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Fragment-Specific Pilon Fracture Fixation Using Special Case Report Series JOT CASE REPORTS www.jorthotrauma.com JOURNALOF ORTHOPAEDIC TRAUMA OFFICIAL JOURNAL OF Orthopaedic Trauma Association AOTrauma North America Belgian Orthopaedic Trauma Association Canadian Orthopaedic Trauma Society Foundation for Orthopedic Trauma International Society for Fracture Repair The Japanese Society for Fracture Repair Sponsorship provided by Smith & Nephew, Inc. Fragment-Specific Pilon Fracture Fixation Using Mini Fragment Plates Richard A. Lindtner, MD, PhD* and Reza Firoozabadi, MD, MA† Key Words: Summary: Internal fixation or external fixation, with or pilon fractures, tibial plafond fractures, ORIF, mini fi fi without limited internal fixation, is considered the treatment fragment plates, fragment-speci c xation of choice for the majority of displaced pilon fractures. However, regardless of the chosen method, surgical stabiliza- INTRODUCTION tion of pilon fractures is challenging and technically demand- Surgical management of pilon fractures continues to be ing. Anatomic reduction of the articular surface, which is one challenging and technically demanding. Pilon fractures comprise of the main goals of operative treatment, is often difficult to a wide spectrum of skeletal and soft tissue injuries and typically obtain and maintain, especially in complex fracture patterns. result from higher energy mechanisms, with significant axial Even precontoured periarticular distal tibial plates cannot loading of the distal articular surface of the tibia.1 Complex fracture optimally address every fracture pattern and do not always patterns involving articular surface impaction, comminution, and offer optimal screw trajectory. Mini fragment plates allow significant soft tissue compromise are common.2,3 Despite advan- for fragment-specific fixation, can be used independently or as ces in implant technology, surgical approaches, and timing of sur- a useful adjunct to conventional plates, and enable the gical intervention, the rate of postoperative complications is still orthopaedic traumatologist to expand their internal fixation substantial, and the clinical outcome is not always favorable.4–9 armamentarium for the treatment of these complex injuries. Optimal treatment of pilon fractures is still controversial, and The objective of this article is to illustrate the successful use a wide variety of treatment strategies have been described. of mini fragment plates for fragment-specificpilonfracture Depending on the injury pattern and soft tissue condition, treatment fixation. options may range from nonoperative treatment (for completely nondisplaced fractures or patients who cannot tolerate surgery) to primary ankle arthrodesis in extremely rare selected unreconstruct- able cases. However, for the majority of displaced pilon fractures, From the *Department of Trauma Surgery, Medical University of Inns- internal fixation or external fixation, with or without limited bruck, Innsbruck, Austria; and †Department of Orthopaedic Surgery, Har- internal fixation, is considered the treatment of choice.10 The main borview Medical Center, University of Washington School of Medicine, goals of operative treatment include anatomic reconstruction of the Seattle, WA. articular surface; restoration of length, alignment, and rotation of R. Firoozabadi is a consultant for Smith and Nephew. The remaining the distal tibia; and stable fixation to maintain reduction until heal- author reports no conflict of interest. ing and to allow early joint motion. Reprints: Reza Firoozabadi, MD, MA, Department of Orthopaedic Sur- Precontoured periarticular distal tibial plates are commonly used to gery, Harborview Medical Center, University of Washington School of achieve stable fixation and maintain reduction. Mini fragment plates, Medicine, 325 Ninth Avenue, Box 359798, Seattle, WA 98104 (e-mail: however, may provide an additional and useful tool to restore joint [email protected]). congruityinpilonfracturesandallowforfixation of individual The views and opinions expressed in this case report are those of the fragments with separate implants (ie, fragment-specific fixation) authors and do not necessarily reflect the views of the editors of Journal which may facilitate fracture stabilization in cases in which of Orthopaedic Trauma or Smith & Nephew, Inc. precontoured plates may not be optimal. The variety of mini fragment Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. plate configurations, low profile size, distal screw cluster, and variable DOI: 10.1097/BOT.0000000000001099 angle locking screws may offer numerous options for fixation of J Orthop Trauma 2018 www.jorthotrauma.com e1 Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Lindtner and Firoozabadi At admission, neurovascular injuries were ruled out, and systematic physical examination did not reveal additional injuries. The soft tissue envelope around the ankle was closed and moderately swollen. Preoperative radiographs and CT images displayed an OTA/AO43-B3 (Rüedi and Allgöwer type 3) pilon fracture with multifragmentary articular surface fracture, but without metaphy- seal comminution. There was significant impaction particularly anteriorly and in the central zone of the tibial plafond. The associ- ated distal third fibula fracture was transversely oriented, not com- minuted, and displayed minimal varus malalignment (Fig. 1). A staged management was chosen, and it consisted of initial ankle-spanning external fixation with fibular fixation and delayed definitive open reduction internal fixation (ORIF) of the tibia using fragment-specific fixation after the soft tissue swelling had subsided. SURGICAL TECHNIQUE On the day of admission, the associated fibula fracture was percutaneously stabilized, and an ankle-spanning external fixator was applied. Preoperative analysis of the fracture pattern revealed a tension-based failure laterally at the fibula and a compression- based failure of the medial aspect of the tibia at the joint (Figs. 1 FIGURE 1. Preoperative anteroposterior (A) and lateral (B) ankle and 2). Because of the poor skin status of this elderly patient, the radiographs. use of immunomodulators, and because of the fact that it was a tension-based failure laterally, we decided against an ORIF of individual fracture components and thus may be helpful to reach the fibular fracture with a plate but rather opted for percutaneous treatment goals. It is important to note that mini fragment plates intramedullary screw fixation. The patient was positioned supine should not be used in lieu of standard larger plates in cases of complete under general anesthesia. A small skin incision was made distal to articular injuries; however, they can be used as an adjunct form of the tip of the lateral malleolus, and the entry point for the screw fixation. The purpose of this report therefore is to illustrate the use of was determined under anteroposterior and lateral fluoroscopic mini fragment plates for fragment-specific pilon fracture fixation. guidance, with the start site centered on the canal of the fibula on both views. The minimal varus displacement of the distal fibula PATIENT INFORMATION was percutaneously reduced using a Schanz pin, and thereafter, A 72-year-old woman sustained a right closed comminuted a 3.5-mm drill was advanced from the entry point proximally to pilon fracture and an associated closed distal third fibula fracture the level of the fracture, and a 2.5-mm drill was passed into the after a fall from a ski lift. The patient was osteopenic and on medullary cavity (Fig. 3A). A 3.5-mm cortical screw was then immunodulators for a recent history of breast cancer. Radiologic inserted and lagged by a technique across the fracture (Figs. 3B– workup at an outside hospital included standard ankle radiographs D). In the second step, an ankle-spanning triangular external fix- after the patient had a splint placed (Fig. 1); full-length radiographs ator was applied to stabilize the tibial component of the injury, of the tibia and fibula as well as computed tomography (CT) with 2 Schanz pins placed through the proximal tibial diaphysis, imaging were obtained on presentation at our institution (Fig. 2). one transcalcaneal pin and an additional pin placed from the FIGURE 2. Preoperative lateral (A), coronal (B), and axial (C) CT re- constructions. e2 www.jorthotrauma.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Fragment-Specific Pilon Fracture Fixation FIGURE 3. Fluoroscopic images showing drilling (A) for percutaneous intramedullary screw fixation of the associated fibula fracture. A percutaneous screw placed into the lateral malleolus guides fracture reduction. B, Insertion of a 3.5-mm cortical screw across the reduced fracture. C and D, Anteroposterior and lateral fluoroscopic images after fibula stabilization. medial to the middle cuneiform to neutralize the foot. Distraction distractor bars, and the joint was visualized. Once the exposure was was applied with the correction of coronal and sagittal deformities performed, the tourniquet was elevated. This is a standard practice of using appropriate vector adjustments through the bars and the senior author for the treatment of pilon fractures. Delayed elevation clamps. It is critical to restore the relationship of the talus to the of the tourniquet allows more time for the tourniquet to be elevated plafond on the sagittal view. In cases of significant anterior pla- during the joint
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