Pilon Fractures

Courtesy: Jamal al Asiri, FRCSC, FACS
McMaster University and Hamilton Health, Ontario, Canada

PILON FRACTURES

History
• Described in 1911 by Etienne destot
• Pilon = pestle
• High complication rate with early total care
• Managed conservatively early-mid 1900
• Ruedi-Allgower principles:  1969

Pilon fracture classification systems
1. Reudi-allgower classification (1979)
2. AO classification (1987)
3. Topliss classification (2005)
4. Leonetti classification (2017)

Reudi-allgower and AO classification systems are the most reliable among those currently used for pilon fractures, but with lower agreement at the AO group level
The use of Topliss and Leonetti classification systems are not recommended because of less favourable results

Assess for neurovascular injuries
• Axial Load Injury- Be aware of associated injuries – Spine Fractures, Hip Fracture, Tibial Plateau Fracture
• Associated Vascular Injury: High rate: 52%

Assess for soft tissue: Fracture Blisters
• Represented cleavage injuries at the dermal-epidermal junction
• Giordano et al (1995):

Two clinical types of fracture blisters:

• Clear filled: Associated with rapid re-epithelialization
• Blood filled (Hemorrhagic): associated with increased complication rates, scarring, and delayed surgical intervention.
• There is no compelling evidence to support any method over another in treating the blisters.
• Do not operate through traumatized tissue

Assess for Open Fracture
*~20% associated with open fracture
*Medial and anterior open fracture wound location were significantly associated with deep infection

• Higher Energy Injuries (Type III) result in the poorest outcome and highest complication rate
• Independent risk factors for infection were diabetes, smoking and need for soft tissue coverage

Pilon fractures. Treatment protocol based on severity of soft tissue injury.
• Grade 0 or 1 injuries treated with ORIF
• Grade 2 or 3 treated with external fixation

Treatment options
• Nonoperative Treatment Indications:
-Non-displaced fracture pattern
-Severely debilitated patients
-Patients at significant risk of wound healing complications or compromise
• The results of operative treatment were superior to the results of nonoperative treatment.

Operative DECISION MAKING
• Should treatment be staged or done all at once?
• Should an external fixator be used?
• Should it be placed temporarily or used for definitive treatment?
• Should we fix the fibula acutely?
• What kind of incision should be made, medial or lateral?
• Which implant will maintain the reduction the best?

Treatment options
1969 Ruedi and Allgower
• 84 consecutive pilon fractures treated with ORIF
• 4 principles:
1. Restoration of fibular length with plating
2. Anatomical reconstruction of the articular surface of the tibia
3. Cancellous autograft for metaphyseal Tibial defects
4. Plating of the anteromedial tibia to prevent varus
• 74% good or excellent results at 4 years

Operative treatment
>Helfet et.al 1994 Staged Management

Temporary spanning ex fix

• Stabilise to protect soft tissues
• Restores length and may reduce articular fragments by ligamentotaxis
• Strict elevation
• Definitive fixation when soft tissues settle
• Healing of skin blisters: Skin wrinkling: between 7 to 21 days

Pilon Fracture: External fixation

• Spanning External Fixator (outside the ZOI)
• Allows soft tissues time to heal
• Allows planning of surgical approaches
• CT Scan may be done after patient placed in “travelling traction”
• Apply External Fixator and give the soft tissue time to recover

Is It Safe to Prep the External Fixator In Situ During Second-Stage Pilon Surgical Treatment?

-Retrospective Study
-Comparable to previously reported infection rates.
-The overall deep infection rate was 13%
-The superficial infection rate was 11%.

Definitive Plates Overlapping Provisional Externa Fixator Pin Sites: Is the Infection Risk Increased?

-Retrospective comparison study.
-Significantly increases the risk of deep infection (24%) Vs (10%)

Locking or “Low-Tech” Plating
– 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking).
– The results showed locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture.

Prospective Randomized Comparison of Locked Plates Versus Nonlocked Plates for the Treatment of High-Energy Pilon Fractures
• No significant differences between the lock and nonlock groups for ankle hindfoot scores
• The results presented in this study may be subject to type II error as indicated by the low incidence of reduction loss.

Acute Fibula Fixation
• Plating the Fibula
Establish length
Help stabilize (providing lateral buttress)
Decrease surgical time next visit
• No Plating
The surgical mistakes have to be corrected
Surgical approaches now more complex
• Not a necessary step in the reconstruction of pilon fractures, may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation
• Higher rate of plate removal if the fibula was fixed.
• It is associated with significant rate of complications, and good clinical results may be obtained without fixing the fibula

New Principles in Pilon Fracture Management
Revisiting Ruedi and Allgower Concepts:
• Fibular fixation is not always the first stage, depending on the pattern and complexity of the fracture.
• In the presence of severe intra-articular comminution, the quality of joint reduction can be sacrificed to prioritize stability and alignment.
• Bone grafting is reserved for cases of substantial metaphyseal bone loss, and in general, in a delayed stage.
• Not only does the medial column have to be stabilized, but all damaged pillars in the pilon fracture.

Pre-Op Planning
• CT Scan can be very appropriate.
-Most useful after initial closed reduction or external fixation
-Helps to determine the surgical approach
-Implants
-Fixation vs primary fusion

Surgical tactic notes
1. Supine position, bump, tourniquet radiolucent table
2. Universal distractor and indirect reduction
3. Anterior arthrotomy (minimal), evaluate joint surface, excise nonviable fragments
4. Percutaneous clamps, provisional wires
5. Lag screws 1,2,3,4,5 via stab wounds
6. External fixator (3 wires): posterolateral to medial (through fibula), lateral to medial (in front of fibula), posterolateral to anteromedial (behind fibula)
7. Full exposure with medial plate application if necessary

Computer Based Puzzle Solving
*Begin with clinical pre-op CT scan of fractured and intact bones
*End with final 3D digital blueprint for reconstructing the bone

Pre-Op Planning
• The concepts defined by Ruedi and Allgower were stated based on studies carried out with radiographs, but after the advent of CT scans in recent decades, we have better understood the morphology and patterns of fractures.

Pre-Op Planning
• Pilon fractures: a new classification and therapeutic strategies
• Described the four-column theory in decision-making therapeutic strategies for Pilon fractures.

Surgical Management PEARLS
• The timing of definitive ORIF depends on the soft tissue.
• Surgical approach for articular reduction and fixation is based on: Pre-op images, Avoiding severe soft tissue injury
• Buttress plates should be applied on the column of dominant displacement
Medial plate for varus
Anterolateral plate for valgus-recurvatum or anterior impaction
*Although the minimal skin interval between incisions is unknown and likely is variable, skin bridges of 6-7 cm appear to be safe
*Three vertically oriented angiosomes exist, supplying the overlying soft tissue envelope of lower leg ankle

Surgical approaches
• Anterior
• Anterolateral
• Medial
• Posteromedial
• Modified posteromedial
• Posterolateral
• Lateral
Every column needs to be fixed

Fixation of the Medial Column
• Ruedi and Allgower: Independent fixation of the medial column with a buttress plate as the mainstay of fixation.
• Recently, many surgeons using the anterolateral locking plates.
• No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments.
• Place a medial plate subcutaneously through minimally invasive incisions to buttress and correct any varus deformity

The Anteromedial approach
• The classic approach used in ORIF
• Maintain cuff of extensor retinaculum on tibia for repair at the time of closure

Limitations
• Difficulty in visualizing the lateral chaput fragment
• Risk of implant prominence and wound breakdown
• Bowstringing of tibialis anterior and increased tension for skin closure

The Anterolateral Approach(Bohler’s)
• It provides excellent visualization of the articular surface to the medial shoulder.
• Avoiding dissection of the anteromedial tibial face.
• The impaction at the medial shoulder is difficult to reduce with this exposure.
• Fibula fracture can be fixed through the same incision.

Direct Anterior approach
PEARLS
• Meticulous soft-tissue handling
• Closure of extensor retinaculum
-Prevents bow-stringing of the tibialis anterior tendon
-Provides good coverage over internal fixation
-Minimizing tension on skin for closure
PITFALLS
• Avoid extensile exposure in high-energy injuries with significant metaphyseal comminution and soft-tissue injury.
• Avoid forceful retraction or prolonged use of self-retainers to minimize additional tissue injury.
• Poor or incomplete closure of extensor retinaculum over tibialis anterior results in bowstringing and increased tension and pressure on skin closure, increasing risk of wound dehiscence.

The posteromedial approach- between FDL and neurovascular bundle
The modified posteromedial approach- between neurovascular bundle and FHL
The posterolateral approach- between peroneal tendons and FHL

Newer approaches

• the extensile approach
• fibular notch approach

Wound Closure
• The Allgöwer-Donati suture technique:
-Improved incision perfusion compared with vertical mattress closure.
-Theoretically, this may enhance soft tissue healing and decrease the risk of wound complications

Anterior Impaction pilon fractures
• A retrospective cohort study in 50 patients with an average follow up of 25 months

Results
• More advanced PTOA at the final follow up
• Higher rate of implant removal for pain
• Greater anterior talar subluxation on preoperative and final follow up radiographs
If the fracture is already healed with that impaction on presentation an anterior tibial plafond-plasty may be considered

Management of Bone Defect
• Various agents have been used for smaller defects (Autologous bone graft
>Structural (fibular strut graft)
>Cancellous allograft
>Demineralized bone matrix
>Synthetic substitutes (calcium phosphate and calcium sulfate).

In the setting of an open injury:
• Debridement of nonviable bone may result in a significant bone defect that is not amenable to filling agents:
-Induced membrane technique (Masquelet technique)
– Acute shortening with distraction osteogenesis
-Bone transport
-Vascularized bone graft
-Composite osteocutaneous grafts, such as vascularized fibula

• Acute shortening (non-articular osseous debridement in combination with fibular shortening):
-In patients who are poor candidates for complex soft tissue reconstructions: It will facilitate closure of the traumatic wound and simultaneously addresses osseous defects encouraging both osseous and soft tissue healing without the necessity for complex reconstruction and regenerative efforts to either.
-This can be performed by acutely shortening and plating defects up to 3-4 cm.

Primary Ankle Arthrodesis
*An option for severely comminuted type C fracture.
*>50% of the tibial plafond delineated on preoperative CT
*Primary ankle arthrodesis has a lower rate of nonunion & comparable functional outcomes to ORIF

Total Ankle Replacement for osteoarthritis following pilon fracture
• Patients with degenerative arthritis following pilon fractures showed improvement in pain, stiffness and function scores from preoperative to 1 year after surgery
• Similar patient reported outcomes were observed between the group with degenerative arthritis following pilon fractures and other groups undergoing TAR for different reasons
• Patient satisfaction survey results demonstrated overall satisfaction among all groups at 2 years post surgery. Complication rates were distributed evenly among all groups

CLINICS CARE POINTS
*Always plan your surgery based on a CT study; it allows an adequate understanding of the fracture that is, not feasible only with a radiograph.
*Fibular fixation is not recommended at the time of external fixation as a part of the first stage of step management. If so, it should then be performed by the same surgeon who will perform the final fixation as part of well-designed planning.
*At the time of ORIF, start fixation by the fibula only if you are sure to regain length, alignment, and rotation. In cases of much fibular comminution, it is sometimes better to start from the tibia.
*Always try to achieve an anatomic joint reduction (it is an element that improves functional prognosis) unless soft tissue damage or comminution does not allow this to be possible.
*The use of bone grafting is not always necessary, particularly with the development of percutaneous techniques that offer better soft tissue care.
*Not only must the medial column of the fracture be stabilized, but all that is compromised, particularly in the presence of metaphyseal comminution must be stabilized

Post Op Protocol
• Very well-padded back slab
•No movement until the wound is healed
• ROM begins at about 2 weeks
• Physiotherapy starts at 2 weeks for motion- 25% WB at 8 weeks, 50% WB at 10 weeks,100% WB at 12 weeks

Treatment Outcome
• Poor Prognostic Factors:
-Patients with a tibial plafond fracture and concomitant syndesmotic injury had significantly worse PROMIS PF scores, more end-stage ankle reconstructions, and more open fractures.
-Syndesmotic injury in the setting of tibial plafond fractures portends worse patient outcomes.
-Inadequate reduction (greater than 2 mm of joint incongruity)
-Divorced status
-Older than 55 years
-Lower education level
-Type-C fracture

VANCOMYCIN Powder
Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection: A Multicenter, Randomized, Controlled Trial (VANCO Study)
• Lower proportion of Gram +ve bacteria in the treatment group (55% vs 76%)
• No important difference in the rates of MRSA (17% vs 11%) or G-ve Bacilli infection (52% vs 42%)

The Effect of Local Antibiotic Prophylaxis on Postoperative Deep Infection in Fracture Surgery: A Systematic Review and Meta-Analysis
• The risk of deep infection was significantly reduced when local antibiotics were applied.
• This beneficial effect was observed in open fractures but failed to reach statistical significance in closed fractures.

Hyperbaric Oxygen Therapy
Perioperative supplemental oxygen to reduce surgical site infection after open fixation of high-risk fractures: a randomized controlled pilot trial.
-Use of a high concentration of FIO2 is safe
-It shows a trend toward reduction of surgical site infection.
-No significant difference

INPWT (Incisional VAC)
Incisional Negative Pressure Wound Therapy After High-Risk Lower Extremity Fractures
• 263 fractures (Plateau, pilon & calcaneus)
• Lower infection rate (10% vs 19%)
• Lower dehiscence rate (16% vs 8%)

VANCOMYCIN Powder
Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures A Randomized Clinical Trial
Key Points
Question – Does intrawound vancomycin powder reduce deep surgical site infections in patients with high-risk tibial plateau and pilon fracture?
Findings -In this randomized clinical trial of 980 patients, Intrawound vancomycin reduced deep surgical site infection rates by 3.4%. A post hoc analysis found that this effect was a result of a reduction in gram-positive infections.

Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High-Energy Fracture Surgery (OXYGEN Study) —–On going