PIlon Fractures

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PIlon Fractures

• Jeff Anglen, MD
• Indiana University School of Medicine
• Orthopaedic Trauma Association

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WWW.OTA.ORG
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Historical Perspective

• Prior to 1960s Not amenable to surgery
• Acceptable results in lt50

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Ruedi and AlgöwerInjury 192-99, 1969
75 -90 Good and Excellent outcomes Results
durable for up to 10 years of follow-up
Four principles of operative treatment

• fix the fibula to restore length and alignment
• anatomically restore the articular surface
• bone graft metaphyseal defects
• buttress plate on the medial side

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US series in the 1980s

• Osteomyelitis

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• Nonunion

• Arthritis

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• Amputation

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Alternatives to classic ORIF

• External Fixation
• Modified ORIF

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External Fixation

• Same side ( ankle sparing)
• All fixation above ankle joint
• Ring wire
• Ring/wire pins (Hybrid)

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External Fixation

• Cross ankle (spanning)
• Fixation into foot
• rigid
• articulated

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External fixation - Outcomes

• Papadokostakis et. al, JBJS-Br 2008
• Systematic English literature review
• 15 studies, 1990-2006, 465 fractures
• Results
• No difference between ankle spanning and sparing
• Infection 3-4
• NU 6
• More malunions in spanning fixators 13 vs. 6

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Modified ORIF

• Careful patient selection
• Correct Operative timing (Delay)
• Indirect reduction technique
• percutaneous insertion
• New implants

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Patient Selection

• ORIF
• External
• Fixation
• Slide courtesy of Larry Marsh, MD

• Rotational mechanism
• Little comminution
• Minimal soft tissue injury
• Reduction and fixation predicted without
  stripping

• Axial loading fractures
• Comminuted
• Soft tissue injury

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Patient Selection

• Patient factors age, systemic disease (DM),
  tobacco addiction, compliance
• Injury factors mechanism, high vs. low energy,
  fracture pattern, soft tissue damage

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NO Incisions!
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The bad results after ORIF areWORSEthan the
bad results after other treatment methods
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Infection or wound failureis worse
thanarthritis or malunion
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Operative Timing

• The Window of Opportunity myth

Its safe to operate early, If you can get to
it before X hours
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Timing the Staged Protocol

• delay to definitive surgery
• Sirkin JOT13(2), 1999 -- 14 days
• Cole JOT 13(2), 1999 -- 24 days
• Anglen JOT 13(2), 1999 -- 20 days

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Traveling traction Temporary fixator
Maintains length and alignment
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Should you fix the fibula?
Probably NOT
Williams TM et al. JOT 12 16-20, 1998
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While waiting

• Elevation
• Foot pumps
• Manage blisters
• Debride, Silvadene
• Optimize condition
• Nutrition
• smoking cessation

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Modified ORIF

• Careful patient selection
• Operative timing
• Indirect/ percutaneous reduction technique
• limited exposure/percutaneous insertion
• New implants

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Classic Pilon Incision
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Modified approaches
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Minimal incision pilon ORIF

• Helfet DL, Shonnard PY, Levine D, Borrelli J
• Minimally invasive plate osteosynthesis of
  distal fractures of the tibia.
• Injury 1997 28(supplement 1) SA42-SA48

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Surgical Techniques

• Incisions
• Placement over fracture lines
• avoid flaps (dissection between layers), unless
  planning a rotation flap
• minimize size (percutaneous)

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Indirect Reduction by Ligamentotaxis
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AP and Mortice images in temporary ext. fix.
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Percutaneous K-wire joysticks
Step 1
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Step 2
Reduction of joint fragments, temporary K-wire
fixation
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Step 3
Percutaneous placement of pre-contoured plate
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Metaphyseal screw buttress function
Step 4
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Step 5
Additional plate screws
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Lag screws as needed
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Modified ORIF

• Careful patient selection
• Operative timing
• Indirect/ percutaneous reduction technique
• limited exposure/percutaneous insertion
• New implants

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Fixation Implants

• small fragment, low profile
• Variable thickness
• Still need mechanical stability, good buttressing
• Lag screws at the joint
• Medial and lateral column buttress
• Locking peri-articular implants
• Pre-contoured plates

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PLATE FAILURE
1/3 RD TUBULAR PLATE Alone NOT STRONG ENOUGH
Slide courtesy of Roy Sanders, MD
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Outcomes
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Results Bone HealingReliably achieved
Bridging callus works well in the distal tibia!
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Healed pilon 4 months After surgery
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5 to 11 years after injury
Excellent results are only rarely achieved

• Most have some ankle pain
• Can not run or play sports
• Measurable effect on general health status
• 70 with moderate or severe arthrosis

Larry Marsh, MD
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5 to 11 years after injury
Fair to Good Results Are the Norm

• Most rate their outcome as good
• Arthrodesis rate only 5
• Most feel they improve for years

Larry Marsh, MD
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Fair to Good Results Are the Norm
8 years
Ankle score - 80 Works as a laborer
Larry Marsh, MD
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Tibial Plafond FracturesOutcomes are impossible
to predict
5 years - no pain ankle score 95
Larry Marsh, MD
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Tibial Plafond FracturesOutcomes are impossible
to predict
6.5 yrs - miserable - ankle score 45
Larry Marsh, MD
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However..

• Technique is still important
• Whatever you do, you must do it well

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Summary

• Select correct treatment for patient and injury
• Delay definitive Internal fixation
• Early temporary external fixation
• Dont fix the fibular early
• Gently reduce and limit incisions
• Stable fixation
• Lag screws
• Buttress plates

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Thanks

• Jeff Anglen, MD