Fragment-Specific Pilon Fracture Fixation Using

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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

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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 metaphyseal comminution. There was significant impaction particularly anteriorly and in the central zone of the tibial plafond. The associated distal third fibula fracture was transversely oriented, not comminuted, 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

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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 reduction, which allows for better visualization in fond impaction, the talus has the tendency to escape anteriorly, addition to the added benefit of cauterizing punctate bleeding in the and this should be corrected with the frame. soft tissues that could potentially be missed if the tourniquet is elevated Ten days after admission, the soft tissue swelling had sufficiently during the exposure. resolved, and the patient was brought to the operating room again for The next step involved reducing the multiple articular frag- definitive ORIF of the multifragmentary articular fracture of her distal ments and obtaining an anatomic reduction of the articular tibia. She was positioned supine on a radiolucent table under general surface. There were 3 separate areas of significant impaction anesthesia. A small bump was placed under the ipsilateral hip, and the with 1 large central impaction zone. After external rotation of the operative leg was positioned on a soft ramp cushion to facilitate lateral anterolateral fragment, the articular reduction sequence started fluoroscopy. Her lower extremity was prepped and draped in the usual working from posterior to anterior using a Freer elevator and sterile fashion with a tourniquet on her right thigh. The decision was multiple osteotomes to reduce the impacted pieces of articular made to use an anteromedial approach which would allow excellent cartilage. Then, the reduction sequence proceeded from the lateral visualization of the medial gutter comminution and reduction of the to medial direction to obtain what was thought to be an anatomic large anterolateral fragment which appeared to have excellent cortical reduction of the articular surface. The obtained reduction was reads based on CT. The incision started proximally 1 cm lateral to the provisionally stabilized with multiple K-wires. Of note, the tibial crest and sharply curved medially at the joint line to a point central impacted fragments were initially reduced with reference approximately 1 cm distal to the medial malleolus. The saphenous to the presumably unviolated posterolateral articular surface. nerve and vein were identified and protected distally. After dissection Lateral fluoroscopic imaging, however, revealed that the reduc- was performed through the skin, subcutaneous tissue, and fascia, the tion resulted in an apical deformity of the articular surface, which tibialis anterior tendon was identified. After sharp incision just medial is not uncommon. This is routinely due to marginal impaction of to this tendon, a full-thickness flap medial to the tendon was elevated, the posterior lateral joint surface, also known as the “skid zone” the fracture was exposed, and arthrotomy was performed over the (Fig. 4A). To avoid an apical deformity of the tibial plafond, the anterior sagittal fracture line. The severe comminution in the medial K-wires were removed and the impacted anterior aspect of the gutter anteriorly became visible. The external fixator was now posterolateral joint surface was disimpacted using curved and adjusted, and approximately 1.5 cm length was gained through the straight osteotomes (Figs. 4B–D). After an adequate posterior

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FIGURE 4. A, Lateral ﬂuoroscopic image exhibiting that the reconstructed joint surface is too steep (underreduced) because of initially missed marginal impaction of the anterior aspect of the posterolateral joint surface (“skid zone”). B and C, Disimpaction of the skid zone using osteotomes. D, Satisfactory joint surface restoration without apical deformity. reduction was obtained, the joint surface was built off the ana- medial gutter and medial malleolus fracture were addressed in the tomically reduced posterior articular surface and provisionally sta- last step, and additional K-wires were used to obtain and maintain bilized with multiple K-wires (Fig. 5A). The severely comminuted a reduction of this area. Cancellous allograft bone chips were then

FIGURE 5. A, Provisional K-wire ﬁx- ation with distraction temporarily increased to visualize articular surface. B, First, mini fragment T-plate placed anterolaterally to maintain reduction of the Chaput fragment and the disimpacted central articular fragments. C, Partially threaded 4.0-mm cannulated screw placed across the medial malleolus fracture to obtain compression. e4 www.jorthotrauma.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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FIGURE 8. A and B, Anteroposterior and lateral radiographs 12 months postoperatively.

FIGURE 6. fl A and B, Anteroposterior and lateral uoroscopic appropriate. First, a T-plate (DePuy Synthes, variable angle LCP images after surgical stabilization displaying the position of all 3 T-fusion plate 2.4/2.7) was placed on the anterolateral side to secure mini fragment plates applied. the anterolateral Chaput fragment and to maintain reduction of the disimpacted central articular fragments (Fig. 5B). A partially threaded packed into the metaphyseal voids left after reduction of the impacted 4.0-mm cannulated screw was then placed across the medial malleo- articular fragments. lus fracture to obtain compression (Fig. 5C). Subsequently, a Smith & Fragment-specific mini fragment fixation was performed using 3 Nephew EVOS mini fragment 2.4-mm locking T-plate was applied plates and was started from the lateral side toward the medial side. Of just medial to the first plate to gain further fixation into multiple note, mini fragment fixation alone is not recommended for C-type articular fragments and to provide an area to prevent subsidence injuries; however, in this B-type partial articular fracture, it is (Figs. 6A, B). An additional 2.4-mm EVOS straight tine plate was finally used as a buttress plate to gain further fixation of the medial malleolus fragment (Figs. 6A, B) and to prevent varus collapse. Two Kirschner wires that entrapped the medial gutter pieces were bent and tamped into the cortical surface as described by Firoozabadi et al.11 The tourniquet was released, and punctate bleeding was stopped with electrocautery. Radiographs were obtained to verify reduction (Figs. 6A, B). The wound was closed by a periosteal closure to the tibialis anterior fascia and skin sutures in the Allgöwer–Donati fashion. The external fixator bars were then readjusted and reattached to obtain a neutral foot position. Final radiographs verified that the talus was appropriately centered beneath the anatomic axis of the tibia at the end of the procedure (Figs. 6A, B). The external fixator was left in place for 4 additional weeks and was then removed in the clinic. The patient was kept non–weight bearing on crutches for 12 weeks after definitive fixation. Follow- up x-rays at 6 weeks and 12 months postoperatively are shown in Figures 7 and 8, respectively. At 12 months, the patient reported no complaints except for an “odd sensation” over the anterior aspect of her ankle during cold weather.

DISCUSSION Despite the wide variety of pilon fracture patterns, the goals and principles of the surgical treatment remain the same: anatomic reconstruction of joint congruity; restoration of distal tibial and FIGURE 7. A and B, Anteroposterior and lateral radiographs 6 ﬁbular alignment; minimization of soft tissue trauma; bone grafting weeks postoperatively. of osseous voids left after reduction and disimpaction; and stable

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fixation to maintain reduction and to allow early joint motion. Mini REFERENCES fragment plates provide a versatile system to achieve these goals 1. Crist BD, Khazzam M, Murtha YM, et al. Pilon fractures: advances in – and may be used as an alternative or adjunct to conventional plates surgical management. J Am Acad Orthop Surg. 2011;19:612 622. fi fi 2. Topliss CJ, Jackson M, Atkins RM. Anatomy of pilon fractures of the and external xators. They are low pro le, can be contoured, and distal tibia. J Bone Joint Surg Br. 2005;87:692–697. offer a wide array of options for fragment-specific fixation because 3. Cole PA, Mehrle RK, Bhandari M, et al. The pilon map: fracture lines and of variable angle locking screws and multiple plate configurations. comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Fragment-specific fixation using mini fragment plates has already Trauma. 2013;27:e152–e156. 4. Wang D, Xiang JP, Chen XH, et al. 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An update on the management deemed reasonable because of simple fracture configuration and only of high-energy pilon fractures. Injury. 2008;39:142–154. minimal displacement. Intramedullary screw fixation similar to 20. Tomas-Hernandez J. High-energy pilon fractures management: state of the fibular nailing requires less extensive soft tissue dissection than art. EFORT Open Rev. 2016;1:354–361. fi 21. White TO, Guy P, Cooke CJ, et al. The results of early primary open plate and screw xation. Both procedures have been reported to reduction and internal fixation for treatment of OTA 43.C-type tibial pilon provide reliable fixation and to result in a lower rate of wound fractures: a cohort study. J Orthop Trauma. 2010;24:757–763. complications.22,23 In contrast to fibula plating, the minimal incisions 22. Loukachov VV, Birnie MFN, Dingemans SA, et al. Percutaneous intra- required for percutaneous fixation do not interfere with future ap- medullary screw fixation of distal fibula fractures: a case series and sys- – proaches for delayed definitive ORIF. tematic review. J Foot Ankle Surg. 2017;56:1081 1086. 23. White TO, Bugler KE, Appleton P, et al. A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal CONCLUSIONS fixation for fixation of ankle fractures in elderly patients. Bone Joint J. – The presented case demonstrates that mini fragment plates may 2016;98B:1248 1252. be successfully used for fragment-specific pilon fracture fixation. Mini fragment plates may be a useful alternative or adjunct to conventional plates or external fixation. They are less prominent, Read the rest of the JOT Case Reports online on www. more amenable to being contoured, and offer numerous options for jorthotrauma.com. It’s the Grand Rounds series from the Jour- fixation of a broad range of fracture patterns because of the variety nal of Orthopaedic Trauma, the official journal of the Ortho- of plate configurations, distal screw cluster, and variable angle paedic Trauma Association. locking screws.