Abstract
Intra-articular fractures of the distal end of the tibia, more commonly referred to as pilon fractures, account for approximately 5% to 7% of all tibial fractures1,2. Type-C fractures present a unique surgical challenge: a total articular fracture contained within a vulnerable soft-tissue envelope. Treatment options include internal fixation3, external fixation with or without limited internal fixation4, and primary ankle arthrodesis2. The management, and particularly the timing, of surgery is often dictated by the patient’s general state of health, soft-tissue condition, and fracture comminution as well as the experience of the surgeon. The surgical goals are to reconstruct the articular surface of the plafond, restore limb alignment, and protect the soft-tissue envelope. Since the publication of the seminal paper by Sirkin et al.5 in 1999, it has become orthopaedic orthodoxy to stage the surgery of pilon fractures, adopting a so-called span, scan, and plan approach. We more commonly operate early, and in a recently published retrospective review of 102 type-C pilon fractures in 99 patients, 73 patients (73 fractures; 71.6%) underwent primary internal fixation6. Outcomes were equivalent to the results of a staged protocol: 36 complications in 28 patients (28 fractures; 27.5%), with superficial (n = 9) and deep (n = 9) infection being the most common. Forty-one fractures (40.2%) required at least 1 additional operation, with removal of symptomatic metalwork being the primary indication (n = 30). No patient required an amputation. At a mean follow-up of 6 years, both the mean Foot and Ankle Disability Index (FADI) and mean Foot and Ankle Outcome Score (FAOS) were 76 (range, 0 to 100). Median patient satisfaction was 7 of 10. The results demonstrated a satisfactory outcome following primary internal fixation in appropriately selected patients. This instructional video outlines the surgical technique used. The key steps of the procedure are (1) preoperative planning with assessment of imaging and soft tissues; (2) application of a thigh tourniquet and placement of the patient predominantly in the supine position, unless the fracture configuration requires a prone position; (3) intraoperative use of a spanning external fixator; (4) careful exposure of the distal end of the tibia, dictated by the fracture configuration, with the anterolateral, anteromedial, and direct medial approaches most commonly used, elevating full-thickness tissue flaps wherever possible; (5) fracture reduction and fixation through a joint arthrotomy and fracture windows, allowing visualization of the articular margins, followed by initial Kirschner wire stabilization and definitive lag screw fixation; (6) application of a low-profile, locking or nonlocking plate in either buttress or bridging mode, joining the articular-metaphyseal block to the distal tibial diaphysis; (7) fixation of an associated fibular fracture, typically with intramedullary nailing and removal of the external fixator; (8) layered closure according to surgeon preference; and (9) postoperative protocol, consisting of a removable orthosis with a strict non-weight-bearing restriction for up to 3 months.
Acknowledgments
Note: The authors thank Gillian Nelson and Stephen Punton of the Medical Photography Department (Royal Infirmary of Edinburgh) for their invaluable assistance with filming and video editing and Laura Sheils, Iain Campbell, and Professor Gordon Findlater of the Department of Anatomical Sciences (University of Edinburgh) for their help with procurement of anatomical specimens and facilitating filming within the University. They also thank the Scottish Orthopaedic Research Trust into Trauma for their help with procurement of surgical equipment and implants. The radiograph and computed tomography (CT) scan of a pilon fracture and the illustration showing the OTA/AO classification system for pilon fractures in Video 1 and the axial CT scan and corresponding illustration of a pilon fracture in Video 3 are reproduced, with permission of Elsevier, from: White TO, Mackenzie SP, Gray AJ. McRae’s orthopaedic trauma and emergency fracture management. 3rd ed. Edinburgh: Elsevier; Copyright 2016. Ankle pilon; p. 506-13. The excerpt from the article by Duckworth et al. in Video 1 is reproduced, with permission of The British Editorial Society of Bone & Joint Surgery, from: Duckworth AD, Jefferies JG, Clement ND, White TO. Type C tibial pilon fractures: short- and long-term outcome following operative intervention. Bone Joint J. 2016 Aug;98-B(8):1106-11.
Published outcomes of this procedure can be found at: Bone Joint J. 2016 Aug;98-B(8):1106-11.
Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A261).
References
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