External Fixation In Pilon Fractures Gillian Jackson North

External Fixation In Pilon Fractures Gillian Jackson North West Regional Sp. R Teaching 14 th March 2008

• Indications • Types • How to… • Evidence

Indications “First Aid” • Stabilise injury • Reduce soft tissue tension • Management of open wound • Analgesia • Quick • Poly trauma • Vascular surgeons

Buy Some Time • Allow soft tissues to settle • Further Imaging • Plan joint reconstruction/ ORIF • Order kit • Referral • Foot and Ankle service • Trauma centre

As Definitive Treatment • In isolation • With limited articular fixation • Interfragmentary screws • Olive wires with frame • +/- fibular plating • Supplement ORIF

Types

Complications • Pin site problems • Malunion • Delayed union • Non union

How To…. .

Hybrid Frame

Literature • • • ORIF vs External Fixation Spanning vs sparing Fibular fixation Retrospective series Severe injuries often ex-fixed Most studies supplement with limited screw fixation to restore articular surface.

ORIF vs External Fixation • • • Only one RCT Wyrsch 1996 18 vs 20 patients ORIF vs Ex-fix +limited ORIF “Randomised surgeon” design. No difference clinical scores at 2 years Increased frequency/severity complications in ORIF group.

Malunion vs Wound Problems • Watson 2000, 107 patients. Prospective protocol • ORIF in # with severe soft tissue - higher rates of • Non/Mal union • Severe wound complications • Pugh 1999 60 patients • ORIF vs Spanning vs hybrid • Ex-fixed groups increased malunion but less wound problems. • Independent of fibular fixation or bone grafting

Fibular plating • Williams 98 • 53 monolateral ex-fix • 22 fibula fixed, • 31 not fixed • No difference • X-ray arthrosis • Ankle score • Complication rate

Joint spanning vs sparing • Papadokostakis 2008 (JBJS) • Systematic review • 15 articles 465 fractures • Time to union 4. 3 mths (both grps) • Malunion higher in spanning fixation. • Increased plantar flexion in hybrid vs articulated • More minor (pin site) infections in hybrids • Septic arthritis 0. 6% in hybrids

Joint spanning vs sparing • Okcu 2004 • Ilizarov vs articulated external fixation • Retrospective 50 patients • All united • No difference functional ankle score • Ilizarov greater ROM • 74% vs 53% of other limb.

In Staged ORIF • Sirkin 1999 Initial ORIF fibula + spanning Ex-fix • 56 patient series retrospective • Delayed ORIF • Minimal wound problems • Blauth 2001 • 51 patients • Primary ORIF(MIPO) vs Ex-fix and delayed MIPO. • Delayed MIPO lowest complication rate. • Unequal numbers.

External Fixation • Can achieve our objectives • Preserve life • Preserve leg • Straight leg • Mobile joint • By. . • Quick application • Soft tissue healing/ preservation • Articular reconstruction • Meta/diaphyseal union

• Still should be considered the first aid of choice. • Always consider in high energy/ open injuries • Can be your definitive treatment • With articular reconstruction. • Move towards use in combination with delayed ORIF.