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Barker EP, Harimtepathip PP, Steflik MJ, Graulich BL, Blair JA, Davis JM. Financial Analysis of Preoperative Nasal Decolonization With Povidone-Iodine in Closed Pilon Fracture Definitive Fixation. J Foot Ankle Surg 2024; 63:119-122. [PMID: 37742870 DOI: 10.1053/j.jfas.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 08/18/2023] [Accepted: 09/16/2023] [Indexed: 09/26/2023]
Abstract
The purpose of this study is to determine the financial practicality for the use of nasal povidone-iodine (NP-I) in the preoperative holding area in attempt to decrease the rate of infection that is associated with operative fixation of closed pilon fractures. Institutional costs for treating postoperative infection following a closed pilon fracture, along with costs associated with preoperative NP-I use, were obtained. A break-even equation was used to analyze these costs to determine if the use of NP-I would decrease the current infection rate (17%) enough to be financially beneficial for routine use preoperatively. The total cost of treating a postoperative infection was found to be $18,912, with the cost of NP-I being $30 per patient dose. Considering a 17% infection rate and utilizing the break-even equation, NP-I was found to be economically viable if it decreased the current infection rate by 0.0016% (Number Needed to Treat = 63,051.7). This break-even model suggests that the use of NP-I in the preoperative holding area is financially beneficial for decreasing the rate of infection associated with the treatment of closed pilon fractures.
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Affiliation(s)
- Elizabeth P Barker
- Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, GA.
| | - Peter P Harimtepathip
- Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, GA
| | | | | | - James A Blair
- Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, GA
| | - Jana M Davis
- Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, GA
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2
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Korrapati A, Ta CN, Mitchell BC, Wall PV, Gurusamy P, Dwight K, Girard PJ, Schwartz AK, Kent WT. Fracture blisters: predictors for time to definitive fixation in pilon fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:161-166. [PMID: 37386191 PMCID: PMC10771370 DOI: 10.1007/s00590-023-03623-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity. METHODS Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs. RESULTS 314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2 days vs 7.9 days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007). CONCLUSION The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.
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Affiliation(s)
- Avinaash Korrapati
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Canhnghi N Ta
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Brendon C Mitchell
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Pelle V Wall
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Pradyumna Gurusamy
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Kathryn Dwight
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Paul J Girard
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - Alexandra K Schwartz
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA
| | - William T Kent
- Department of Orthopaedic Surgery, University of California San Diego, 200 W Arbor Drive, MC 8894, San Diego, CA, 92103, USA.
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Shafiq B, Zhang B, Zhu D, Gupta DK, Cubberly M, Stepanyan H, Rezzadeh K, Lim PK, Hacquebord J, Gupta R. Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters. J Orthop Trauma 2023; 37:532-538. [PMID: 37226911 DOI: 10.1097/bot.0000000000002637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures. DESIGN Retrospective cohort study. SETTING 3 Level 1 tertiary academic trauma centers. PATIENTS/PARTICIPANTS The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures. MAIN OUTCOME MEASUREMENTS Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal. RESULTS The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating. CONCLUSIONS While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Bo Zhang
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Diana Zhu
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Deven K Gupta
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Mark Cubberly
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Hayk Stepanyan
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Kevin Rezzadeh
- Department of Orthopaedic Surgery, New York University Langone Health, New York, NY
| | - Philip K Lim
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Jacques Hacquebord
- Department of Orthopaedic Surgery, New York University Langone Health, New York, NY
| | - Ranjan Gupta
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
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Kim YJ, Richard RD, Scott BL, Parry JA. Acute Fixation Protocol for High-Energy Tibial Pilon Fractures Decreases Time to Fixation and Lowers Operative Costs Without Affecting Wound Complications and Reoperations. J Orthop Trauma 2023; 37:525-531. [PMID: 37296084 DOI: 10.1097/bot.0000000000002639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To determine whether an acute fixation protocol for high-energy tibial pilon fractures increases the rate of wound complications. DESIGN Retrospective comparative study. SETTING Urban level 1 trauma center. PATIENTS/PARTICIPANTS One hundred forty-seven patients with OTA/AO 43B and 43C high-energy tibial pilon fractures treated with open reduction and internal fixation (ORIF). INTERVENTION Acute (<48 hours) versus delayed ORIF protocols. MAIN OUTCOME MEASUREMENT Wound complications, reoperations, time to fixation, operative costs, and hospital length of stay (LOS). Patients were compared by protocol, regardless of ORIF timing, for an intention-to-treat analysis. RESULTS Thirty-five and 112 high-energy pilon fractures were treated under the acute and delayed ORIF protocols, respectively. In the acute ORIF protocol group, 82.9% of patients received acute ORIF versus 15.2% of patients in the standard delayed protocol group. The 2 groups had no observed difference (OD) in the rate of wound complications (OD -5.7%, confidence interval (95% CI) -16.1% to 7.8%; P = 0.56) or reoperations (OD -3.9%, 95% CI, -14.1% to 9.4%; P = 0.76). The acute ORIF protocol group had a shorter LOS (OD -2.0, 95% CI, -4.0 to 0.0; P = 0.02) and lower operative costs (OD $-2709.27, 95% CI, -3582.02 to -1601.16; P < 0.01). On multivariate analysis, wound complications were associated with open fractures (odds ratio 3.36, 95% CI, 1.06-10.69; P = 0.04) and an American Society of Anesthesiologists score >2 (odds ratio 3.68, 95% CI, 1.07-12.67; P = 0.04). CONCLUSION This study suggests that an acute fixation protocol for high-energy pilon fractures decreases time to definitive fixation, lowers operative costs, and shortens hospital LOS without affecting wound complications or reoperations. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ye Joon Kim
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
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5
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Ke C, Dong X, Xiang G, Zhu J. Risk factors and nomogram predictive model of surgical site infection in closed pilon fractures. J Orthop Surg Res 2023; 18:582. [PMID: 37553679 PMCID: PMC10408134 DOI: 10.1186/s13018-023-04058-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model. METHODS From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration. RESULTS SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer-Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification. CONCLUSION Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture.
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Affiliation(s)
- Chenrong Ke
- Department of Orthopaedic, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Xiaoyu Dong
- Department of Orthopaedic, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Guangheng Xiang
- Department of Orthopaedic, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Juanjuan Zhu
- Department of Geriatrics and Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
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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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Flores M, Ciminero M, Kottmeier SA, Botros D, Zelle BA, Shearer DW. Pilon fractures: Consensus and controversy. OTA Int 2023; 6:e236. [PMID: 37533444 PMCID: PMC10392439 DOI: 10.1097/oi9.0000000000000236] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/08/2022] [Indexed: 08/04/2023]
Abstract
Pilon fractures are complex injuries that require an individualized approach to treatment to avoid complications and achieve good outcomes. Staged open reduction internal fixation remains the gold standard for most cases to achieve anatomic articular reduction while minimizing soft tissue complications and infection. Careful preoperative planning based on computed tomography dictates the surgical approach for reduction. A subset of cases may be amenable to early definitive or provisional open reduction and internal fixation based on fracture pattern. In some cases of severe articular comminution where reconstruction is not possible, primary ankle arthrodesis may be a good alternative.
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Affiliation(s)
- Michael Flores
- University of California, San Francisco, Department of Orthopaedic Surgery, San Francisco, CA
| | - Matthew Ciminero
- University of California, San Francisco, Department of Orthopaedic Surgery, San Francisco, CA
| | | | - Daniel Botros
- Stony Brook University, Department of Orthopaedic Surgery, Stony Brook, NY; and
| | - Boris A. Zelle
- UT Health San Antonio, Department of Orthopaedics, San Antonio, TX
| | - David W. Shearer
- University of California, San Francisco, Department of Orthopaedic Surgery, San Francisco, CA
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Gao Y, Zhu H, Guo Y, Yu X. Early Reduction of the Posterior Column: A Surgical Technique in AO/OTA C3 Tibial Pilon Fractures. J Pers Med 2023; 13:jpm13030551. [PMID: 36983732 PMCID: PMC10051139 DOI: 10.3390/jpm13030551] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Staged treatment for pilon fractures is widely accepted. It remains to be discussed how to reduce and fix posterior column fractures while avoiding clinical complications. We provided a staged treatment protocol with detailed surgical techniques for closed AO Foundation/Orthopaedic Trauma Association (AO/OTA) C3 tibial pilon fractures with fibular fractures. In the first stage, the internal fixation of the fibula and distal tibial posterior column is accompanied by an external fixator. After swelling, the medial and anterior columns were fixed via the posteromedial approach in the second stage. We advocate early reduction and fixation of the posterior column and lateral column. The right timing of surgery can ensure well-reduced articular surface and alignment while minimizing soft tissue complications.
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Affiliation(s)
- Yanchun Gao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Hongyi Zhu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Yanjie Guo
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Xingang Yu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
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Can Laser-Assisted Indocyanine Green Angiography Be Used to Quantify Perfusion Changes During Staged Fixation of Pilon Fractures? A Pilot Study. J Orthop Trauma 2022; 36:e388-e392. [PMID: 35580330 DOI: 10.1097/bot.0000000000002405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To quantify soft tissue perfusion changes in pilon fractures during staged treatment using laser-assisted indocyanine green angiography (LA-ICGA). SETTING Level 1 trauma center. DESIGN Prospective cohort study. PATIENTS/PARTICIPANTS Twelve patients with 12 pilon fractures participated in the study. Seven patients had OTA/AO classification of 43-C3, 3 had 43-C2, and 2 had 43-B2. MAIN OUTCOME MEASURES LA-ICGA was performed with the SPY fluorescence imaging platform. Analysis via ImageJ was used to generate a fractional area of perfusion (FAP) based on fluorescent intensity to objectively quantify soft tissue perfusion. Anterior, medial, and lateral measurements were performed at the time of initial external fixation (EF) application and then at the time of definitive fixation. RESULTS FAP within the region of interest was on average 64% medially, 61% laterally, and 62% anteriorly immediately before EF placement. Immediately before definitive open reduction internal fixation, fractional region of interest perfusion was on average 86% medially, 87% laterally, and 86% anteriorly. FAP increased on average 24% medially ( P = 0.0004), 26% laterally ( P = 0.001), and 19% anteriorly ( P = 0.002) from the time of initial EF to the time of definitive open reduction and internal fixation. CONCLUSIONS Quantitative improvement in soft tissue perfusion was identified through the course of staged surgical management in pilon fractures. LA-ICGA potentially may be used to determine appropriate timing for definitive surgical intervention based on the readiness of the soft tissue envelope. Ultimately, these findings may influence clinical outcomes with respect to choice of surgical approach, soft tissue management, surgical timing, and wound healing. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Yeramosu T, Satpathy J, Perdue PW, Toney CB, Torbert JT, Cinats DJ, Patel TT, Kates SL. Risk Factors for Infection and Subsequent Adverse Clinical Results in the Setting of Operatively Treated Pilon Fractures. J Orthop Trauma 2022; 36:406-412. [PMID: 34999622 PMCID: PMC9253198 DOI: 10.1097/bot.0000000000002339] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine patient-specific and injury-specific factors that may predict infection and other adverse clinical results in the setting of tibial pilon fractures. DESIGN Retrospective chart review. SETTING Level 1 academic trauma center. PATIENTS Two hundred forty-eight patients who underwent operative treatment for tibial pilon fractures between 2010 and 2020. INTERVENTION External fixation and/or open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS Fracture-related infection rates and specific bacteriology, risk factors associated with development of a fracture-related infection, and predictors of adverse clinical results. RESULTS Two hundred forty-eight patients were enrolled. There was an infection rate of 21%. The 3 most common pathogens cultured were methicillin-resistant Staphylococcus aureus (20.3%), Enterobacter cloacae (16.7%), and methicillin-resistant Staphylococcus aureus (15.5%). There was no significant difference in age, sex, race, body mass index, or smoking status between those who developed an infection and those who did not. Patients with diabetes mellitus ( P = 0.0001), open fractures ( P = 0.0043), and comminuted fractures (OTA/AO 43C2 and 43C3) ( P = 0.0065) were more likely to develop a fracture-related infection. The presence of a polymicrobial infection was positively associated with adverse clinical results ( P = 0.006). History of diabetes was also positively associated with adverse results ( P = 0.019). CONCLUSIONS History of diabetes and severe fractures, such as those that were open or comminuted fractures, were positively associated with developing a fracture-related infection after the operative fixation of tibial pilon fractures. History of diabetes and presence of a polymicrobial infection were independently associated with adverse clinical results. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Teja Yeramosu
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Paul W. Perdue
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Clarence B. Toney
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Jesse T. Torbert
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - David J. Cinats
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Tejas T. Patel
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L. Kates
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
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11
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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: 4] [Impact Index Per Article: 2.0] [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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