Fri., 10/19/07 Foot & Ankle, Paper #36, 3:47 pm OTA-2007
The Results of a Staged Open Treatment Protocol for Pilon Fractures
David E. Asprinio, MD (n); Travis J. Kemp, MD (n); Scott J. Tarantino, MD (n);
Anna Samartzis, MD (n); Paul Lucas, PhD (n);
Westchester Medical Center–New York Medical College, Valhalla, New York, USA
Purpose: Open reduction and internal fixation (ORIF) of pilon fractures has historically resulted in a high incidence of wound complications, including wound dehiscence and infection. Recent reports have suggested that ORIF when performed in a staged fashion may yield more consistently acceptable results. The purpose of this study was to assess the short- and long-term results of treatment when a staged protocol was utilized.
Methods: 140 consecutive pilon fractures presenting to a Level 1 trauma center between 1996 and 2006 were prospectively treated under the direction of a single surgeon. There were 83 males and 54 females. 78 fractures (55.7%) were secondary to motor vehicle crashes, 55 (39%) falls, 3 (2.1%) pedestrian struck, 3 (2.1%) crushing mechanism, and 1 (0.7%) gunshot wound. Using the AO classification, there were 2 type A injuries, 17 type B injuries, and 120 type C injuries. 59 open injuries included 4 (6.8%) Gustilo type I, 8 (13.6%) type II, 32 (54.2%) type IIIA, and 15 (25.4%) type IIIB. 110 (78.6%) were treated using a staged protocol including initial early external fixation followed by delayed definitive ORIF. Open fractures underwent serial irrigation and débridement with delayed primary closure. Free tissue transfer was necessary for coverage in 17 patients (12.1%). 72 patients sustained additional injuries.
Results: Twenty-seven patients experienced one or more complications, including 9 patients (6.4%) with partial or full-thickness necrosis, 4 (3%) deep wound infection, and 3 (2.3%) nonunions. One patient required amputation following wound infection and failed free flap. One required late arthrodesis secondary to severe arthritic pain. Patients with greater than 2 years of follow-up were subject to standardized outcomes measures including the Modified Mazur Ankle Score and the Short Form-36 General Health Survey. Although patients scored poorly on physical function measures (P <0.05), they scored higher in mental health compared to age-matched uninjured controls (P <0.05).
Conclusion and Significance: The authors report a low incidence of early and late complications with high patient satisfaction in a group of patients sustaining predominantly high-energy injuries including 86% AO type C and 42% open fractures. The low complication rate is attributed to use of a staged treatment protocol and meticulous attention to soft-tissue management. The high patient satisfaction in the presence of poor functional outcome is attributed to well-informed patients with a realistic perception of the initial severity of injury and inevitable consequence of injury
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