Pilon fracture – timing, approach and fixation

Pilon fracture – timing, approach
and fixation
M. Cimerman, A Kristan
Dpt. For Traumatology, Univ. Medical Centre
Ljubljana, Slovenia
Slovenia
Slovenia; 20.000 km2 ; 2 million people
Ljubljana, 200 000 inhabitants
Prof Matej Cimerman, MD, PhD
General and Trauma surgeon,
Head of Department
Univ. Med. Centre
Ljubljana
Department for
Traumatology:
•200 beds
•Aprox.5000 operations
per year
•Approx.300-400
polytraumatised patients
Pilon fractures:
• „ankle fractures that involve the weight
bearing distal tibial articular surface“
Destot E, 1911
• Pilon means pestle (talus)
Pilon fractures: mechanism of injury
Talus impacts tibial art. surface
Rockwood and Green 2010
SPECTRUM OF FRACTURES
SPECTRUM OF SOFT TISSUE INJURIES
Pilon fractures: general comments
• Terrible injuries
• No consensus regarding the optimal
treatment
• „Excellent“ results are rearly achived
• Fair-good results are the norm
• Outcomes impossible to predict
• Avoid treatment complications
Classifications: Ruedi Allgower
Ruedi et al. Helv
Chir Acta 1968
Classifications: AO/OTA
Classifications
• Intraobserver agreement is poor for both cl.
Martin JS, Marsh JL et al. J Orthop Trauma 1997
Swiontkowski MF et al. J Orthop Trauma 1997
Anatomy of pilon fractures
Medial
Chaput
Volkmann
Treatment principles
•
•
•
•
Anatomic reduction
Stable fixation
Early motion
Atraumatic technique
Treatment principles
•
•
•
•
Anatomic reduction
Stable fixation
Early motion
Atraumatic technique
EASY TO SAY…
…DIFFICULT TO PERFORM
Treatment
• First „promising ages“ ORIF good results (Ruedi T
et al. Injury 1973)
Treatment
• Dark ages: 40% of early complications (Teeny SM
et al. Clin Ortho Relat Res 1993, Wyrsch B et al. JBJS 1996, Mc
Ferran et al. JOT 1992)
Dark ages…
…because of soft tissue underestimation
Key stone: soft tissue!
New approaches to pilon fractures: staged
managment (second „promising ages“)
1. Staged treatment : Ex fix (y/n fibula ORIF)
Intermediate period (10-21 days)
Definitive fixation
Complications 5% (Patterson MJ et al. J Orthop Trauma 1999, Sirkin M et
al. J Orthop trauma 1999, Blauth M; et al. J Orthop Trauma 2001)
2. Ex fix definitive (sparing, spanning, ring): y/n fibula, y/n
minimal internatl
Less soft tissue complications, worse reduction
Emergency treatment
• Ex fix (medial, „Y“), gentle distraction
• Fibula fixation
Ex Fix: never reduces impaction
Is fibula plating always necessary?
• FP can cause specific complications, problems with
posterior approach
• FP less angular malunion
Basically no difference (Wllliams TM et al. J Orthop trauma 1998)
Is fibula plating always necessary?
• FP ca cause specific complications, problems with
posterior approach
• FP less angular malunion
Basically no difference (Wllliams TM et al. J Orthop trauma 1998)
Intermediate period
• CT scan
• Soft tissue care
• Preoperative planning:
1.complete understending of
the fracture and soft tissue injury,
right op approach,
2. understand the patint needs,
3. understand the sugeon team .
EBS planning tool
Approaches: anterior med, anterior lat, posterior
lat, posterior med.
Anteromedial approach: A
• Intraarticular components mostly anterior
Case: female, 33y, fall from 3m: ex fix in the emergeny op
Courtesy dr. Malovrh
EBS planning
Timing; after 10 days, wrinkle sign
Anteorlateral approach: B
• Intraarticular components mostly anterior
Case: male 40y, motorcycle accident
Posterolateral approach: D
• Visualisation of Volkmann triangle and dist. fibula
11-year-old girl , in-line skating
Courtesy dr. Kastelec
post-reduction
5 weeks
Male, 50y, car colsion
Posteromedial approach: E
• Visualisation posteromedial part of tibia and medial
malleolus
Female, 55y, fall from 3m
Ring fixator
• Need the expert
• Can be done as secondary procedure
Male 60y, motorcycle accident
Courtesy dr.
Gril Iztok
Take home message
•
•
•
•
Very difficult injury
Soft tissue is the key to succes
Staged procedure
Understand the injury, the patient and the
fracture in details
• Combined approaches
• Excellent results are rare
Thank you for your kind attention