Sat., 10/18/08 Foot & Ankle/Pediatrics, Paper #57, 11:15 am OTA-2008
Revision of Provisional Stabilization in Pilon Fractures Referred from Outside Institutions
Michael J. Gardner, MD (n); Sean E. Nork, MD (a-AO, EBI, Synthes, Smith + Nephew, Stryker,
Zimmer); Stephen K. Benirschke, MD (a-Synthes; a,e-Zimmer);
David P. Barei, MD (a,b-Synthes, Zimmer; b-AO, Smith + Nephew);
Harborview Medical Center, Seattle, Washington, USA
Purpose: Pilon fractures are often the result of high-energy impact, and can be associated with significant injury to the soft-tissue envelope. Protocols that involve immediate application of provisional external fixation, with or without fibular fixation, followed by a delay prior to definitive fixation, result in decreased complication rates. When provisional stabilization is performed, anatomic length and alignment of the distal tibial segment, as well as anatomic fibular reduction and stable fixation, must be achieved to facilitate later reconstruction and avoid iatrogenic complications. When these goals are not met, additional revision procedures may be required and the complication rate may be increased. The purpose of this study was to evaluate the treatment course of pilon fractures that were provisionally stabilized at outside institutions and subsequently transferred, with focus on the incidence and reasons for revision procedures.
Methods: A prospective trauma database was queried for all pilon fractures. Between 2000 and 2007, 668 pilon fractures were treated at our institution. Of these, 39 consecutive patients with 42 fractures had a temporizing surgical procedure prior to referral, and were included in the study. Patient demographics, injury characteristics, the distance of referring institution, reason for revision, and subsequent complications were determined. Average clinical follow-up was 60 weeks (range, 1-281 weeks).
Results: The average patient age was 41 years (range, 18-78 years), and 27 patients were male. 22 fractures (52%) were open, and 38 (90%) were associated with a fibular fracture. The average number of days between injury and presentation was 5.8 (range, 1-20 days). 40 of the 42 fractures (95%) required revision of the pretransfer fixation prior to definitive fixation. Reasons for revision included tibial malreduction (33 patients, 83%), fibular malreduction (4 patients, 10%), pins in the proposed incision (5 patients, 13%), or loose pins (3 patients, 8%). Transverse tibial pins placed through the anterior compartment were frequently associated with pin loosening, purulence, and soft-tissue necrosis. Of the 34 fractures in which distal pins were placed, 24 (71%) required revision for multiple reasons including pin malposition, loosening, drainage, talar placement, or extraosseous placement. Late complications occurred in 14 fractures (33%), which included deep infection in 10 (24%), and nonunion in 3 (7%). 23 patients (55%) underwent additional procedures following definitive fixation, including 9 soft-tissue coverage procedures and 3 amputations.
Conclusions: The vast majority of patients with pilon fractures treated with provisional stabilization followed by referral to another institution required revision prior to the definitive procedure. This resulted in many avoidable additional procedures, as well as a complication rate higher than recent series of similar injuries.
Significance: If immediate provisional stabilization of pilon fractures is performed, tibial half-pins should be placed in the anteromedial subcutaneous surface, and should be at least 20 cm proximal to the ankle joint to avoid compromising future incisions. Distal pins should be placed from medial to lateral posteriorly in the calcaneal tuberosity and should avoid the talus. Adequate length and rotation of the tibia and fibula should be obtained. Alternatively, if the fracture is closed and the soft tissues are not acutely threatened, immediate referral of the patient in a splint may minimize the need for additional procedures and subsequent complications.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.