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Stamatos NJ, Ostrowski TJ, Mori BV, Fiscella K, Anoushiravani AA, Rosenbaum A. Team Approach: Perioperative Management of Pilon Fractures. JBJS Rev 2023; 11:01874474-202303000-00002. [PMID: 36913508 DOI: 10.2106/jbjs.rvw.22.00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
» Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse. » A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes. » The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.
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Affiliation(s)
| | - Tyler J Ostrowski
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | | | - Kimberly Fiscella
- Department of Surgery, Division of Plastic Surgery, Albany Medical Center, Albany, New York
| | | | - Andrew Rosenbaum
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
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Watts A, Sadekar V, Moulder E, Souroullas P, Hadland Y, Barron E, Muir R, Sharma H. A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames. Injury 2023; 54:996-1003. [PMID: 36682926 DOI: 10.1016/j.injury.2022.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Traditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal. METHODS Tibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days. RESULTS 274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex. CONCLUSION Ilizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.
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Affiliation(s)
- Arun Watts
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
| | - Vilas Sadekar
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
| | - Elizabeth Moulder
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
| | - Panayiotis Souroullas
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
| | - Yvonne Hadland
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
| | - Elizabeth Barron
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
| | - Ross Muir
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
| | - Hemant Sharma
- Trauma and Orthopaedics Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, United Kingdom.
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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: 12] [Impact Index Per Article: 6.0] [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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Liang H, Li L, Yang J, Du Y, Peng W. Treatment of open and comminuted mid-distal tibial fractures by bilateral external fixation combined with limited-internal fixation. Acta Orthop Belg 2021; 87:745-750. [PMID: 35172442 DOI: 10.52628/87.4.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Open and comminuted mid-distal fractures often result from high-energy trauma, and a concomitant poor blood supply often leads to skin necrosis, infection, and bone union. To circumvent such complications, we used limited-reduction and bilateral-external fixators to treat open and comminuted mid-distal tibial fractures with compromised soft tissue. A retrospective series of 34 patients who had open and comminuted mid-distal tibial fractures and treated by bilateral-external fixators with limited-internal fixation were analyzed. Patients were followed for 10-25 months (mean: 12 months) post-treatment and osseous union was achieved in each case. The average union time was 16.3 weeks. Based on the Johner- Wruhs criteria, the retrospective series consisted of 21 'excellent' cases, 8 'good' cases, 4 'fair' cases, and a 'poor' case. The total percentage of 'excellent' and 'good' cases of fracture recovery was 85.29%. Bilateral-external and limited-internal fixators pro- vided high bone union rate and excellent ankle-joint motion. Hence, it is an appropriate surgical approach for treating open and comminuted mid-distal tibial fractures with compromised soft tissue.
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Use of a Motorized Intramedullary Bone Transport Nail for Trauma: Tips, Tricks, Corticotomy Techniques, and Rate and Rhythm. J Orthop Trauma 2021; 35:S31-S38. [PMID: 34533484 DOI: 10.1097/bot.0000000000002121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
The introduction of internal magnetic nails (IMNs) for bone lengthening and bone transport has given us exciting new tools with which to treat segmental bone loss. Distraction osteogenesis has a long record of success in recreating even large segments of bone, but the availability of IMNs now offers the possibility of performing distraction osteogenesis without the drawbacks of external fixation. However, there are aspects of treatment with IMNs that are critical to understand to achieve success and minimize complications. These include assessment of feasibility in relation to available bone stock and segment configuration, the condition of the soft tissue envelope, and the presence of contamination or infection. They also include execution aspects such as bone end preparation, nail placement, need for and positioning of adjuvant fixation, corticotomy techniques, rate and rhythm of distraction, staged screw exchange, docking site preparation, and nail extraction. We discuss these issues in detail and introduce some novel techniques not previously described including the comminuted wedge osteotomy, testing of the nail with initial compression, and retention plug application for nail extraction to assist in optimizing success in certain clinical situations.
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Radiographic evaluation of reconstructive surgery for segmental bone defects: What the radiologist should know about distraction osteogenesis and bone grafting. Clin Imaging 2020; 67:15-29. [DOI: 10.1016/j.clinimag.2020.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/18/2020] [Indexed: 11/19/2022]
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Zelle BA, Dang KH, Ornell SS. High-energy tibial pilon fractures: an instructional review. INTERNATIONAL ORTHOPAEDICS 2019; 43:1939-1950. [PMID: 31093715 DOI: 10.1007/s00264-019-04344-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/01/2019] [Indexed: 12/16/2022]
Abstract
High-energy tibial pilon fractures continue to represent a significant challenge to the treating orthopaedic surgeon. Pre-operative evaluation includes a careful clinical assessment of the associated soft tissue injury, which frequently dictates surgical management. Staged surgical reconstruction remains the standard treatment protocol at most trauma centres. This includes application of a temporary spanning external fixator for approximately one to four weeks, followed by open reduction and internal fixation once the surrounding soft tissues are amendable. Despite careful soft tissue management protocols, the risk of wound complications continues to be relatively high compared to other orthopaedic trauma procedures. The functional long-term outcomes of these injuries remain limited, and recent data has emphasised that the majority of patients do not regain their pre-operative work status. In addition, the health-related quality of life scores fare poorly when compared to other orthopaedic and non-orthopaedic patient populations, and many patients develop post-traumatic arthritis within the tibiotalar joint. It has been shown that the quality of fracture reduction may significantly correlate with the long-term functional outcomes. While the orthopaedic community has come a long way with regard to safe management of high-energy tibial pilon fractures, the clinical outcomes continue to remain limited. In particular, the persistently high rates of wound complications and the limited functional long-term outcomes leave significant room for improvement. Future investigators may focus on further innovations to minimise the risk of wound complications. The surgical team may emphasise the quality of fracture reduction as an important treatment goal.
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Affiliation(s)
- Boris A Zelle
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA.
| | - Khang H Dang
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Samuel S Ornell
- Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
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Naude J, Manjra M, Birkholtz FF, Barnard AC, Glatt V, Tetsworth K, Hohmann E. Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex. Strategies Trauma Limb Reconstr 2019; 14:142-147. [PMID: 32742430 PMCID: PMC7368362 DOI: 10.5005/jp-journals-10080-1443] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Aim The purpose of this study was to compare the functional and radiological outcomes of complex tibia fractures treated with two different hexapod fixators. Material and methods This is a retrospective comparative study of patients treated for complex tibial fractures between 2010 and 2015. Inclusion criteria was patients between 18 years and 60 years of age, who sustained a complex comminuted open or closed tibial fracture with or without bone loss, who had a minimum of 12 months’ follow-up, and who have been treated definitively using either Taylor Spatial Frame (TSF) or TrueLok-Hexapod System (TL-HEX). The outcome measures were Association for the Study and Application of the Method of Ilizarov (ASAMI) score, foot function index (FFI), EQ5-D, four-step square test (FSST), and timed up and go (TUG) test. Descriptive statistics were used to assess patient demographic information. Categorical variables (ASAMI and EQ5D-5L) were analysed using the χ2 test. Continuous variables (FFI, functional tests, and radiographic outcomes) were analysed with two-tailed Student’s t tests. Results In all, 24 patients were treated with the TL-HEX and 21 with the TSF. The mean time for external fixation was 219 ± 107 days (TL-HEX) and 222 ± 98 days (TSF). Union occurred in 92% (TL-HEX) and 100% (TSF). The mean follow-up was 777 ± 278 days (TL-HEX) and 1211 ± 388 days (TSF). Using the ASAMI scores, there were 17 excellent and 6 good results for the TL-HEX and 10 excellent and 11 good results for the TSF (p = 0.33). The FFI was 30 ± 28.7 (TL-HEX) and 26.1+23.9 (TSF) (p = 0.55). The EQ5D was 0.67 ± 0.3 (TL-HEX) and 0.73 ± 0.2 (TSF) (p = 0.43). The mean TUG and FSST were 9.2 ± 3.2 and 10 ± 2.9 seconds (TL-HEX) and 8.4 ± 2.3 and 9.6 ± 3.1 seconds (TSF) (p = 0.34 and 0.69). Conclusion The results of this study suggest that both hexapod external fixation devices have comparable clinical, functional, and radiographic outcomes. Either fixator can be used for the treatment of complex tibial fractures, anticipating good and excellent clinical outcomes in approximately 80% patients. Level of evidence Therapeutic level III How to cite this article Naude J, Manjra M, Birkholtz FF, et al. Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex. Strategies Trauma Limb Reconstr 2019;14(3):142–147.
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Affiliation(s)
- Jaco Naude
- Department of Orthopaedic Surgery, University of Pretoria, Pretoria, Gauteng, South Africa
| | - Muhammad Manjra
- Department of Orthopaedic Surgery, University of Pretoria, Pretoria, Gauteng, South Africa
| | - Franz F Birkholtz
- Department of Trauma and Orthopaedics, University of Pretoria, Pretoria, Gauteng, South Africa; Walk-a-Mile Centre for Advanced Orthopaedics, Centurion, South Africa
| | - Annette-Christy Barnard
- Department of Orthopaedic Surgery, Walk-a-Mile Centre for Advanced Orthopaedics, Pretoria, Gauteng, South Africa
| | - Vaida Glatt
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | - Erik Hohmann
- Medical School, University of Pretoria, Pretoria, Gauteng, South Africa
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