1. External Fixation In Pilon Fractures Gillian Jackson North West Regional SpR Teaching 14 th March 2008

2. Indications Types How to… Evidence

3. Indications “First Aid” Stabilise injury Reduce soft tissue tension Management of open wound Analgesia Quick Poly trauma Vascular surgeons

4. Buy Some Time Allow soft tissues to settle Further Imaging Plan joint reconstruction/ ORIF Order kit Referral Foot and Ankle service Trauma centre

5. As Definitive Treatment In isolation With limited articular fixation Interfragmentary screws Olive wires with frame +/- fibular plating Supplement ORIF

6. Types

7. Complications Pin site problems Malunion Delayed union Non union

8. How To…..

10. Hybrid Frame

12. Literature ORIF vs External Fixation Spanning vs sparing Fibular fixation Retrospective series Severe injuries often ex-fixed Most studies supplement with limited screw fixation to restore articular surface.

13. ORIF vs External Fixation Only one RCT Wyrsch 1996 18 vs 20 patients ORIF vs Ex-fix +limited ORIF “Randomised surgeon” design. No difference clinical scores at 2 years Increased frequency/severity complications in ORIF group.

14. Malunion vs Wound Problems Watson 2000, 107 patients. Prospective protocol ORIF in # with severe soft tissue - higher rates of Non/Mal union Severe wound complications Pugh 1999 60 patients ORIF vs Spanning vs hybrid Ex-fixed groups increased malunion but less wound problems. Independent of fibular fixation or bone grafting

15. Fibular plating Williams 98 53 monolateral ex-fix 22 fibula fixed, 31 not fixed No difference X-ray arthrosis Ankle score Complication rate

16. Joint spanning vs sparing Papadokostakis 2008 (JBJS) Systematic review 15 articles 465 fractures Time to union 4.3 mths (both grps) Malunion higher in spanning fixation. Increased plantar flexion in hybrid vs articulated More minor (pin site) infections in hybrids Septic arthritis 0.6% in hybrids

17. Joint spanning vs sparing Okcu 2004 Ilizarov vs articulated external fixation Retrospective 50 patients All united No difference functional ankle score Ilizarov greater ROM 74% vs 53% of other limb.

18. In Staged ORIF Sirkin 1999 Initial ORIF fibula + spanning Ex-fix 56 patient series retrospective Delayed ORIF Minimal wound problems Blauth 2001 51 patients Primary ORIF(MIPO) vs Ex-fix vs Ex-fix and delayed MIPO. Delayed MIPO lowest complication rate. Unequal numbers.

19. External Fixation Can achieve our objectives Preserve life Preserve leg Straight leg Mobile joint By.. Quick application Soft tissue healing/ preservation Articular reconstruction Meta/diaphyseal union

20. Still should be considered the first aid of choice. Always consider in high energy/ open injuries Can be your definitive treatment With articular reconstruction. Move towards use in combination with delayed ORIF.