morgan ota boot camp pilon 203 · 2018. 5. 8. · 4 surgical timing old school low energy fractures...
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Pilon Fractures
Steven J Morgan, MDMOTUS
Swedish Medical CenterDenver Colorado
Initial Radiographic Evaluation
• 3 views ankle
• Full length tibia
*** Joint above and joint below***
Initial Treatment GOAL
• Soft tissue management
• Restore Mechanical axis
– Length
– Alignment
• + Fibula Plating
• Relax soft tissues AT LENGTH
• Address open injuries
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Temporizing Ex‐fix
• Ex‐fix placement
– Out of zone of injury
– “Safe Zone”
• Proximal
– Distal to tibial tubercle
• Distal
– + Talar neck
– Calcaneus
» Posterior tuberostiy
» Anti‐equinus
Versatility To Accommodate Soft Tissue Injury
To Plate The Fibula or Not ?
• Fix the fibula acutely?
– Helps with alignment
– Maintenance soft tissue
• Fix the fibula ever?
– Definitive ORIF
– Definitive Ex‐fix
• Why fix the fibula?
– Lateral column stability
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Acute Fibula Fixation
• What is the ultimate “work horse incision”?
• Draw that approach on the leg first
• Ensure > 5 cm between incisions
• Reported 30% Wound Complication rate
CT Scans – After initial reduction
• Tornetta and Gorup, CORR, 1993
22 patients
Increased fragments in 12
Increased impaction in 6
Operative plan changed in 14 (64%)
Additional info gained in 18 (82%)
Stage One Management
Span It !
Plan It !
Scan It !
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Surgical Timing
Old School Low Energy FracturesRüedi and Allgöwer
• 60/84 low energy twisting
• 74% good functional results
• 90% return to work
• Low complications• 5% infection
• 12% wound problem
Injury 1969, 1973
Low Energy Boot‐top Injury
New School High Energy FracturesStaged Protocol Popularized
• 4 – 43C1
• 10 – 43C2
• 42 – 43C3
• 34 closed fx’s
– Avg 12.7 day delay• 5 minor wound issues tx’d non‐op
• 1 osteomyelitis
• 22 open fx’s
– Avg 14 day delay• 2 minor wound issues tx’d non‐op
• 1 ROH & IV Abx
• 1 amputation
Sirkin MS, et al: JOT 1999
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Practical ApproachTo definitive surgery?
• Blisters epithelialized
• “Wrinkle test”
– Without manipulation
wrinkling of skin around
ankle
NIGHT 1NOT READY
>7 daysWRINKLESREADY !!!
Exceptions
Open FracturesEarly Limited Internal Fixation
• Night 1
• Meta‐diaphyseal spikes
– May simplify definitive reconstruction
– May protect soft tissues
Dunbar RP, et al: JOT 2008
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Night 1: I&D open wounds, limited fixation
Post‐op CT
Day 5: Repeat I&D w/ fibula plate
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Day 12: Definitive Surgery
Day 12: The Real Deal
It’s the right time…
What to do?
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Principles
I. Restore length, fibula
II. Reconstruct joint
III. Bone graft defect
IV. Buttress
Rüedi, injury 1969
• Absolute stability – Articular Surface• Absolute or Relative stability – Metaphysis / Diaphysis
ORIF ‐ Overview
• Where to attack the injury from– CT Scan
• What is the fixation– LAG the JOINT when possible !!!
– Neutralize / Bridge / Compress metaphysis & diaphysis
– RESPECT soft tissues along the way
• Wound management
Choosing the surgical approach
• Choices
– Anteromedial
– Direct Anterior
– Anterolateral
– Posterolateral
– Posteromedial
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Reduction AidTemporizing Ex‐fix vs Femoral Distractor when
going from the front
• Can be useful
• Pin position determines “pull” & “visualization”
• Both give distraction
Neutral Axis
Dorsi‐flexionMoment
Plantar flexionMoment
Fixation Strategy
• Go through the front
• Work from back to front
• Joint distraction
– Ex‐fix
– Femoral Distractor
Surgical Approaches…
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Anteromedial Approach
• Incision starts ~5cm proximal to tibio‐talar joint line just lateral to tibialcrest
• Extends distal‐medial crossing crest (following medial border of TA tendon)
• *Watch for saphenous vein
Anteromedial Approach
• Do NOT violate TA tendon sheath
• Elevate anterior compartment from medial to lateral
• Incise anterior ankle capsule
• Preserve periosteum
Anteromedial Approach
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Anteromedial Approach
Anteromedial Approach
Anterior Approach
• Center of Mortise
• Access to AM & AL joint
• Watch for superficial peroneal nerve branches
• Incise extensor retinaculum
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Anterior Approach
TOES
• Center of Mortise
• Access to AM & AL joint
• Watch for superficial peroneal nerve branches
• Incise extensor retinaculum
Anterior Approach• Intervals
– EHL/TA – EHL/EDL – EDL/peroneous tertius
• Proximal to tibio‐talar joint NV bundle between TA and EHL
• Distal to tibio‐talar joint NV bundle beween EHL and EDL
• Excise anterior ankle capsule and intra‐articular fat
Anterior Approach
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Anterior Approach
• Absolute stability – Articular Surface• Absolute or Relative stability – Metaphysis / Diaphysis
Posteromedial Approach
• Prone or “figure 4” positioning
• Btw Achilles and posteromedial tibia
• Identify the NV bundle
• Free structures from fx site
• Extra-articular reduction
• Visualization of joint through the fracture only
Anterior with Posteromedial
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Anterior with Posteromedial
PTTFDL
Anterior with Posteromedial
Anterior with Posteromedial
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Anterior with Posteromedial
Anterior with Posteromedial
• Absolute stability – Articular Surface• Absolute or Relative stability – Metaphysis / Diaphysis
Anterolateral (Bohler’s) Approach
• Incision in line with 4th MT
• Centered at the ankle joint
• Protect the superficial peroneal nerve which crosses the incision
• Incise the extensor retinaculum
• Elevate anterior compartment from lateral to medial
• Joint arthrotomy
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Anterior Lateral Locked Tibia Plate
• Heavy Plate
• Improved Fixation
• Better Soft Tissue Coverage
• No Fibular Plating
Post Op Ant Lateral Plate
Closure
• Retinaculum – prevent “bowstring”
• Limited subcutaneous sutures
• Consider Modified Allgower‐Donatisutures for skin– Sagi HC et al: JOT 2008
• Consider Wound VAC
• Splint to Rest Tissues
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Post Op Plan
• Splint 2 weeks
• Removable Boot or Splint
• Active Motion
• NWB or TDWB for 10 Weeks
• Outcome – Hard to Predict
Pitfalls
Mal‐Union
Poor Reduction ?
Poor Fixation ?
Poor Plate Placement ?
Preventable Outcome
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Pitfalls
Percutaneous Plates
Percutaneous Medial Based Broad Plates Prone to Wound Breakdown & Infection
To Much Hardware
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Take Home points
Soft tissue stabilization
• Span It
– External Fixation
• Scan It
– CT scan
• Plan It ! Or Punt It!
• LAG It !
• Neutralize It!
Thank You