A staged protocol for soft tissue management in the treatment of complex pilon fractures

Current principles of treatment in the clinical practice of articular fractures

The current treatment of fractures involving articular surfaces is based on fracture surgery principles evolved over the past 40 years, suggesting that anatomic reduction and stable fixation is required for optimal recovery of joint function. These principles are outlined here. However, the evidence supporting such treatment methods is based on limited understanding of the response of articular cartilage to injury. Poor outcomes are still encountered despite careful adherence to these principles, and satisfactory outcomes are seen in some joint fractures despite residual incongruity. Is perfect reduction required in all cases, or are some joints able to tolerate incongruity better than others? Many different factors may influence outcome, such as severity of injury, bone quality, and complications. Rigid application of the current principles may not be possible or advisable in all cases if complications are to be minimized. Our ability to assess the quality of reduction is limited and our understanding of tolerance of malreduction is still lacking. Such dilemmas support the need for further research. The current principles should not be abandoned, but as clinicians, we should strive to better understand these injuries to provide an optimum outcome with the least complications.

Management of ipsilateral pilon and calcaneal fractures: a report of 2 cases

Although uncommon, the management of ipsilateral pilon and calcaneal fractures is a challenging problem for foot and ankle surgeons. There are several issues that may affect the outcome. Aside from damage to the soft-tissue envelope, technical issues such as positioning of the patient, application of traction, and tourniquet time may complicate surgical intervention. The authors present their experience with 2 patients who sustained this fracture pattern and highlight the mechanism, management, and possible complications of these injuries.

Fixation of tibial pilon fractures with percutaneous cannulated screws

Closed reduction and internal fixation with percutaneous cannulated screws was performed on seven patients with closed pilon fractures. The mean follow-up was 30.6 months. They were assessed using a subjective scoring system. The average score was 90.8/100. This method of fixation avoids extensive soft tissue dissection and gives excellent results. To our knowledge, this method of closed reduction and stabilisation of pilon fractures solely by percutaneously inserted cannulated screws has not been previously reported.

Limited open reduction and Ilizarov external fixation in the treatment of distal tibial fractures

The authors reviewed 31 distal tibial fractures (16 involving the tibial plafond) treated with Ilizarov external fixation. The study population was composed of 19 males and 12 females, with an average age of 54. The fractures were classified according to the AO classification: A1 (3), A2 (6), A3 (6), C1 (2), C2 (8), C3 (6). There were six open injuries. In 14 pilon cases, open reduction of the intra-articular fragments and bone grafting via a limited incision was performed. Clinical follow-up averaged 28 months (range 18-42). All but one fracture united with an average healing time of 13.9 weeks. Nearly all patients with AO type A fracture had excellent or good functional scores. The 14 cases of AO C2 and C3 group had five (38%) good results, five (38%) fair results and three (24%) poor results. This method yielded results comparable with previous studies using open reduction and internal fixation. Twenty-nine percent of the patients had pin track infection, which remained the most important complication of this method.

Soft-tissue injury associated with closed fractures: evaluation and management

Determination of the severity of injury to the soft tissues is an important component of patient assessment and affects management of closed fractures. The response of soft tissue to blunt injury involves microvascular and inflammatory processes that produce localized tissue hypoxia and acidosis. Incisions placed through such compromised tissue can lead to wound breakdown and deep infection. Therefore, recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures. Many treatment options, including splinting, cryotherapy, compression, and delayed surgery, help limit further soft-tissue injury and facilitate its rapid recovery before surgical intervention. Emerging surgical techniques based on improved management have resulted in decreased rates of soft-tissue complications.

Outcomes after treatment of high-energy tibial plafond fractures

BACKGROUND

Although a number of investigators have documented clinical outcomes and complications associated with tibial plafond, or pilon, fractures, very few have examined functional and general health outcomes associated with these fractures. Our purpose was to assess midterm health, function, and impairment after pilon fractures and to examine patient, injury, and treatment characteristics that influence outcome.

METHODS

A retrospective cohort analysis of pilon fractures treated at two centers between 1994 and 1995 was conducted. Patient, injury, and treatment characteristics were recorded from patient interviews and medical record abstraction. Study participants returned to the initial treatment centers for a comprehensive evaluation of their health status. The primary outcomes that were measured included general health, walking ability, limitation of range of motion, pain, and stair-climbing ability. A secondary outcome measure was employment status.

RESULTS

Eighty (78%) of 103 eligible patients were evaluated at a mean of 3.2 years after injury. General health, as measured with the Short Form-36 (SF-36), was significantly poorer than age and gender-matched norms. Thirty-five percent of the patients reported substantial ankle stiffness; 29%, persistent swelling; and 33%, ongoing pain. Of sixty-five participants who had been employed before the injury, twenty-eight (43%) were not employed at the time of follow-up; nineteen (68%) of the twenty-eight reported that the pilon fracture prevented them from working. Multivariate analyses revealed that presence of two or more comorbidities, being married, having an annual personal income of less than 25,000 US dollars, not having attained a high-school diploma, and having been treated with external fixation with or without limited internal fixation were significantly related to poorer results as reflected by at least two of the five primary outcome measures.

CONCLUSIONS

At more than three years after the injury, pilon fractures can have persistent and devastating consequences on patients' health and well-being. Certain social, demographic, and treatment variables seem to contribute to these poor outcomes.

Early internal fixation and soft tissue cover of severe open tibial pilon fractures

We studied 32 consecutive patients with open distal tibial pilon fractures. All patients had radical debridement with immediate skeletal stabilisation and early soft-tissue cover with a vascularized muscle flap. The minimum follow-up was 1 (range 1-8) year. There were four superficial infections, two deep infections and two amputations. There were no long-term problems with union and no patient required an ankle fusion. Patients were assessed using the SF-36 questionnaire. There were significant differences from the US norm in physical function score ( p<0.01), role physical score ( p<0.05) and physical component score ( p<0.01). Physical component score of 38.5 was significantly better ( p<0.01) when compared with amputees from severe lower-extremity trauma. Our protocol for management resulted in a good functional outcome with low infection and amputation rates.

High-velocity gunshot wounds of the tibial plafond managed with Ilizarov external fixation: a report of 13 cases

OBJECTIVE

To report the results of using Ilizarov fixation for the treatment of open tibial plafond fractures caused by high-velocity gunshot injuries. DESIGN Retrospective review of consecutive patients.

SETTING

Military academic hospital.

PATIENTS

Using the AO classification, three type C1, five type C2, and five type C3 open tibial plafond fractures due to high-velocity gunshot injuries were treated with irrigation, débridement, primary closure, and Ilizarov fixation. Eleven of the fractures were type IIIA, and the remaining two were type IIIB according to the Gustilo-Anderson classification. There were also multiple traumas in one case.

METHODS

Plafond fractures were treated by Ilizarov technique in all 13 cases. In three of the cases, additional osseous transport to eliminate a skeletal defect was performed.

MAIN OUTCOME MEASURES

Results were evaluated according to Bone's clinical grading system.

RESULTS

Average follow-up was 38.4 months (range 26 to 50 months). Callus began to form in 21 to 35 days (average 27.9 days). The fractures united in 126 to 154 days (average 137.6 days), and the apparatus was removed from the limb at that time. There were six good, three fair, and four poor results. Minimal skin necrosis around the wound was seen in four cases, wound infection and purulent discharge were seen in two cases, and angular deformity was seen in two cases. Delayed union and reflex sympathetic dystrophy were not seen in any cases. Although tibiotalar narrowing was seen in four cases, no cases required tibiotalar arthrodesis or subsequent bony reconstruction at the time of their most recent follow-up. The average residual ankle range of motion was plantar flexion 18.5 degrees and dorsiflexion 11.5 degrees.

CONCLUSIONS

Early aggressive débridement of nonviable tissues, stabilization with an Ilizarov external fixator, and either primary or delayed primary closure followed by early ankle range of motion and weight bearing is an alternative treatment method of these injuries.

The use of early flap coverage in severe open physeal fractures: a report of two cases

Open physeal fractures associated with severe overlying soft tissue loss present significant challenges to the pediatric orthopaedic surgeon. In addition to providing adequate soft tissue coverage, preventing chronic infection, and achieving bony healing, surgical care should attempt to preserve the physis to maintain growth for the best long-term outcomes. Here we present two cases of open physeal disruptions with severe soft tissue loss. In each case, early use of vascularized flap coverage assisted in fracture healing and contributed to preservation of the physis and subsequent bony growth.

Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity

Complex intra-articular and periarticular fractures of the lower extremity are challenging injuries to treat. Recently, the concept of utilizing a staged approach with temporary external fixation, a delay to allow soft-tissue healing followed by open reduction and internal fixation, has gained popularity. Historically high complication rates appear to be significantly improved with this strategy. Temporary external fixation is also useful in other settings, such as in the initial management of polytraumatized patients with multiple complex fractures, augmentation of internal fixation in osteoporotic bone, etc. This article reviews current indications, techniques, potential complications, and results of temporary external fixation for complex fractures of the lower extremity.

Percutaneous plating of distal tibial fractures

This article presents our experience with 24 patients who had distal tibial fractures and were treated by percutaneous plate fixation. Distribution of the fractures according to the AO/OTA classification was as follows: five patients suffered from a 43 A type fracture, six from a 43 B type fracture, and 13 from a 43 C type fractures. Four of the fractures were open. Exclusion criteria included 43 C3 fractures and Gustilo III open fractures. All fractures showed radiographic signs of union enough to enable full weightbearing within an average time of 12.3 weeks. All patients showed a good range of motion (average dorsiflexion 12 degrees and average plantiflexion 18 degrees). Two fractures united with mal-union: one with an 8 degrees valgus deformity and another with a 7 degrees varus deformity. Both cases, which had a metaphyseal component, were treated by means of a "soft" (flexible and manually adjustable) AO 3.5 mm reconstruction plate. Except for one case of superficial infection, no infections were detected in any of the patients. The biological percutaneous plate fixation of distal tibial fractures with no extensive intra-articular involvement is a good soft tissue preserving technique. It provides a rigid and anatomical fixation in most cases. We conclude that type B fractures with one intact column can be fixed with either "soft" or "rigid" plates, and type A and C fractures with a metaphyseal component should be fixed with "rigid" plates (AO 4.5 mm Dynamic Compression Plate). In these fractures the reduction should be performed cautiously due to the tendency of sagittal plane mal-reduction.

Pilon fractures: assessment and treatment

The treatment of high-energy intra-articular fractures of the tibial plafond involves many potential complications. A protocol has been developed. This protocol recognizes the importance of the surrounding soft tissues and is based on sound principles and thorough clinical experience. This article discusses this protocol and its use and explains why it is now more widely accepted.

High energy plafond fractures treated by a spanning external fixator initially and followed by a second stage open reduction internal fixation of the articular surface--preliminary report

Early open reduction and internal fixation (ORIF) with plates and screws for plafond injuries caused by skiing initially reported by Ruedi and Allgower proved inadequate for the treatment of high-energy motor vehicle accident type injuries. The purpose of our study was to review our treatment protocol using a spanning external fixator placed semi-emergently medially across the joint and a later staged ORIF of just the articular surface to achieve and maintain anatomic reduction.

METHODS

We preformed a retrospective study of 35 patients with 37 highly comminuted severe (OTA 43-B3 and -C3 or Ruedi type II or III) tibial plafond fractures treated by a single surgeon. All patients were treated with an initial spanning unilateral external fixator and subsequent ORIF. Radiographs were examined for: classification, number of pieces of the tibial dome, evidence of ground-glass comminution (more than three pieces <2mm in size on CT), anatomic reduction, alignment, and presence/absence of arthritis.

RESULTS

Evidence of ground glass comminution existed in 26/37 patients (70%). Following ORIF, articular reduction was perfect (0-1mm displacement) in 29/36 (81%), imperfect (1-3mm) in 6/36 (17%) and poor (>3mm) in 1/36 (3%) cases. Joint alignment was anatomical in 35/37 (96%), with 15 degree anterior angulation in one patient and 5 degree valgus angulation in another patient. Radiographic arthritis was present in 10/36 patients (28%) at latest follow-up. Joint distraction at time of reduction was present in 27/37 patients (73%). A total of 25/37 patients (65%) had no post-operative complications, while 3/37 (8%) had a joint infection requiring one patient to have hardware removed. A total of 4/37 (11%) showed loss of reduction at latest follow-up. A total of 3/37 (8%) had a secondary arthrodesis; A total of 1 (3%) had a primary arthrodesis; 1 (3%) diabetic man had a below-knee amputation after a failed arthrodesis.

DISCUSSION AND CONCLUSION

We treat severe tibial plafond fractures with a spanning external fixator at the time of injury, wait between 10 and 21 days to allow for soft tissue healing, and then perform a limited ORIF of the articular surface with canulated screws. In a group of high-energy plafond fractures, we achieved 81% good to excellent results with this protocol. We conclude that use of a spanning external fixator with delayed ORIF compares favorably with the literature.

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

OBJECTIVE

To determine whether long-term results of one of three different management protocols for severe tibial pilon fractures offer advantages over the other two.

DESIGN

In a retrospective study, patients were examined clinically and radiologically after internal fixation of severe tibial plafond fractures (i.e., 92 percent Type C fractures according to the AO-ASIF classification).

SETTING

Department of Traumatology, Hanover Medical School. Level I trauma center.

PATIENTS

Fifty-one of seventy-seven patients treated between 1982 and 1992 were examined clinically and radiologically at an average of sixty-eight months (range 13 to 130 months) after injury.

INTERVENTIONS

The patients were treated in three different ways: primary internal fixation with a plate following the AO-ASIF principles (n = 15), which was reserved for patients with closed fractures without severe soft tissue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least four weeks (n = 28); and a two-stage procedure entailing primary reduction and reconstruction of the articular surface with minimally invasive osteosynthesis and short-term transarticular external fixation of the ankle joint followed by secondary medial stabilization with a plate using a technique requiring only limited skin incisions (a reduced invasive technique) (n = 8).

MAIN OUTCOME MEASUREMENTS

Objective evaluation criteria were infection rate, amount of posttraumatic arthritis, range of ankle movement, and number of arthrodeses. Subjective criteria were pain, swelling, and restriction of work or leisure activities.

RESULTS

Because only closed fractures were treated by primary internal fixation with a plate, there was a statistically significant difference (p < 0.005) in the distribution of open fractures between the three treatment groups. Fracture classification in these groups were not significantly different. All but four fractures were classified as Type C lesions according to the AO-ASIF system. The soft tissue was closed in 63 percent (n = 32) and open in 37 percent (n = 19). No significant relationship could be found between the soft tissue damage and degree of arthritis or between the type of surgical treatment and extent of posttraumatic arthritis. However, none of the patients who required secondary arthrodesis (23 percent of all cases) were in the group who had undergone two-step surgery (p < 0.05). The range of ankle movement was much greater in the two-step group than in the others; these patients also had less pain, more frequently continued working in their previous profession, and had fewer limitations in their leisure activities. These differences did not reach statistical significance. The incidence of wound infection did not differ significantly among the three groups.

CONCLUSIONS

On the basis of our results, we now prefer a two-step procedure for the treatment of severe tibial pilon fractures with extensive soft tissue damage. In the first stage, primary reduction and internal fixation of the articular surface is performed using stab incisions, screws, and K-wires. Temporary external fixation is applied across the ankle joint. After recovery of the soft tissues, the second stage entails internal fixation with a medial plate using a reduced invasive technique.

Soft tissue reconstruction for calcaneal fractures or osteomyelitis

A systematic approach of the surgical management of a calcaneal fracture can minimize the potential of soft tissue complications. When reducing a closed calcaneal fracture, the incision used affects the postoperative complications. The L-shaped incision with the horizontal limb lying on the lateral glabrous junction ensures maximum blood flow to either side of the incision. Whether or not the wound can be closed primarily depends on the preexisting edema, the lost calcaneal height, and the delay between the fracture and reduction (Fig. 20). The wrinkle test is a good indicator that the incision can be closed primarily if the amount of height restored is minimal. If the edema is too great, steps should be taken to reduce it sufficiently to allow successful wound closure. If the wound, after reduction, is too wide to allow primary closure, an ADM flap laterally or an AHM flap medially should be used. For larger defects, a free flap should be considered. The three important steps to reconstruction of soft tissue defects around the calcaneus include good blood supply, a infection-free wound, and the simplest soft tissue reconstructive option that covers the wound successfully. Adequate blood supply can be determined by the use of Doppler. If the supply is inadequate, revascularization is necessary before proceeding. Achieving a clean wound requires aggressive debridement, intravenous antibiotics, and good wound care. Adjuncts that can help in achieving a clean wound include topical antibiotics (silver sulfadiazine), the VAC, and hyperbaric oxygen. Osteomyelitis has to be treated aggressively. Any suspicious bone has to be removed. Only clean, healthy, bleeding bone is left behind. Antibiotic beads can be useful when there is doubt as to whether the cancellous bone is infection-free. The beads are not a substitute for good debridement, however. Soft tissue reconstruction ranges from delayed primary closure to the use of microsurgical free flaps (Fig. 21). When bone or hardware is exposed, a muscle flap should cover the wound because of the extra blood supply it carries with it. The soft tissue option depends on the width of the wound. For wounds 1 cm wide or less, the options include allowing the wound to close by secondary intention (VAC), delayed primary closure, or a local muscle flap. For wounds 2 cm wide or less, allowing the wound to close by secondary intention (VAC) and a local muscle flap are the best options. For wider wounds, one has to assess whether the local muscle flap has sufficient bulk to close the defect. If it does, it is the simplest solution. If the local muscle is inadequate, a microsurgical free flap has to be used. The VAC sometimes can convert a large wound to a smaller wound so that a local muscle flap can be used. This procedure takes time, however, and adds to the cost of the repair.

Applications of ring fixators in complex foot and ankle trauma

There is a growing base of literature that supports the use of external ring fixators in the treatment of complex foot and ankle fractures. Clinical studies that determine definitively the optimal treatment for particular injuries are absent. Small wire ring fixators have a growing role in allowing the stabilization of complex skeletal injuries with a minimum of iatrogenic soft tissue injury. Ring fixators should be considered in the algorithm of treatment of complex lower extremity fractures with associated significant soft tissue injury. One of the cornerstones of trauma management is the preservation of reconstructive options after injury. As interest in ankle arthroplasty increases and experience broadens, such options may be available to patients who sustain severe tibial plafond or talus fractures. It is imperative that hindfoot alignment and height be maintained and infection avoided so that reconstructive osteotomy, arthrodesis, and arthroplasty remain as options for patients who sustain severe trauma.

The treatment of pilon fractures

Soft tissue complications, skin slough, and superficial infection lead to deeper infection and amputation. By avoiding these complications, it is expected that better results can be obtained. Two techniques are available to do this. The first is to limit incisions and use external fixation to obtain stability. Even in these cases, care must be taken with the soft tissues. The second is a staged reconstruction, whereby stage one allows soft tissue stabilization. To this end, the fibula is plated, and transarticular external fixation is performed; this maintains anatomic length, preventing soft tissue contraction and permitting edema resolution. The second stage, formal tibial open reduction and internal fixation, is performed with plates and screws when operative intervention is safe. These methods appear to be equally effective in reducing major soft tissue complications. Surgeons should treat these complex fractures with the method with which they are most comfortable. Surgeons who feel comfortable with techniques of internal fixation are best qualified to perform open reductions. Surgeons who have experience with percutaneous fixation and hybrid external fixator application should use this method. Surgeons with limited or minimal experience with pilon fractures should consider fibula fixation and transarticular external fixation followed by transfer to an orthopedic trauma surgeon for definitive management.

Complications of ankle fractures in diabetic patients

Ankle fracture in patients with DM mandates a stepwise protocol to minimize the potential complications of delayed fracture healing, wound complications, and development of Charcot arthropathy. For nondisplaced ankle fracture, a nonoperative approach with increased duration of immobilization seems successful based on experience of the limited series. A displaced ankle fracture in a patient with DM requires a surgical intervention. The authors advocate tight glucose control in both groups to improve the fracture milieu and to ameliorate the potential complications. Appropriate stable fixation with adequate length of immobilization is crucial for successful fracture resolution.

Complications after treatment of tibial pilon fractures: prevention and management strategies

Complications after treatment of tibial pilon fractures can occur intraoperatively or in the early or late postoperative period. Perioperative complications include malreduction, inadequate fixation, and intra-articular penetration of hardware, all of which may be minimized by preoperative planning and meticulous operative technique. Wound complications can lead to deep infection, with potentially catastrophic consequences. The incidence of wound complications may be lessened by delaying surgery 5 to 14 days, until the posttraumatic swelling has subsided. Temporary fixation with a medial spanning external fixator is recommended if definitive internal fixation is delayed. Fracture blisters should be left undisturbed until the time of surgery. Incisions through blood-filled blisters should be avoided whenever possible. Limited incisions to achieve reduction and fixation should be made directly over fracture sites, to minimize soft-tissue stripping. An indirect reduction technique involving the use of ligamentotaxis and low-profile small-fragment implants that minimize tension on the incision should be used. Late complications, such as stiffness and posttraumatic arthritis, correlate with the severity of the initial injury and the accuracy of reduction. Loss of ankle motion can be minimized by early range-of-motion exercise after stable fixation has been achieved. Posttraumatic ankle arthrosis should be initially treated with anti-inflammatory medication, activity modification, and walking aids. Symptomatic patients often require an ankle arthrodesis.

Percutaneous methods of tibial plateau fixation

Various methods of percutaneous fixation of tibial plateau fractures are available. The optimal method of fixation is dictated by soft tissue injury, fracture characteristics, and functional demands of the patient. Unicondylar fractures are amenable to percutaneous stabilization with screws or plates although some fractures are best approached with open techniques. Hybrid and ring external fixators are most appropriate for patients with bicondylar injuries who have severe soft tissue trauma. Use of intramedullary nails to align ipsilateral shaft fractures adjacent to percutaneously fixed plateau injuries remains controversial but may be indicated for some patients with bicondylar lesions and combined plateau and shaft fractures.

Posterolateral approach for tibial pilon fractures: a report of two cases

Open reduction and internal fixation (ORIF) of displaced tibial pilon fractures can lead to a high percentage of good and excellent functional results, but has also been associated with a meaningful incidence of wound breakdown and infection. The use of the posterolateral approach to the distal tibia for ORIF of tibial pilon fractures is presented. This may be used instead of the standard anteromedial incision in certain fracture configurations. The flexor hallucis longus muscle coverage overlying the plate fixation of the tibia and ability to fix both the tibia and fibula through the same incision may decrease the risk of deep infection and wound complications in these injuries frequently associated with marked soft tissue trauma.