OTA 1997 Posters - Foot & Ankle Fractures

Minimizing Complications Associated with Internal Fixation of Severe Pilon Fractures: Results of Delayed ORIF

Paul D. Protomastro, MD, Toan Le, MD, Brendan Patterson, MD, John Wilber, MD

Metro Health Medical Center, Case Western Reserve University, Cleveland, Ohio, USA

Introduction: Operative management of high energy tibial pilon fractures is associated with high complication rates and poor functional results. The resultant soft tissue injury makes treating these injuries most difficult. We performed a retrospective review of our experience to determine outcome of severe pilon fractures using a standard protocol for internal fixation.

Materials and Methods: We performed a review of 31 high energy pilon fractures treated by a standard treatment protocol from 1994 to 1996. The protocol included immediate stabilization of the fibula and delayed ORIF of the tibial plafond. All 31 fractures were classified using the AO classification: 2(6%) fractures were Type B, and 29(93%) were Type C. Thirty-nine percent of fractures were open with 8 Type IIIA and 4 Type IIIB. Definitive internal fixation of the axial weight bearing portion of the tibial plafond in accordance with AO technique via an anterior approach was delayed until soft tissue swelling had subsided. The average delay from injury to definitive treatment was 6.2 days. Subjective and objective functional outcome was quantified at latest follow up using the criteria of Phillips et. al. (JBJS 67 1085).

Results: Severe wound complications occurred in 7%, resulting in 2 free flaps. Deep infection occurred in 6%, resulting in the removal of fixation in one and an amputation in one. The incidence of malunion and/or nonunion requiring reoperation was 9%. One primary arthrodesis was performed. Two patients (2%) developed symptomatic hardware necessitating removal after union. Functional outcome at an average of 28 months was obtained for 21 of 31 patients. Ten patients were unavailable at the time of review. The average functional outcome score was 83, corresponding to 78% good to excellent, 12% fair, and 10% poor outcomes. At latest follow up 2 patients were contemplating arthrodesis. Patients with open fractures had a 50% complication rate compared to 10% for closed injuries. Similarly, patients whose definitive procedure was delayed more than 5 days had fewer complications (18%) than those treated earlier (26%).

Discussion: Tibial pilon fractures require meticulous soft tissue handling, rigid fixation and an experienced surgeon to restore limb function and minimize complications. By delaying definitive fixation of the tibial component, the incidence of wound problems can be greatly reduced. The rate of free flaps, amputation and infection in this series is below that of previous series of Type C injuries. Similarly, the functional outcome of this group of patients is comparable to previously reported series. ORIF can still be considered the procedure of choice for most Type C fractures.