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External Fixation In Pilon Fractures Gillian Jackson North West Regional SpR Teaching 14 th March...
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Transcript of External Fixation In Pilon Fractures Gillian Jackson North West Regional SpR Teaching 14 th March...
External FixationIn Pilon Fractures
Gillian JacksonNorth West Regional SpR Teaching
14th 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 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.