group II (61.9 ± 8.4 min), and there was a statistically significant difference (P < 0.05). There were no statistically significant differences between the two groups in original residual deformities before correction and residual deformities after correction (P > 0.05). The rate of postoperative complication was similar between the two groups. There was no statistical significance in demographic data and clinical outcomes between the two groups (P > 0.05). CONCLUSIONS There is no difference in clinical outcomes between intraoperative acute correction and postoperative gradual correction for tibial shaft fractures with multiplanar posttraumatic deformities using the hexapod external fixator. Postoperative gradual correction may shorten the duration in the operation room and decrease the potential intraoperative risk.
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