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External Fixation In Pilon Fractures

External Fixation In Pilon Fractures. Gillian Jackson North West Regional SpR 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.

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External Fixation In Pilon Fractures

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  1. External FixationIn Pilon Fractures Gillian Jackson North West Regional SpR Teaching 14th March 2008

  2. Indications • Types • How to… • Evidence

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

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

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

  6. Types

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

  8. How To…..

  9. Hybrid Frame

  10. 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.

  11. 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.

  12. 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

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

  14. 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

  15. 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.

  16. 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 vs Ex-fix and delayed MIPO. • Delayed MIPO lowest complication rate. • Unequal numbers.

  17. 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

  18. 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.

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