TIBIAL PILON FRACTURES CLASSIFICATION

CURRENT MANAGEMENT OF TIBIAL
PILON FRACTURES
Roderick S Kuo, MBBS FRACS (Orth)
Specialty Orthopaedics,
SAN Orthopaedic Conference
October 21, 2011
TIBIAL PILON FRACTURES
• Incidence: 1-10% of
lower extremity
fractures
• Aetiology:
- MVA
- Falls from height
- Skiing injuries
CLASSIFICATION
• AO – Type 43-C
- C1 – articular simple, metaphysis simple
- C2 – articular simple, metaphysis comminuted
- C3 – articular and metaphysis communited
• Poorest prognosis
HISTORY
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HISTORY
• Early 1990’s: Swing to External Fixation with limited
ORIF
- Tornetta 1993, Wyrsch 1996
• Late 1990’s – 2000’s: Sirkin 1999, Patterson 1999
- Staged protocols with temporary EF and delayed
ORIF
1911 : Destot – term “pilon” used
1960’s: Bonnier 1960 / Gay 1963: Non operative Rx
1970’s: Ruedi / Allgower ORIF
1980’s: Bourne 1983 / Teeny 1993 – High
complications with ORIF
- but poor respect for soft tissues – ORIF’s done at
d3-5 ie at time of peak swelling!!
CONTROVERSIES
Indirect v Direct Reduction
Ex Fix v ORIF
Bone Graft v Bone Substitute v Allograft
Locking v Non Locking Plates (lower profile /
anatomic)
• Size – Small / Mini Fragment 2.7 / 3.5 v Basic 4.5
• 2 Stage v 3 Stage (Convert Type C # into Type B) +/GS
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COMPLICATIONS
• Wound breakdown
- Free flap
- SSG over Tib Ant
sheath
- VAC
• Infection
• Malunion / Nonunion
• Arthrosis
STAGED PROTOCOL RESULTS
Patterson 1999 JOT
Retrospective
C3 pilon – 22 patients (6 open)
Average 24 days before definitive ORIF
21/22 union at 4.2 months, 77% Good results (Borwell
and Charnley criteria) at 22 months (R18-65)
• No infections or soft tissues complications
• 9% arthrodesis rate
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STAGED PROTOCOL RESULTS
Sirkin 1999 JOT
Retrospective
56 fractures – C3 42 patients; 22 open #
Average time to definitive ORIF – 12-14 days
Closed # group – All wounds healed, 1 late deep
infection, 17% partial skin necrosis
• Open # group – All wounds healed, 2 late deep
infections
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OUTCOME PAPERS
• Pollak et al 2003 JBJSAm 85A:1893-900:
- 103 pt, FU 3.2 yrs, SF36
- Poorer prognosis: Ex Fix, lower SES, 2 or more
comorbidities
OUTCOME PAPERS
• Harris et al 2006 Foot Ankle Int 27:256-65
- 79 fractures, FU 2 yrs, Staged ORIF v EF / ltd IF
- MFA, FFI
- Poorer Prognosis: C3 injuries, Ex Fix (increase
complications, OA, poorer scores – but more often
EF used with C3 injuries)
- Staged ORIF better
ORIF v Ex Fix Ilizarov
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ORIF V Ex Fix (ltd)
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Wang et al, Arch Orthop Trauma Surg 2010
Prospective
Type B3 and C, closed
56 pts, ORIF (2 stage)
ORIF – less superficial infection (S), less radiation (S)
Ex Fix – higher delay/malunion, OA (NS)
Both gps equal ankle function
Key factors on outcome – Smoking and # pattern
Bacon et al, Injury 2008
Prospective Study
Type C
42 pts, Lvl 1 Trauma
28 ORIF (2 stage), 14 Ilizarov
ORIF – longer to heal but lower rates NU, MU and
infection (NS)
ASSESSMENT
Look at SOFT TISSUES
TIMING is critical!
Avoid peak swelling
Surgery immediately or
10-14 days later
• Oedema between times
may lead to wound
problems
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OPERATIVE PRINCIPLES
• Soft tissue protection – stabilize skeleton to allow
injured soft tissues to hang off
• Full thickness skin flaps
• Anatomical reduction of joint
• Bone graft metaphyseal defect
• Stable internal fixation
• Early postoperative joint ROM
TIBIAL PILON FRACTURE
OPERATIVE PRINCIPLES
• Protect soft tissue
• STAGED fixation
• Stage 1: ORIF Fibular with plate + Ankle spanning
External Fixator (temporary)
• Interval period – elevate, investigate ie CT
• Stage 2: Definitive ORIF Pilon +/- BG
APPROACHES
CT SCAN AFTER ORIF FIBULA
STAGED ORIF TIBIA
METICULOUS WOUND CLOSURE
DONATI –ALLGOWER SUTURE
FEMORAL DISTRACTOR
C3 PILON – EFFECT OF
DISTRACTION
PLATE OPTIONS
AO – 4.5 Narrow DCP
Spoon/ Cloverleaf
1/3 Tubular, T plates
Trend to smaller, lower
profile, anantomic
contoured plates to
minimize soft tissue
complications eg
Zimmer periartic
• Locking plates
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PLATE OPTIONS – SPOON
4.5 NARROW DCP / CLOVERLEAF
Mr SG : G3A OPEN TIBIAL PILON # Syndesmosis disruption / Shortening
Mr SG: Preop CT
Mr SG: Post op
Mr JA: Pilon /Calcaneus # -Tongue
Mr LN: M51, MBA, Open 3B R Tibial shaft /
pilon, Bone loss, Sensate sole foot, pulses OK
CLINICAL PHOTOS
Day 1: I&D, ORIF Fibula (DCP) / Ankle
Spanning Ex Fix Tibia, Day 2: I&D
CT Scan Postop ORIF Fib / Ex Fix
Day 3 ORIF Tibia / Lat Dorsi Free Flap /
SSG / Med Ex Fix / 8-9 cm bone defect
• SSG – 85% take
• S. aureus at SSG site
- Rx Fluclox
• Bone graft autograft (Ant
ICBG) / OP1 at 14 weeks
6 Months postop
Mr LN
• R/O Ex Fix 8 mos
• 30 mos – deep sepsis
- iv Fluclox 6 weeks then
oral
• 3 years - R/O plate,
- MCS – No growth, ceased
oral Fluclox 3 mos postop
Mr LN – 3 Yrs postop
Mr LN – 3.5 Yrs post injury
SUMMARY
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Respect soft tissues to minimize complications
Restore anatomy, stable fixation for early ROM
Lower profile contoured locking implants available
Staged protocol recommended
- Stage 1: Early ORIF Fibula + Ankle spanning
External Fixator
- Await soft tissue to settle (2 weeks)
- Stage 2: Definitive ORIF Tibial pilon with bone
graft