external fixation - amazon web services metaphysis •usually ... conversion of spanning delta frame...
TRANSCRIPT
2/24/2015
1
External
Fixation &
Surgical
Staging
VuMedi Webinar – Pilon Fractures – 02/24/2015
Pat Yoon, MDMinneapolis, MN
Hennepin County Medical Center
University of Minnesota
Disclosures
• Orthofix (consultant)
• Arthrex, Inc. (consultant)
• JAAOS (reviewer)
• FAI (reviewer)
Outline
• Introduction
• Initial management
• Debridement
• Fix the fibula?
• External fixator
• Planning for ORIF
2/24/2015
2
Definition of Plafond / Pilon
fractures
• High-energy fracture of distal
tibial metaphysis
• Usually compressive injury /
axial load
• Soft-tissue compromise
• Articular surface and fibula
usually (not always) fractured
• Severe injury - Educate the
patient early !
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Pilon versus Ankle
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Do not treat pilons like an ankle
• Immediate ORIF
• Large plates
• 37-40% major
complications
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
3
Pilon fractures
• High energy
• Axial load
• Standard orif doesn’t work well
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Therefore:
• AVOID early ORIF
with large incisions
and bulky implants
• Early percutaneous
treatment in selected
cases may be OK
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Outcomes of open pilon fractures
• Staged protocol
• 59 consecutive open pilon fractures (most IIIA)
• Initial debridement, spanning ex-fix, sponge and
suction drains
• Repeat debridement q 48-72 hours
• Deep infection rate 3%
• One BKA
• SF-36: PCS 40.3, MCS 54.0
Boraiah et al JBJS 90:346-52, 2010
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
4
Initial workup
• Tetanus
• Antibiotics
• Sterile dressing
• Evaluate for
associated injuries
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Initial presentation
• Thinner soft
tissues medially
• Obliquity usually
produces a
medial spike on
the proximal
fragment
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
5
Debridement
• Deliver the bone ends!
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
Debridement
• Open wounds usually transverse
• Extend longitudinally
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
Extend incisions
• If you can’t deliver the bone ends, extend
the traumatic wounds
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
2/24/2015
6
Often more soft tissue injury than initially
apparent
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
Often more soft tissue injury than initially
apparent
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
Remove all
foreign debris
and
devitalized
bone
fragments
Can be very
proximal!
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
2/24/2015
7
Check:
• Skin
• Subcutaneous tissue
• Muscle / tendon
• Fascia
• Periosteum
• Bone
• Major articular
segments – save ?
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
Check:
• Skin
• Subcutaneous tissue
• Muscle / tendon
• Fascia
• Periosteum
• Bone
• Major articular
segments – save ?
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
Check:
• Skin
• Subcutaneous tissue
• Muscle / tendon
• Fascia
• Periosteum
• Bone
• Major articular
segments – save ?
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
2/24/2015
8
Check:
• Skin
• Subcutaneous tissue
• Muscle / tendon
• Fascia
• Periosteum
• Bone
• Major articular
segments – save ?
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
• Sponge and suction drain
• Sterile dressings
• +/- Loose primary closure ?
• Repeat debridements q 48-72h as needed
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
Fibula ? Ex-fix Preop PlanningDébridementIntroduction
2/24/2015
9
Do you fix the fibula initially ?
Yes if:
• It can be anatomically
restored, and
• It will not compromise
later ORIF
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Do you fix the fibula initially ?
No if:
• It can’t be anatomically
restored, or
• It compromises later ORIF
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Do you fix the fibula initially ?
No if:
• It can’t be anatomically
restored, or
• It compromises later ORIF
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
10
Do you fix the fibula initially?
Anticipated anterolateral
approach
WAIT
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
When do you fix the fibula?
This one may need a
posterior incision –
fibula can be fixed
through that
WAIT
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
When do you fix the fibula?
• Anticipated
anteromedial
approach
• Unlikely to need a
posterior incision
Go ahead!
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
11
Make it as posterior as possible!
Wide bridge
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
When in doubt – leave the
fibula for now
• I rarely fix it initially
• Definitive plan usually not known at
presentation (need CT with frame on)
• Fixing the fibula initially might compromise
your eventual plan
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
12
When do you ex-fix?
• For
– Shortening
– Impaction
– Subluxation / gross
displacement
– Soft Tissue
Problems
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
When do you ex-fix?
• For
– Shortening
– Impaction
– Subluxation / gross
displacement
– Soft Tissue
Problems
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
When do you ex-fix?
• For
– Shortening
– Impaction
– Subluxation / gross
displacement
– Soft Tissue
Problems
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
13
When do you ex-fix?
• For
– Shortening
– Impaction
– Subluxation / gross
displacement
– Soft Tissue
Problems
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Benefits of spanning ex-fix
• Decreases pressure on skin – improves
soft tissues
• Makes later ORIF easier (fx out to length)
• Gives you time for preop planning
• Gives you time for transfer if needed
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
This is a very difficult xray to
plan off ofMuch easier!
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
14
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Ligamentotaxis
Posterior syndesmotic
ligaments
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
AITFL
Ligamentotaxis
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
15
Anterior inferior tib-fib
ligament
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Tibial pins
• 2 pins in diaphysis
far from fx
• Usually 5mm
• Predrill
• Blunt pins
• Insert by hand
Ant
Lateral
Medial
Post
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
• Draw out later
incisions
• Keep pins away
from the lines
Tibial pins
Avoid this !
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
16
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Calcaneal pin
Medial to lateral
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
17
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
18
• If possible attach
each bar to both
pins
• “Delta frame”
• Keep clamps
loose for now!
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
• One person pulls
out to length
• Other person
tightens all clamps
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
• Length
• Alignment
• Rotation
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
19
• Length
• Alignment
• Rotation
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
• Length
• Alignment
• Rotation
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Bump of towels to adjust
sagittal alignment
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
20
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
21
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Posteriorly directed vector
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Posterior translation!
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
22
Posterior translation!
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
• Helps maintain
alignment
• Prevent equinus
• 3-4 mm
Optional foot pin
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Foot pin helps
prevent pressure on
sole of foot
“Yeah, but what about
just adding a posterior
splint?”
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
23
Medial pin alone may
supinate the foot
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
5th met pin to
balance foot
More even!
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Danger of 1st
metatarsal pin
Barrett MO JBJS 90: 560-4, 2008
• 50% injury to deep plantar
branch of dorsalis pedis
• 18mm danger zone
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
24
Alternatives
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Dorsal to plantar 1st
metatarsal pin
Alternatives
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Medial /
intercuneiform
pin
Alternatives
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
25
Talar
neck/head
pin
Alternatives
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
For obtunded patients
Keep heel off bed!
Helps prevent pressure ulcers
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
When temporary spanning
fixation isn’t so temporary …
• Patient lost to follow-up
• Medically unstable
• Skin condition never allows safe ORIF in a
reasonable time frame
• Significant comorbidities for ORIF
• Patient doesn’t want further surgery
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
26
Spanning fixation as
definitive treatment
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Spanning fixation as
definitive treatment
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Spanning fixation as
definitive treatment
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
27
5 months in frame
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2 year follow-up
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Conversion of spanning delta frame to a
spanning circular fixator
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
28
Conversion of spanning delta frame to a
spanning circular fixator
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Conversion of spanning delta frame to a
spanning circular fixator
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
Conversion of spanning delta frame to a
spanning circular fixator
Fibula ? Ex-fix Preop PlanningIntroduction Débridement
2/24/2015
29
Next steps
• Antibiotics
• Elevate
• Nonweightbearing
• DVT prophylaxis
• Repeat debridement(s) as needed
• Soft tissue coverage
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Introduction Fibula ? Ex-fix Preop PlanningDébridement
CT Scan
Plain films underestimate amount of articular involvement
CT scan affects operative plan majority of the time
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
30
By bringing fx out to
length the true gap
is appreciated
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Get the CT with the fixator on!
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Get the CT with the fixator on!
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
31
Now what?• At this point:
– Wounds are debrided
– Frame is in place
– Fibula may or may not be fixed
– You have your CT scan
• You have time to:
– Wait for soft tissues and fix it
– Transfer if you don’t feel comfortable fixing
– Or treat in frame!
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Analyzing the CT scan
Cole PA et al OTA 2004
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Cole PA et al OTA 2004
2/24/2015
32
AM
AL
P
F
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Cole PA et al OTA 2004
AMAL
P
AMAL
P
Introduction Fibula ? Ex-fix Preop PlanningDébridement
AM
Anteromedial
fragment
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
33
AL
Anterolateral
fragment
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Introduction Fibula ? Ex-fix Preop PlanningDébridement
P
Posterior
fragment
AMAL
P
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
34
Approaches:
PBPL
PT
EHLEDL
TA
FHL
Achilles
Anterocentral
PosterolateralPosteromedial
AnterolateralAnteromedial
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Choosing the right approach
• Where is the major articular displacement?
• Where is there better soft tissue
coverage?
• Is there a large wound I can use?
• What stabilizes this fracture the best?
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Where is the articular displacement?
Anterolateral or
anterocentral
approach is best to
remove central
fragments
Anterolateral
Anterocentral
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
35
Where is there better soft tissue coverage?
• Open wounds are usually medial
• Anterolateral skin usually in better shape
• More soft tissue coverage laterally if skin
breaks down
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Fracture obliquity
Posterior plate
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
36
Medial plate
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Lateral plate
Introduction Fibula ? Ex-fix Preop PlanningDébridement
How long do you wait?
• Wrinkle sign
• Wounds clean
• Blisters resolved
• Usually 1-2 weeks but
can be longer
Introduction Fibula ? Ex-fix Preop PlanningDébridement
2/24/2015
37
6h 6d
Swelling
Time
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Introduction Fibula ? Ex-fix Preop PlanningDébridement
Now you’re
ready for
ORIF !
Summary
• Thorough, conscientious debridement
• Reduction and external fixator
– Carefully placed pins
– Remember the fixator might be definitive
• Fibula fixation only if definitive plan is known
• Staged ORIF once the patient and soft
tissue condition are ready
2/24/2015
38
Thank You !
2/16/2015
1
Tibial Pilon Fractures –Surgical Approaches
S. Andrew Sems, M.D.
Department of Orthopaedic Surgery, Mayo Clinic
Disclosure
• Royalties- Depuy/Biomet- Affixus Nail
Classification
AO-OTA
• A: Non-articular
• B: Simple articular
• C: Complex articular
2/16/2015
2
Epidemiology
• 7% to 10 % of all tibia fractures
• Most occur secondary to high energy mechanisms
• Concomitant injuries are common and should be ruled out
Mechanism of Injury
• Axial Compression-significant comminution w/ articular impaction
• Shear-torsion injury, usually w/ two or more large fragments and minimal articular comminution
• Combined-high energy, often associated w/ other injuries
Results of ORIF
Historically many complications
•18% nonunion
•20% superficial infection / wound problems
•17% osteomyelitis
•27% arthrodesis / arthroplasty
•6% BKA
•54% PTA
•42% malunionMcFerran, JOT 6: 195, 1992
2/16/2015
3
• Fractures healed in an avg. 4.2 months
• 1 nonunion requiring bone grafting & 1 malunion requiring an osteotomy
• No infections & No wound healing problems were encountered
• Subjective & Objective measurements:
• 17 good/excellent, 3 fair, 2 poor results
Patterson MJ. Two-staged delayed open reduction and internal fixation of severe pilon fractures. Journal of Orthopaedic Trauma. 13(2):85-91, 1999
Results of Staged Approach
Results of Staged Approach
• Closed Fx
• 17%- partial skin necrosis
• 3.4%-osteomyelitis
• all wounds subsequently healed
• Open Fx:
• 10% deep wound infections
Sirkin M. A staged protocol for soft tissue management in the treatment of complex pilon fractures. Journal of Orthopaedic Trauma. 13(2):78-84, 1999 Feb
The results of early primary open reduction and internal fixation for
treatment of OTA 43.C-type tibial pilon fractures: a cohort study.
White TO, Guy P, Cooke CJ, Kennedy SA, Droll KP, Blachut PA, O'Brien
PJ.
J Orthop Trauma. 2010 Dec;24(12):757-63.
• 93/95 patients underwent ORIF within 48 hrs. of admission
• 6% wound dehiscence/infection
• 90% anatomic reductions
• 78% mild arthritis or worse at 1 year
2/16/2015
4
Initial Management before ORIFExternal Fixation
Patterson MJ, Cole JD. Two-
staged delayed open reduction
and internal fixation of severe
pilon fractures. J Orthop Trauma.
1999 Feb;13(2):85-91.
Sirkin M, Sanders R, DiPasquale
T, Herscovici D Jr. A staged
protocol for soft tissue
management in the treatment of
complex pilon fractures. J Orthop
Trauma. 1999 Feb;13(2):78-84.
• Leave intact; if ruptured, leave roof intact
• Most complications occur with blood filled blisters
• Takes 3 wks to re-epithelialize
Giordano CP, Fracture Blisters, CORR. (307):214-21, 1994 Oct
Initial Management before ORIFSoft Tissue Management
Initial Management before ORIFSoft Tissue Management
Boraiah S, Kemp TJ, Erwteman A, Lucas PA, Asprinio DE. Outcome following open reduction and internal fixation of open pilon fractures. J Bone Joint Surg Am. 2010 Feb;92(2):346-52.
2/16/2015
5
Timing of ORIF
• 12 days (closed)
• 14 days (open)
• 24 days
Sirkin M, Sanders R, DiPasquale T, Herscovici
D Jr. A staged protocol for soft tissue
management in the treatment of complex
pilon fractures. J Orthop Trauma. 1999
Feb;13(2):78-84.
Patterson MJ, Cole JD. Two-staged delayed
open reduction and internal fixation of
severe pilon fractures. J Orthop Trauma. 1999
Feb;13(2):85-91.
Timing of ORIFDVT Prophylaxis
Sems SA, Levy BA, Dajani K, Herrera DA, Templeman DC. Incidence of deep venous thrombosis
after temporary joint spanning external fixation for complex lower extremity injuries. J Trauma.
2009 Apr;66(4):1164-6.
LMWH
Duplex US
2.1% rate of DVT
Mechanism of Injury
• Fibula Fractures
• Fractured Fibula (85%)
• Leads to valgus deformity and lateral plafond impaction
• Intact Fibula (15%)
• Leads to varus deformity and medial plafond impaction
2/16/2015
6
Initial ManagementFibular Fixation
• Length
• Beware Comminution of fibula
• Complicates posterolateral approach
Technique of ORIFChoosing the Optimal Approach
Peter A. Cole, MD; Robert K. Mehrle, MD; Mohit Bhandari, MD;
Michael Zlowodzki, MD The Pilon Map: Assessment of Fracture Lines and Comminution
Zones in AO C3 Type Pilon Fractures. OTA 2004 Poster #5 Foot and Ankle
Anterolateral
Anteromedial
Posterolateral
2/16/2015
7
Technique of ORIFPosterolateral Approach
Technique of ORIFAnterolateral Approach
Options for Internal FixationAnterolateral Plate
2/16/2015
8
Technique of ORIFAnteromedial Approach
Technique of ORIF Locking Plates
2/16/2015
9
Staged Posterior Tibial Plating for the Treatment of
Orthopaedic Trauma Association 43C2 and 43C3 Tibial Pilon
Fractures.
Ketz J, Sanders R.
J Orthop Trauma. 2012 Jan 20.
Improved:
AOFAS
Maryland Foot and Ankle Score
Articular Reduction
Less:
Arthrosis
2/16/2015
10
Postoperative Management
2/16/2015
11
Summary
• Immediate external fixation
• Delayed internal fixation
• Posterolateral approach
• Trap the talus
• Avoid medial plates if possible
2/16/2015
1
Posterior Approaches
Paul M. Lafferty, MDAssistant Professor
University of MinnesotaOrthopaedic Trauma
Regions HospitalSt. Paul, MN
Disclosures
• None
2/16/2015
2
Posterior Column
Posterior Pilon Variant
Posterior Pilon Variant
2/16/2015
3
Comminuted PilonLarge Posterior Fragment
Comminuted PilonLarge Posterior Fragment
Comminuted PilonLarge Posterior Fragment
2/16/2015
4
Posterolateral Approach(PL)
Prone
Lateral
2/16/2015
5
Tibial Nerve
Transverse Intermuscular
Septum
PL
MPM
PM
2/16/2015
6
2/16/2015
7
Posteromedial Approach(PM)
Prone
Supine
2/16/2015
8
Transverse Intermuscular
Septum
Tibial NervePL
MPM
PM
2/16/2015
9
2/16/2015
10
Modified Posteromedial Approach(MPM)
Prone
Supine
2/16/2015
11
Tibial Nerve
Transverse Intermuscular
Septum
PL
MPM
PM
2/16/2015
12
2/16/2015
13
Thank You
Paul M. Lafferty, MDAssistant Professor
University of MinnesotaOrthopaedic Trauma
Regions HospitalSt. Paul, MN
2/24/2015
1
Percutaneous Techniques for Tibial Pilon Fractues
Matthew D. Karam
University of Iowa Hospitals
Disclosures
• Grant funding from OTA, ABOS, AHRQ and NBME-Educational Research
• No relevant financial conflicts of interest
Tibial Pilon Fractures
• Factors that affect ultimate outcome
– Mechanical
– Biologic
– Clinical
2/24/2015
2
Mechanical
Mechanical
Biological
2/24/2015
3
Axial Loading
2/24/2015
4
Rotational ankle fracturesare different – slow load, less energy
few complications
Anatomical reduction critical??
What is the relative effect of the injury compared to our treatment?
Does an anatomical reduction of the displaced articular surface really guarantee a good outcome
in high energy fractures?
2/24/2015
5
What do we know about patient outcome!
b) Pain and decreased function common
a) Complications create disasters!
Absolutely determine outcome
Complications have decreased!
Factors leading to decreased complications –
plateau/pilon
Prioritize the soft tissue injury
Delay to definitive surgery
Use of temporary spanning fixation
Definitive external fixation
Low profile plates
Indirect reduction techniques
Percutaneous techniques for reduction and placement of implants
2/24/2015
6
The Soft Tissue Injury!!
Red Blisters
Clear Blisters
OpenFracture
The Injury/Management of the Soft Tissue
Envelope is the Key
Relative Success
Dismal Failure
vs
A- Frame – Restorelength and alignment
Surgical delay enhanced using
Spanning fixation!
2/24/2015
7
Plating through limited approaches
Plating through limited approaches
2/24/2015
8
The use of definitive external fixation
2/24/2015
9
CT Spinning
Frame off at 5 months – Healed
2/24/2015
10
Frame off at 5 months – HealedXrays at 2 years
36 yo male fell out of deer standClosed soft tissue swelling, no blisters
Definitive Spanning Fixator
Limited or percutaneous approachesand use of reduction aids
2/24/2015
11
Screw Fixation only supported by a spanning fixator
14 months – works full time
as a salesman,hunted one year after injury
2.5 years - continues to hunt.
2/24/2015
12
Summary
• Tibial Pilon Fractures are common
• Complex interplay of mechanical, biologic and clinical factors
• Complications can lead to disasters
• Some residual pain and dysfunction is common
• Limited approached when utilized appropriately can mitigate some risk of complications
2/24/2015
13