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Pilon fracture- Internal fixation using Stryker AxSOS 3Ti plate

    Overview

    Learn the Pilon fracture: Internal fixation using Stryker AxSOS 3Ti plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Pilon fracture: Internal fixation using Stryker AxSOS 3Ti plate surgical procedure.
    Pilon fractures are fractures of the distal tibial plafond and by definition are intra-articular and in a load bearing joint, this renders them serious and often life changing fractures. The fracture is sustained by a mixture of shear and compressive loads to the distal tibial metaphysis.
    Pilon fractures make up between 5 and 10% of all lower limb fractures and because of the energy involved are associated with a high (15 – 55%) complication rate. Significant rotational force can also cause distal tibial fractures which involve the plafond and these are also pilon fractures. This mechanism though usually has less severe soft tissue damage and less compromise to the articular surface in terms of comminution and cartilage damage.
    The most frequent mechanism of injury is a fall from height and this case demonstrates this , being sustained after a 4 metre fall onto concrete through a weak roof .
    The big debate is when to use ORIF or minimally invasive plate osteosynthesis (MIPO), and when to use an external fixation frame (such as an Ilizarov or other fine wire construct) as definitive treatment. In my hands and working in a unit with excellent fine wire fixation skills locally we tend to treat those cases where there is very severe soft tissue damage or where the articular surface is grossly comminuted with a frame. Those cases where the degree of articular comminution is less severe are usually treated with plate fixation as was the case presented here.
    Author :Mr Chris Blundell FRDS (Tr & Orth)
    Institution: The Northern General Hospital , Sheffield ,UK.
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    Indications

    INDICATIONS
    Pilon fractures most often occur in a fall from height as in this case and are often accompanied by associated fractures of the pelvis (vertical shear), lumbar spine (burst fractures) and the ipsilateral foot (calcaneal fractures being the most common). Pilon fractures make up between 5 and 10% of all lower limb fractures and because of the energy involved are associated with a high (15 – 55%) complication rate. Significant rotational force can also cause distal tibial fractures which involve the plafond and these are also pilon fractures. This mechanism though usually has less severe soft tissue damage and less compromise to the articular surface in terms of comminution and cartilage damage.
    The outcomes of these fractures are related to the degree of violence which has been inflicted on the articular surface and also to accuracy of the restoration of articular congruity.
    Throughout the treatment of these injuries focus should remain on the soft tissues as it is these which if compromised will lead to a disastrous outcome. With this in mind care must be taken to time intervention and it is often best to allow the soft tissue hit to settle down by resting the limb with the use of a bridging mono-lateral external fixator as was demonstrated by Sirkin et al in 2004 (see results).
    In this case intervention was within 24 hours after the fracture and the soft tissues were healthy enough to allow primary open reduction and internal fixation.

    SYMPTOMS & EXAMINATION
    Full ATLS guidelines must be followed in patients with these injuries as life threatening associated injuries are not uncommon. The limb must be inspected fully for breaches to the skin either from within (ie an open fracture) or from outside in which may or may not communicate with the fracture but which non-the-less may compromise operative treatment. The limb must be assessed for neurovascular compromise. Immediate splintage in the form of a full length backslab cast is mandatory to provide comfort and to assist in soft tissue management.
    IMAGING
    Plain AP and Lateral radiographs are needed and should also include the whole leg to the knee. CT scanning is extremely helpful to plan intervention. I would not intervene in my hospital without one as my approach to the fracture is determined by the fracture configuration with particular reference to the transverse sections.
    ALTERNATIVE OPERATIVE TREATMENT
    The big debate is when to use ORIF or minimally invasive plate osteosynthesis (MIPO), and when to use an external fixation frame (such as an Ilizarov or other fine wire construct) as definitive treatment. The literature does not help greatly here though the Watson et al paper (see Results) is one of the more compelling papers towards fine wire fixation whilst more recently the techniques and outcomes described by Xianfeng’s group (see Results) leads one to have confidence in ORIF.
    In my hands and working in a unit with excellent fine wire fixation skills locally we tend to treat those cases where there is very severe soft tissue damage or where the articular surface is grossly comminuted with a frame. Those cases where the degree of articular comminution is less severe are usually treated with plate fixation as was the case presented here.
    We not infrequently combine approaches also. For example, where there are a few fragments which can be reduced and stabilised with screws or a die punch fragment which can be reduced with minimally invasive assistance but the whole limb secured then with a circular frame.
    NON-OPERATIVE MANAGEMENT
    If the soft tissues are severely compromised such as in a pre-existing neuropathic limb or a vasculopath, the risks of a non healing wound may well outweigh the benefits of articular restoration. In such cases the limb is best treated with a cast but with frequent inspection of the soft tissues to ensure the situation is not worsening.
    CONTRAINDICATIONS
    In a situation where the limb is unsalvageable usually due to vascular or neurological compromise or where there is significant soft tissue loss; then a well timed and carefully considered amputation can lead to an early return to function and an acceptable outcome especially in the strong and fit young patient.

    Setup

    The patient has a general anaesthetic if able. Blocks in my opinion are best avoided due to the small but very real possibility of masking a compartment syndrome post operatively.
    The patient is supine with sandbag under the ipsilateral buttock to position the limb in neutral rotation.
    A tourniquet at the thigh is applied and I prefer to operate with this inflated so that I can have a clear view of the surgical field. I prep the limb to well above the knee as rotation needs to be carefully assessed. Unless the injury is an open one with bone loss then iliac crest bone grafted is not needed.
    Antibiotics on induction of anaesthesia are mandatory and in our hospital currently this is in the form of teicoplanin and gentamycin delivered iv.
    An image intensifier will be required later on and I ensure the equipment is in the operating room before I begin.
    The plain radiographs and CT scans are displayed on the screens to help reference the approach and remind us of the pre-operative plan and specifically which fragments to attach to which.

    Operation – 1

    Classification 1
    Regarding classification the most useful classifications that I use are the AO Classification (https://www.aofoundation.org/documents/mueller_ao_class.pdf) where this is considered a complete articular fracture of the distal tibia, making it a 43C Fracture. The articular surface is multifragmentary and so by definition this is a 43C3 Fracture. I use this as it helps in discussion with colleagues regarding the use of a frame or ORIF with a plate.

    Classification 2
    In terms of the CT classification I use the system described by Topliss et al in 2005. This particular fracture fits the Coronal family and is a Y-type of fracture with a large articular fracture fragment which I considered to be a true die punch fragment. This classification is essential in our management where the approach is made directly to the most major displacement with fixation sometimes being made remote to this. The classification allows careful assessment of approach and fixation to avoid fixation being placed through the fracture lines. I recommend the reader looks carefully at this important paper from 2005.

    It can be seen that this case has not had a severe injury to the soft tissues which look healthy. Note the absence of bruising, swelling or blisters all of which would signify soft tissue injury and instability. If these signs were present I would elect to put on a bridging mono-lateral external fixator in Delta construct and come back another day.


    This case is in the operating theatre within 24 hours of injury. I prefer to operate early if the situation allows it. An external fixator applied as a bridging mono-lateral device is very helpful to buy some time and keep the limb safe if soft tissues are concerning or if surgery cannot be carried out soon. A mono-lateral ex-fix should be applied within the first 24 hours if definitive fixation is delayed for any reason.
    The timing of definitive care here needs to be judged on experience and is individual case and surgeon dependent.

    I mark out my incision by putting green needles into the fracture site. My approach is as described by the Topliss et al paper (2005 – see Results) which characterised the pilon fracture families and patterns to be expected. This approach minimises the degree of “second injury” to the fracture by utilising the zone of fracture where the periosteum has already been stripped to allow reduction. The approaches are non-anatomic in that they are not necessarily classical approaches but are driven by the fracture. The approach I use is to go into the fracture at the site of maximal displacement – in other words to use the fracture gap and open it like a book to allow the articular fragments to be reduced and then to “close the book” thus giving some immediate stability to the reduction.

    The needles can be seen to lie in the principle fracture line to guide the approach.

    Careful dissection with very delicate handling of the soft tissues is made. The approach is ‘non-anatomic’ in that we approach directly into the area of the fracture where the periosteum has already been stripped. In this case the antero-lateral approach is close to where I expect the superficial peroneal nerve lies and I look out for this in the subcutaneous fat.

    The muscle belly and tendon of extensor digitorum longus is reflected. I do not use self retaining retractors at this stage as I find they can cause too much pressure on the skin edges. Small Langenbeck retractors are better.

    The zone of subperiosteal bleeding / bruising indicates the fracture site. The ankle joint capsule is opened in line with the fracture. Periosteum may need to be cut but not stripped off to gain access to the fracture.

    The anterior tibial artery (A) lying close to fracture is isolated and reflected laterally away from the fracture. The fracture can be clearly seen (B).

    Now we are deep and the neurovascular bundle has been located a self retaining retractor can be used but minimal tension is applied.

    The fracture site is opened (“opening the book”) and haematoma washed and sucked out so that the full site of the injury can be inspected and any tiny fragments which might block reduction are removed. Often flakes of cartilage and tiny osetochondral fargments are washed out at this stage.

    The talar articular surface (T) can be clearly seen distally and it is also inspected for cartilage defects which may be amenable to reduction and fixation if they are large – I use an absorbable pin to do this. None were present in this case.

    I use a “dental hook” to open up the fracture and once small fragments are removed the more major intra-articular die punch element is pushed down onto the talar surface with a blunt pusher. I often use the flat end of the Langenbeck.
    I then use the hook again and this also allows me to manipulate the fracture down and “close the book”

    The hook is used here to “close the book” – ie reduce the fracture

    However the fracture cannot be reduced anatomically and I am suspicious that there is a further displaced metaphyseal fragment blocking reduction. The fracture is therefore opened again and further inspection carried out proximal to the articular surface. Only anatomical reduction of the articular surface can be accepted as we know that this will improve overall outcome and is the primary goal of ORIF vs external fixation.

    Here the culprit is seen. One of the “die punch fragments”. I can see where this has come from and I therefore put this fragment back into the distal metaphysis – keeping the book open to do so.

    In the manner described in slide 12, the fragment is tamped into place with the flat side of my mini Langenbeck

    Now the book is closed and we can see anatomic reduction of the cortical piece. An image intensifier is used to confirm reduction.

    Reduction at the level of the joint is confirmed

    The distal construct is held in place with a percutaneous wire away from the site of plate application. The articular surface now needs to be stabilised to the shaft. A small incision is made medially to position tenaculum forceps in to pull the shaft laterally onto the distal segment. It is held there with a further percutaneous wire. Again image intensifier is used to check reduction at this stage.

    Here the wires can be seen holding the joint line and the clamp reducing this to the shaft.

    A Stryker AxSOS 3Ti distal tibia anterolateral plate is chosen to provide stability. A submuscular pocket is made with the flat ended soft tissue elevator. It should be emphasised that this plate is not going to be lying subperiosteally though and that this device is not named a Periosteal elevator as the pocket is superficial to the periosteum in fact.
    It is difficult to ensure the plate will lie straight up the tibia and not sit off proximally and so care must be taken at this stage to direct the elevator in the correct direction.

    The plate is slid into the pocket created and again an image taken to check it is lying correctly to the shaft. The plate is introduced with a locking guide (called an Aiming Block in the AxSOS system) and an introducing handle to assist in its placement and to guide the drill for locking fixation. Although the plate can be bent in the non locking area of the plate I find generally the precontour works well in these plates and so do not tend to need to bend them.

    Once in place the introducing handle can be removed leaving the aiming guide in situ. 4.0mm partially threaded screws can be used through the plate to lag fracture fragments together prior to using the plate as a neutalisation device with angle stable locking screws. The distal articular construct is stabilised first.

    Operation – 2

    Another 4.0mm partially threaded screw is used to lag the distal stable construct to the shaft.

    The plate and fractures are now neutralised with the addition of 4.0mm locking screws. Not every plate hole needs to be filled of course!

    An AP image intensifier view shows the articular surface to be anatomically reduced. The plate can be seen to be standing off the bone a little more proximally as is often the case. With locking screws unless this is excessive it will not cause the fracture to unstable and providing there is no irritation of the muscle belly of EDL it is not a cause for concern.

    A true lateral of the joint shows excellent reduction and no encroachment of the joint by the hardware.

    The extensor retinaculum is carefully approximated to prevent bowstringing of the tendons in the early post operative period which could lead to wound healing problems. I prefer to use interrupted sutures to provide more security.

    Skin is closed without tension with interrupted sutures. I use a petroleum gel dressing over the skin and then orthogauze. The wound will leak a little and this is my rationale for interrupted skin closure to prevent the formation of a wound haematoma which can lead also to wound breakdown or potential infection.

    I then use a plaster backslab, with the ankle plantargrade, for two weeks to allow the wound to be sufficiently stable to allow range of movement exercises to commence at two weeks.

    Post Operative

    The limb is rested in a plaster backslab in neutral for two weeks. Patients are provided with thromboprophylaxis according to a risk assessment – in our institution we use a Thrombin Xa inhibitor (Rivaroxaban) until weight bearing or range of movement is effective. In a complaint patient I will get the cast off and sutures out at 2 weeks and commence non-weight bearing range of movement exercises supervised by the physiotherapists. In a non-compliant case then the cast is kept on for 6 weeks.
    Weight bearing is gradually commenced in either case for 6 weeks with full weight by 12 weeks.
    Images at 6 and 12 weeks are taken to ensure no hardware failure and to confirm the ongoing stability of the fracture and fixation.

    Recommended Reading

    Topliss CJ, Jackson M and Atkins RM.Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg (Br). 2005 May;87(5):692-7.
    In a series of 126 consecutive pilon fractures, we have described anatomically explicable fragments. Fracture lines describing these fragments have revealed ten types of pilon fracture which belong to two families, sagittal and coronal. The type of fracture is dictated by the energy of injury, the direction of the force of injury and the age of the patient.
    Sirkin M, Sanders R, DiPasquale T, Herscovici D., Jr A staged protocol for soft tissue management in the treatment of comples pilon fractures. J Orthop Trauma. 2004;18:S32–S38
    A key paper demonstrating the benefit of delayed ORIF where there was soft tissue damage. Although the technique used would now be considered out moded (using a lateral plate and a monolateral fixator) they clearly showed the importance of soft tissue respect and that of delayed definitive care.
    Watson JT, Moed BR, Karges DE, Cramer KE. Pilon fractures. Treatment protocol based on severity of soft tissue injury. J Clin Orthop Relat Res. 2000;375:78–90
    These authors emphasized that minimally invasive separation of soft tissue not only protects the blood supply of the fractured bone but also provides indirect reduction. Watson suggested choosing the surgical approach on the basis of the condition of the injured soft tissue, and recommended the use of limited exposure and stabilisation with small wire circular external fixators.
    Xianfeng He, Yong Hu, Penghan Ye, Lei Huang, Feng Zhang and Yongping Ruan. The operative treatment of complex pilon fractures: A strategy of soft tissue control. Indian J Orthop 2013 Sep; 47(5):487-492
    The authors review 36 cases of ORIF with the emphsis on soft tissue care operatively and the use of vacuum assisted wound dressings. They show good results and low complications. This is a modern approach to ORIF of Pilon fractures.

    Reference

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