Fri., 10/9/09 Pilon/Foot & Ankle, Paper #59, 4:40 pm OTA-2009
Primary Arthrodesis of the Tibiotalar Joint with Reconstruction of the Distal Tibial Metaphysis following Highly Comminuted C2 and C3 Pilon Fractures
Gary S. Gruen, MD(n); Ryan L. McMillen, DPM (n); Jason Dragavon Dahl, BS(n);
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Purpose: The treatment of a highly comminuted tibial pilon fracture is controversial. These injuries are complicated by a compromise of the soft-tissue envelope and extensive impaction of the articular surface of the distal tibia. Some of the most devastating injuries (OTA C2 and C3) that appear nonreconstructable have historically been treated with open reduction and internal fixation, only to develop early traumatic arthritis of the joint or a nonunion of the metaphyseal segment. In other patients, amputation was required for infection of the soft tissues or bone. As an alternative, a subset of patients may benefit by primary arthrodesis of the tibiotalar joint and acute osseous reconstruction of the metaphyseal region of the tibia. This study retrospectively evaluated 20 patients who underwent tibiotalar arthrodesis and metaphyseal reconstruction via a posterior approach and blade plate fixation.
Methods: All patient charts from the primary surgeon (G.S.G.) were retrospectively searched using the term “blade plate fusion.” CPT and ICD-9 codes were also used to determine all patients who underwent blade plate fusion of the tibiotalar joint with metaphyseal reconstruction from 1992 to 2007. Demographic data extracted from the patient chart included age, sex, and body mass index. Nonmodifiable risk factors gathered were mechanism of injury, fracture pattern, open versus closed injury, size of tibial bone defect, and presence of peripheral vascular disease (PVD), and diabetes. Modifiable variables included use of bone morphogenetic proteins with autograft, tobacco usage, use of external fixation, staging the fusion procedure from the initial injury, and use of a cannulated system. Data were collected and analyzed by individuals not involved with the surgical team.
Results: All 20 patients with OTA C2 and C3 fractures achieved union of their ankle arthrodesis and distal tibial metaphyseal defect with good to excellent outcomes. Of the 20 patients, 19 required no additional surgical intervention to achieve union. One of the 20 patients required an additional procedure to achieve union. The posterior soft tissues healed uneventfully without complication in all patients. There were no infections and no soft-tissue compromise using the posterior approach. Univariate data analysis showed no significant differences in time to healing of the bone or soft tissues despite comorbid conditions that included tobacco use, PVD, diabetes, or open fractures.
Conclusion: Blade plate fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with a highly comminuted (OTA C2 and C3) pilon fracture who have severely damaged their articular cartilage. This novel method allows for excellent soft-tissue closure, the ability to reconstruct a large tibial bone deficit, and a high union rate of the metaphysis. Even with comorbidities that have been shown to have an increased risk of non-union, such as tobacco usage, diabetes, and open fractures, all patients went on to achieve union. Finally, this technique provides a high patient satisfaction and avoids the heightened risk of secondary infection and amputation.
• 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