Pilon Fracture Fixation: Introduce the Topic Pilon Fracture Fixation: Joseph Borrelli, Jr. MD Professor and Chair Department of Orthopaedic Surgery University of Texas – Southwestern Medical Center Dallas, TX

Objectives: 1- Briefly review radiographic and clinical findings of high energy pilon fractures, 2- Describe the ‘Two-Stage Approach’ for the treatment of high energy pilon fractures, 3- Review surgical options and approaches for these fractures,

Rotational Type: Characteristics: spiral distal tibia fracture, little metaphyseal comminution, few articular fragments, mild/moderate displacement, w/wo fibula fracture, mild to moderate soft tissue injury, spiral distal tibia fracture in which the fracture extends into the articular surface, associated with little metaphyseal comminution, few articular fragments, mild/moderate displacement, with or without associated fibula fracture, mild to moderate soft tissue injury,

Axial Compression Type: Characteristics articular impaction, metaphyseal and articular comminution, moderate to major displacement, severe soft tissue injury/open associated with fibula fracture (85%), intra-articular distal tibia fracture, generally with considerable metaphyseal comminution, many articular fragments, moderate/major displacement 85% with associated fibula fracture, severe soft tissue injury/open,

Recognize the Difference ! Timing of treatment, earlier vs delayed, Type of treatment, approach, ORIF vs limited IF and EF, Complications, Outcome,

Radiographic Evaluation: Plain radiographs: AP Mortice Lateral

Radiographic Evaluation: Axial CT scans, identifying fracture planes, intra-articular fracture fragments, pre-operative planning, prognosis, *

Radiographic Evaluation: CT scans: Coronal reconstructions,

Radiographic Evaluation: CT scans: Sagittal reconstructions,

Goals of Treatment Biological exposure Articular surface restoration (1) Bone graft metaphyseal defect (2) Buttress plate fixation (3) Atraumatic closure Early active ROM (4) Protected weightbearing RÜEDI - ALLGÖWER

‘Two Stage Protocol’ 1st Stage: Ankle Spanning External Fixator, ORIF of the fibula, as soon as possible after presentation, maximize “ligamentotaxis”, stabilize the fracture while soft tissues are recovery, 1st Stage: Temporary Fixation applicatin of temporary spanning external fixator and ORIF of the fibula, as soon after presentation as possible, stabilize the fracture while allowing the soft tissue swelling to resolve,

‘Two Stage Protocol’ Interim: ice, elevation, pre-operative plan, physical therapy, TIME to allow swelling to resolve,

Surgical Timing Patience Timing critical Avoid 1-6 days Await soft tissue envelope (10-21 days)

Fibular Alignment Controls Talus

Fibular Alignment Controls Talus

“traveling traction”

Frame Configuration

“Traveling Traction” Half Pins Transfixation Pin

Posterolateral fibular approach

Interim: Pre-operative Plan !!! Patient Ice, elevation, CT scan, Crutch training, Surgeon Pre-operative plan, TIME to allow swelling to resolve,

Definitive Fixation: Plates/Screws 2nd Stage: Definitive Fixation ORIF tibia and fibula, removal of external fixator, ORIF Fibula, posterolateral approach, maximize skin bridge,

Definitive Fixation: Plates/Screws Anteromedial Approach: Indications Anterior and medial comminution Planning a ant and/or medial plate Approach ½ finger breath lateral to tibial crest, maintain 7 cm skin bridge, parallel to Anterior Tibialis tendon, towards the talonavicular joint, Anteromedial Approach: begin ½ finger breath lateral to crest over the anterior compartment, minimum 7 cm skin bridge, continue parallel to Anterior Tibialis tendon, towards the talonavicular joint,

Definitive Fixation: Plates/Screws Anteromedial Approach: talonavicular joint medial Anteromedial Approach: begin ½ finger breath lateral to crest over the anterior compartment, minimum 7 cm skin bridge, continue parallel to Anterior Tibialis tendon, towards the talonavicular joint,

Definitive Fixation: Plates/Screws Articular Reduction: largest, least displaced fragments first, posterior fragment, reduce fragments and hold, K-wires (1.6 mm), pointed reduction forceps, definitive fixation, lag screws, cannulated screws, reduce articular bloc to shaft, Articular Reduction: start with largest, least displaced articular fragments first, reduced fragments and hold with: K-wires (1.6 or 2 mm), pointed reduction forceps, definitive fixation, lag screws, reduce articular bloc to shaft, plate(s),

Definitive Fixation: Plates/Screws DON’T make medial a incision !!! incision is directly over the bone/plate, difficult to close, increased wound complications, deep infection, soft tissue loss, free flap only bailout, burns bridges for later reconstruction, DON’T make medial a incision !!! the incision ends up directly over the plate, difficult to close, increased wound complications, deep infection, soft tissue loss, free flap only bailout, burns bridges for later reconstruction, NO !!

Definitive Fixation: Plates/Screws Anterolateral Approach (Bohler): Indications: open medial wound, displaced Chaput fragment, lateral articular comminution, Advantage: good soft tissue coverage, uninjured skin, single incision for ORIF of the tibia and fibula, Wolinsky, P, & Lee, M J Ortho Trauma 2008

Anterolateral Approach Deep Dissection: through superior and inferior retinaculae, interval between toe extensors and fibula, elevate muscles off interosseous membrane, Caution: superficial peroneal nerve, 8 cm proximal to joint,

Anterolateral Approach Wolinsky, P, & Lee, M J Ortho Trauma 2008

Definitive Fixation: Plates/Screws Implants: Small Fragment Plates small fragment plates, 3.5 LC-DCP, precontoured medial LCP, anterolateral plates LCP, Screws 3.5 cortical/4.0 cancellous, cannulated: 4.0/4.5

Definitive Fixation: Plates/Screws Implants: Small Fragment Plates small fragment plates, 3.5 LC-DCP, precontoured medial LCP, anterolateral plates LCP, Screws 3.5 cortical/4.0 cancellous, cannulated: 4.0/4.5

Definitive Fixation: Plates/Screws Bone Graft: Theory support articular fragments, augment healing, fill cancellous defects, ICBG, Allograft, Synthetic Calcium putties,

Definitive Fixation: Plates/Screws Meticulous Wound Closure Deep closure, 1-0 vicryl for capsule, 2-0 vicryl for subcutaneous tissue, Skin closure 3-0 nylon, AllgÖwer’s modification of the Donati stitch,

PL 45 y/o MVC

“Two Stage Protocol” “Traveling Traction”

“Two Stage Protocol”

“Two Stage Protocol”

“Two Stage Protocol”

Ligamentotaxis

Definitive fixation

Summary Represent both a bony and soft tissue injury, Tibial Plafond Fractures are challenging injuries, Represent both a bony and soft tissue injury, AO principles have remained the same: articular reduction, stable fixation, early mobilization of the patient and ankle, meticulous soft tissue handling,

Summary “Two Stage Protocol”, Approaches, Implants, spanning external fixation and +/- ORIF fibula, definitive management of the tibia, Approaches, Anteromedial approach, Anterolateral approach, Implants, Small fragment plates and screws, Pre-contoured plates (LCP),

Thank You