2/2/2011

Tibial Plafond/Pilon Fractures

The Spectrum of Fracture

The Spectrum of Soft Tissue Injury

Relative Success

Dismal Failure

vs

The Soft Tissue Injury!!

Red Blisters

Clear Blisters

OpenFracture

Terrible Injuries

“Excellent Results” are rarely achieved

Fair-Good results are the norm

Outcomes are impossible to predict

Treatment complications must be avoided

Bone Soft Tissue

2 yrs.

Unusually good!

Tibial Plafond FracturesFair to Good Results Are the Norm

1991 - anterior B-3 fracture

6 months 3 years

Fair to Good Results Are the Norm

8 years

Fair to Good Results Are the Norm

Ankle score - 80Works as a laborer

5 years - no painankle score 95Case 1

6.5 yrs - miserable -

ankle score 45Case 2

Case 1 Case 2

� Avg. age 35-40

� Rare in children and elderly patients

� Males 3 x more common

� 3-9% of all tibia fractures

� Associated injuries 25-50%

� Increased incidence – Air Bags!!!

Save lives yes, but devastate the foot and ankle

Burgess et al JT 1995Lower extremity injuries in drivers

of air-bag equipped automobiles

Multiply injured patients with and without foot injuries ( 24 and 12 month follow ups)

Dramatic differences in pain, function and health related quality of life

Ankle Soft Tissues

Thin skin

Absent muscle

and adipose tissue

Lack of deep veins

Particularlyvulnerable!

The soft tissues over the anteromedial tibia are vulnerable

Dense trabecular structure of distal tibia

Bone is viscoelastic Axial load is rapid Shift in stress strain curve Tremendous energy release

Displacement

Load

Stress strain curves for rapid vs. slow rate of loading

Rapid axial load

Slow rotational load

Note the greater energy under

the curve!!

Rotational ankle fracturesare different - good prognosis and

few complicationswith standard techniques

Dense trabecular structure Thin soft tissues Axial Loading Typical fracture pattern Severe soft tissue injury

Reudi and Allgower - 1969

Is this a tibial plafond fracture? Does it belong in 43?

Plafond yes!!

C-2?

Or

C-3?

Four principles “stood the test of time”

Anatomical reduction

Stable internal fixation

Atraumatic technique

Early pain-free mobilization

“Precise reconstruction of articular surfaces is the goal, and is always preferred to tolerable malalignment”.

These Principals Illustrated for Fractures of the Tibial Plafond

Ill-Advised

Extensive surgical approaches

Fracture stripping

Prolonged tourniquet times

Bulky implants

Increased soft tissue injury

A recipe for disaster

}

Limb Threatening Complications

McFerran et al JOT 199221pts (40%) with major complications

require 77 additional operations Wyrsch et al JBJS 1996

3/18 amputations in closed fractures

Teeney and Wiss CORR 1993

37% infection and 26% fusion in Type 3’s

Cases Treated1980’sEarly 1990’s

Delays until surgery

Spanning ex fix part of most protocols

Percutaneous and limited approaches

Spanning ex fx Marsh et al JBJS 1995 – 43 cases 0% Wyrsch et al JBJS 1996 – 20 cases 5 %

External fixation same side Court Brown et al JOT 1999 – 24 cases 4% Tornetta et al JOT 1993– 26 cases 7%

Delayed plating Patterson and Cole JOT 2001 – 22 cases 0% Sands et al CORR 1998– 64 cases 6 % Sirkin et al JOT 1999 - 48 cases 6%

0-10%

1. Spanning articulated fixation with percutaneous or limited approaches to the articular surface and screw fixation

2. Percutaneous plating3. Standard plating through open approaches

after long delays for soft tissue recovery

Spanning fixator for three months A large monolateral frame fixed into the

talus and calcaneus Relatively earlier approaches to reduce the

articular surface percutaneously

Suited for all tibial plafond fractures Ideal for very comminuted cases Contraindicated with ipsilateral talus or

calcaneus fractures Beware diaphyseal extension or severe open

fractures which might delay healing

Span the zone of injury

Fixator applied first

Same technique all cases

One step surgery

Largely

percutaneous

AdvantagesArticulated

FIXATOR TECHNIQUE - Same for all cases!

Target the neck of the talus

posterioros calcis

Technical tips

Talar pinparallel to top of talus

Depth of insertion – Hindfoot pins must capture the entire talus and calcaneus

Harris viewCanale view

Position of pinsAssembled fixator

Keep the pins in the same plane!

Technical tips

Center the talus on two views

The articular surface can not be reduced if the talus Is not repositioned

Axial CT scan critical for pre op planning

The more you use limited approachesthe more planning that is required

Limited or percutaneous approachesand use of reduction aids

Reduction forceps based on anterolateral incision –

Watch out for SPN!

Open approaches when necessary based on major anterior fracture line

Direct approaches - no stripping

Percutaneous reduction sequencevisualized flouroscopically

2 year follow up

Never plated

Treat withfixator

Bone graft less

than 10%

ROM

Splinting

Wt. Bearing

~ 3 months after injury Outpatient clinic Calcaneal screw typically

loose Often use SLC for another

month

Uses medial sub cutaneous border Needs pre contoured plate Locking may offer advantages Ideal for a select group of fractures

Non articular distal tibia Limited articular involvement Build back articular block through limited

approaches

Distal tibia without articularDistal tibia without articularinvolvementinvolvement

External fixator Femoral distractor Manual traction Well placed clamps

Reduction: Ligamentotaxis

Femoral distractor

=

If Injured, Repair the Fibula

Pre-size and bend plate

Or use precountoured plate

• Rotation

• Curve

Anatomy:

Medial face

Incision

SubQ Tunnel

Insert plate

Confirm placement

Stab……Drill, Tap, & Screw

Post-op

4 months

Another example in a Another example in a more complex fracturemore complex fracture

5 months

Indicated to treat the range of tibial plafond fractures

Temporary spanning fixation and long delay to definitive surgery

Several different open approaches

1st Stage: Temporary Fixation application of spanning external fixator, ORIF of the fibula, as soon after presentation as possible, stabilize the fracture while allowing the

soft tissue swelling to resolve,

Interim: ice, elevation, pre-operative plan, TIME to allow swelling to resolve,

2nd Stage: Definitive Fixation ORIF tibia, removal of external fixator,

“Traveling Traction”Half Pins

TransfixationPin

Ice, elevation, CT scan, crutch training,

Pre-operative plan, TIME to allow

swelling to resolve,

Fibula posterolateral approach

when an anteromedial approach to the tibia is planned,

maximize the width of the skin bridge,

Fibula Implants:

Metaphyseal fracture 1/3 tubular plate, large screw,

Fibula Implants:

Metaphyseal fracture 1/3 tubular plate, large screw,

Fibula Implants:

diaphyseal fracture 3.5 LC – DCPlate

Rationale: cortical bone, highest energy fractures, slower healing,

Extensile Anteromedial Approach: “Workhorse”,

Anterolateral Approach: gaining in popularity,

Posterolateral Approach: recently proposed,

Anteromedial Approach Superficially:

minimum 7 cm skin bridge, begin ½ finger breath lateral to crest

over the anterior compartment, continue parallel to Anterior Tibialis

tendon, towards the talonavicular joint,

Post-operative soft tissue complications

Anteromedial Approach Superficially:

begin ½ finger breath lateral to crest over the anterior compartment,

continue parallel to Anterior Tibialis tendon,

towards the talonavicular joint, maintaining a 7 cm skin bridge,

Medial

talonavicular joint

medial

Anteromedial Approach Deep dissection:

carried out medial to Anterior Tibialis tendon,

longitudinal arthrotomy, gentle elevation of tendons and

neurovascular bundle,medial

Anteromedial Approach Deep dissection:

remain medial to Anterior Tibialis tendon,

longitudinal arthrotomy, gentle elevation of tendons and

neurovascular bundle,medial

Articular Reduction: largest and least displaced articular fragments

first, reduced fragments held with:

K-wires (1.2 or 1.6mm), pointed reduction forceps, lag screws,

reduce articular bloc to shaft, definitive fixation,

DON’T make medial a incision !!! the incision ends up directly over

the plate, difficult to close, increased wound complications,

deep infection, soft tissue loss, free flap only bailout,

burn bridges later reconstruction,

Not This Incision !!

Make This Incision !!

Anterolateral Approach Indications:

open medial wound, displaced Chaput fragment, lateral articular comminution,

Advantage: plate coverage, uninjured skin,

Caution Superficial peroneal nerve

Anterolateral Approach Deep Dissection:

through superior and inferior retinaculae, interval between toe extensors and fibula, elevate muscles off interosseous

membrane, Caution

Superficial peroneal nerve

Anterolateral Approach Deep Dissection:

through superior and inferior retinaculae,

interval between toe extensors and fibula,

elevate muscles off interosseous membrane,

Caution Superficial peroneal nerve

Advantages a single incision for ORIF

of the tibia and fibula, FHL is positioned

between the skin and the implants in case of post-op wound complication,

Disadvantages limited access to anterior

articular fracture fragments, prone position, sural nerve at risk,

Posterolateral Approach

Implants: Small Fragment Plates

cloverleaf shaped plate, distal radius “T” plates, 1/3 tubular plates, 3.5 LC-DCP,

Screws 3.5 cortical/4.0

cancellous, cannulated: 4.0/4.5

Implants: Small Fragment Plates

cloverleaf shaped plate, distal radius “T” plates, 1/3 tubular plates, 3.5 LC-DCP,

Screws 3.5 cortical/4.0

cancellous, cannulated: 4.0/4.5

Bone Graft support articular

fragments, augment healing, fill cancellous defects,

ICBG, Allograft, Synthetic

Calcium putties,

Meticulous Wound Closure meticulous closure, 1-0 vicryl for capsule, 2-0 vicryl for

subcutaneous tissue, 3-0 nylon for skin,

Allgower’s modification of the Donati stitch,

Allgöwer stitch modified by DonatiAllgöwer stitch modified by Donati

Summary: Tibial Plafond Fractures Represent both a bony and soft tissue injury, AO Principles:

Anatomic articular reduction, stable fixation, early mobilization of patient and limb.

several approaches to the tibia can be safely used, internal fixation is accomplished with small fragment

implants, meticulous soft tissue closure,

Results

Most have some pain

Most return to work

Detectable arthrosis - 50%

Arthrodesis rare

Pain Analysis

� 50% - no/minimal pain

� 35% - pain with weight bearing

� 15% - continuousMarsh et al. JBJS 1995

Sands et al CORR 1998 - 2-4 years after injury Delayed plating

Pollak et al JBJS 2003 – average 3.2 years after injury Plating and external fixation

Marsh et al JBJS Feb 2003 – 5-11 years after injury Spanning external fixation

0

20

40

60

80

100

PF* PR* BP* GH VT SF RE MH

Plafond

Norm

SF-36: Plafond vs Aged Matched Norms

5-11 years after injury (Marsh et al JBJS Feb 03)

Significantlydifferent

Ankle Osteoarthritis Scale: Plafond 5-11 Years after Injury

0

0.2

0.4

0.6

0.8

1

1.2

Pain Disability Mean

Plafond

Norm

0

2

46

8

10

12

1416

18

20

Grade 0 Grade 1 Grade 2 Grade 3

# of patients

25/33 rated their ankle good or excellent

Motion avg. 75% opposite

Only 2/37 late arthrodesis 5.4%

Sequential Ankle Score: 67 at 24 mo, 86 at 92 mo (p<.004)

Time to maximal healing: 2.4 yr (9 mo-5 yr)

Reasonable evidencethat patients improvefor a long time!

Do not be too quick to offerreconstruction!

1986 - 24 yo Male

1 year

7 years

14 years

Works light labor

Prefers high top boots

Occasional pain

Ankle score 80

Most have some ankle painCan not run or play sportsMeasurable effect on general health status70% with moderate or severe arthrosis

Excellent results are only rarely achieved

Most rate their outcome as good or excellent

Arthrodesis rate only ~ 5% Most feel they improve for years

Fair to Good Results Are the Norm

Summary and Conclusions

High energy fractures with severe associated soft tissue injury

Unpredictable outcomes Keep complications – 10% or less Results:

Generally not great But if you stay out of trouble not awful

Long lasting effect on patient health related quality of life and a greater effect on ankle pain and function

Arthrosis common by 2 years after injury and typical in the second five years. The clinical significance is variable.

The variation in outcome is unpredictable

The severity of injury/quality of reduction are important but better techniques to understand this critical interaction are needed

Do not be quick to suggest arthrodesis based on severity of injury or quality of reduction

Patients improve for a long time and most do not require arthrodesis

Complications must be avoided since they produce bad outcomes and the extent that we improve outcome with aggressive surgery is at least unclear