Session I - Tibia Fractures

Results of a Staged Protocol for Wound Management in Complex Pilon Fractures

Michael Sirkin, MD, Paul Gregory, MD, Dolfi Herscovici, DO, Thomas DiPasquale, DO, Roy Sanders, MD

Florida Orthopaedic Institute, Tampa, Florida, USA

Hypothesis: Open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications.

Methods: Between 1/91 and 9/96, 221 pilon fractures (AO type 43A-C) were treated at a regional level I trauma center. A retrospective analysis of a treatment protocol applied to 56/113 AO type 43C fractures was performed. The protocol consisted of immediate (within 24 hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5 DC plate and the application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had normalized. Injuries were divided into

• Group I - 34 closed fractures, and
• Group II - 22 open fractures (3 Gustilo type I, 6 type II, 8 type IIIA, 5 type IIIB).

Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews and physical examination until surgical wound healing was complete for a minimum of 6 months (note: this study was not designed to evaluate long term results of internal fixation).

Results: Group I (closed pilon) Follow-up was possible in 28/34 fractures (82%). Average time from external fixation to open reduction was 12.7 days. All wounds healed. No limb exhibited a wound dehiscence or full thickness tissue necrosis requiring secondary soft tissue coverage post operatively. Eighteen percent (5/28) had partial thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was 1 complication (3.5%), a chronic draining sinus secondary to osteomyelitis which resolved after fracture healing and metal removal. Group II (open pilon) Follow-up was possible in 19/22 fractures (86%). Average time from external fixation to open reduction was 14 days. By definition, all Gustilo type IIIB fractures required flap coverage for the injury. Sixteen percent (3/19) had either cellulitis (1), or partial skin necrosis (2). All were treated with local wound care and oral antibiotics and healed uneventfully. There were two complications (10.5%), both deep infections. One type I open fracture developed a wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection. One type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a BKA.

Discussion and Conclusion: Based on our data, it appears the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotational or free flaps in our series. This technique appears to be effective in closed and open fractures alike.