■ tips & techniques

The No-Touch Approach for Operative Treatment of Pilon Fractures to Minimize Soft Tissue Complications

Lisa K. Cannada, MD

The soft tissue injury and for this is that the fi xator can With the no-touch technique, there is no retraction of the handling of the soft tissue help maintain length. The de- soft tissues, with the exception of the initial placement of envelope are crucial in affect- fi nitive plating can then take the K-wires. The use of the no-touch technique can result ing pilon fracture outcome. place with less manipulation of in a low complication rate. Medially, there is a minimal the soft tissues. soft tissue envelope, and that Various confi gurations exist is where most open fractures for ankle-spanning temporary igh-energy pilon frac- trend in treatment has evolved occur. Because the fractures external fi xation, and they can Htures can have soft tissue to a staged approach involving are caused by high-energy all be effective. In these cases, complications such as infection acute application of an exter- mechanisms, initially there it is important that the pins are and wound dehiscence that can nal fi xator with optional plat- may be signifi cant swelling remote from any planned surgi- lead to amputation of the in- ing of the fi bula (if fractured) that continues to increase cal incisions and also to avoid jured limb.1-8 In addition, these on the patient’s initial presen- within the fi rst 3 to 5 days fol- placement in an injured tissue complications may increase tation. This is followed at a lowing the injury. If fracture envelope. The external fi xators the odds of poor treatment out- later date by defi nitive fi xation blisters are present, there is an can consist of a medial-based come.6,9,10 High-energy pilon with open reduction and stabi- increased risk of infection if frame or a delta-type frame fractures result from signifi - lization. The second stage is an open surgical approach is with a centrally threaded pin in cant injury mechanisms, and completed at the discretion of used. If there is skin necrosis the calcaneus. Once the exter- therefore these fractures may the treating surgeon, who de- from the open wound and sig- nal fi xator is placed, computed be open as much as 30% of the termines when the soft tissue nifi cant edema, there may be tomography (CT) scans are time.2,6 Some of these injuries is appropriate. The time frame some impaired perfusion to obtained to assist in planning may require a rotational fl ap for this is usually 2 to 4 weeks the tissues. the procedure. for soft tissue coverage.11 The after the initial injury. Several surgical approaches This article describes a have been described, including technique of maintaining the extensile, medial, and lateral external fi xator with partial Dr Cannada is from the Department of Orthopedic Surgery, Saint Louis approaches and percutaneous removal of the delta frame to University, Missouri. techniques if the fracture pat- permit fi xation with the ap- Dr Cannada has no relevant fi nancial relationships to disclose. 12-14 This study was performed at the University of Texas Southwestern, Dal- tern is amenable. Since propriate approach, either las, Texas. most pilon fractures are initially anteromedial or anterolateral. The author thanks Obinna Uzodinma, MD, for data collection and as- treated with an external fi xator, If a medial frame is in place sistance with this article. it is helpful to leave a portion and an anterolateral incision is Correspondence should be addressed to: Lisa K. Cannada, MD, De- partment of Orthopedic Surgery, Saint Louis University, 3635 Vista Ave, 7th of the delta frame or a medial- chosen, the fi xator maintains Floor–Desloge Tower, Saint Louis, MO 63110 ([email protected]). based frame in place during the the length and reduction dur- doi: 10.3928/01477447-20100826-16 defi nitive surgery. The reason ing the approach. Whatever

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Cover illustration © Lisa Clark

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1 2A 2B 2C

3 4 5 6 Figure 1: Example of a medial-based external fi xator in place. There is no modifi cation of this external fi xator for the approach described. Figure 2: Maximizing the use of a delta-type external fi xator. Example of a delta-type external fi xator frame commonly used in pilon fractures (A). Delta frame with lateral bars removed, facilitat- ing operative approach (B). Delta frame with lateral bars removed and approach drawn (C). Figure 3: Anterolateral incision. Figure 4: Approach with superfi cial pero- neal nerve visualized. Figure 5: Retraction for placement of K-wire. Figure 6: Placement of K-wire for retraction, demonstrating bent K-wire to protect assistants. approach is appropriate for excluded if they had a chronic frame and an anterolateral ap- The distal extent of the inci- fi xation, we recommend the disorder of their soft tissues, proach is chosen, modifi cations sion is proximal to the talo- “no-touch” technique where since this study evaluated soft are not needed (Figure 1). If a navicular joint. The dissection there is no retractor placed in tissue outcomes. At the discre- delta-type frame is used and through the skin and subcuta- the soft tissues yet adequate vi- tion of the on-call surgeon, a the anterolateral approach is neous tissue is sharp to main- sualization is present to permit patient who presented with an chosen, the bars are left on the tain full-thickness skin fl aps. reduction of the fracture. By us- OTA type 43B or C pilon frac- medial aspect and the bar and The superfi cial peroneal nerve ing the no-touch technique, we ture underwent stabilization clamps are removed laterally to is visualized within the distal minimize any soft tissue com- with external fi xation within allow adequate visualization for portion of the incision (Figure plications and thereby improve 24 hours of presentation. Open the approach (Figure 2). Preop- 4). The fascia over the anterior patient outcome. Additionally, fractures were thoroughly ir- erative antibiotics are given at compartment is incised and by minimizing retraction on the rigated and debrided in the the start of the procedure and a the extensor retinaculum is soft tissues and stripping of the operating room, and primary tourniquet is applied to the in- incised. The anterior compart- muscle off the bone, the risk of wound closure was performed. jured limb. The limb is prepped ment muscles are able to be nonunion can be decreased. Postreduction CT was obtained and draped in the sterile fi eld retracted medially. During the This report describes the to defi ne the fracture pattern of from the level of the tourniquet procedure, the full-thickness no-touch technique used by a the articular surfaces. Patients to the toes. The limb is exan- skin fl ap is gently lifted with a single surgeon in a series of were scheduled for defi nitive guinated by elevation and the small skin retractor and a 0.62 patients with pilon fractures. surgery when there was de- tourniquet infl ated. K-wire is placed distally on creased edema and skin that The anterolateral approach the anterior medial portion of MATERIALS AND METHODS was able to wrinkle. is useful for many complex the ankle joint proximal to the Patients eligible for inclu- and complete articular and par- articular fracture fragments sion were between ages 18 and SURGICAL TECHNIQUE tial articular fracture patterns (Figure 5). An additional K- 65 years with open or closed The technique is described in the OTA 43B and OTA 43C wire may be used proximally distal tibia fractures OTA 43B using the anterolateral ap- type. The incision is anterior for retraction. When placed, and OTA 43C treated at an ac- proach, but it can be applied to to the fi bula and in line with the K-wires are bent at a right ademic level 1 trauma center any open approach. If the exter- the fourth metatarsal (Figure angle to protect any assistants between December 2006 and nal fi xator has been previously 3). Proximally, the extension during this procedure (Fig- February 2008. Patients were placed and it is a medial-based is between the tibia and fi bula. ure 6). The K-wires used for

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7 8A 8B 9 Figure 7: Visualization permitted with this technique. Figure 8: Fracture reduced and ready to plate (A). Defi nitive fi xation in place and ready to close (B). Figure 9: Skin closure. retraction permit excellent RESULTS an average follow-up of 14.2 signifi cant soft tissue compro- visualization of the metaphy- Forty-three patients with 55 months (range, 6-20 months). mise and bony injury. The frac- seal/diaphyseal region and ex- pilon fractures were operated One patient (2%) had a deep tures may be open. There may posure to the medial aspect of on by a single surgeon using soft tissue complication treat- be skin necrosis from the open the distal tibia (Figure 7). this technique and had adequate ed with this approach. This pa- fracture wounds. There may be Reduction should proceed follow-up. Average patient age tient underwent an open reduc- development of fracture blis- to reconstruct the joint surface. was 34 years (range, 15-56 tion internal fi xation (ORIF), ters. Teeny and Wiss8 reported During this time, with the re- years). There were 31 men and was seen in clinic at 2-week that 37% of their patients ex- tracting K-wires in place, there 12 women. The mechanism of follow-up, and then did not re- perienced deep infections after is no excess traction on the skin injury included 21 falls from turn to clinic for 3 months. At ORIF. McFerran et al3 report- and soft tissues. Once adequate a height, 15 motor vehicle or that time, he had been wear- ed a 40% rate of patients with reduction of the fracture is ob- motorcycle collisions, and 7 ing a cast for 3 months and complications following ORIF tained, fi xation is applied (Fig- miscellaneous. Four patients had complete wound break- of their pilon fractures. Since ure 8). The retraction K-wires had multiple orthopedic inju- down. The patient was treated those articles were published, are then removed once the an- ries requiring operative stabili- with multiple debridements treatment has evolved. The terolateral plate is applied. zation. According to the OTA and vacuum-assisted closure advent of delayed, staged fi xa- Wound closure then begins Fracture Classifi cation, there and was discharged. The pa- tion has minimized soft tissue with deep Vicryl sutures (Ethi- were eleven 43B and thirty- tient again was noncompli- complications. con, Somerville, New Jersey). two 43C fractures. Six patients ant in terms of follow-up and However, to adequately vi- The extensor retinaculum is had open fractures. There was came back 4 months later. At sualize the fracture during fi xa- closed with interrupted 2.0 Vic- 1 type I, 3 type II, and 2 type that time he had completely tion, oftentimes the soft tissues ryl sutures. The subcutaneous IIIA open fractures. Two pa- exposed bone and continued are retracted for a signifi cant tissue is closed with interrupt- tients had diabetes. Eleven breakdown of his soft tissues. amount of time. Retraction of ed 2.0 Vicryl sutures, and the patients had initial external We proceeded with a below- the soft tissues and stripping skin is closed with interrupted fi xation with a medial-based knee amputation. of the muscle off the bone can 2.0 nylon vertical mattress su- frame and 30 with the delta- Two patients (5%) had cel- contribute to delayed healing or tures (Figure 9). The external type frame, and 2 had no initial lulitis and were treated with nonunion of the fracture. It can fi xator is then removed and external fi xation. an oral cephalosporin and had also contribute to wound com- the limb is placed in a splint. All patients who under- no further complications. Two plications. The anterolateral ap- The sutures are removed 2 or went an anterolateral approach patients with an OTA 43C proach and its variations have 3 weeks postoperatively, pend- were treated using the no-touch fracture pattern required bone been described recently in the ing the condition of the skin. A technique during this time in- grafting, and in both situations literature.12-14 The advantage cast may be used for the fi rst terval. Ten patients required the fracture went on to union. of the anterolateral approach is 4 to 6 weeks to maximize soft percutaneous medial incision. that it provides a good soft tis- tissue recovery, and then ankle Thirteen patients were treated DISCUSSION sue envelope with development mobilization begins. Weight with fi bular plating through the High-energy pilon fractures of full-thickness fl aps. bearing may commence at 3 same anterolateral approach. represent a challenge to ortho- Multiple factors may con- months if radiographs show All patients were followed until pedic surgeons. With the com- tribute to soft tissue compli- that there is clinical evidence documentation of weight bear- mon axial load mechanism of cations, including using a of healing. ing and healed soft tissue, with a pilon fracture injury, there is tourniquet for an extended pe-

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riod of time. The retraction of a low complication rate. It can 3. McFerran MA, Smith SW, DR. Tibial plafond fractures. Boulas HJ, Schwartz HS. How do these ankles function compromised soft tissues and be applied to any open pilon Complications encountered over time? J Bone Joint Surg swelling that is often present at fracture approach. This tech- in the treatment of pilon frac- Am. 2003; 85(2):287-295. J Orthop Trauma tures. . 1992; 10. Pollak AN, McCarthy ML, the time of fi xation may lead nique has not been described 6(2):195-200. to complications. The swell- in the literature. Bess RS, Agel J, Swiontkowski 4. Ovadia DN, Beals RK. Frac- MF. Outcomes after treatment ing may be decreased from the Our population of patients tures of the tibial plafond. J of high-energy tibial plafond initial injury but is still present had high-energy pilon frac- Bone Joint Surg Am. 1986; fractures. J Bone Joint Surg Am. 68(4):543-551. 2003; 85(10):1893-1900. at fi xation and can contribute tures. Despite this, there was 5. Patterson MJ, Cole JD. Two- 11. Pollak AN, McCarthy ML, to a poor outcome. In addition, only 1 soft tissue deep infec- staged delayed open reduction Burgess AR. Short-term wound patient factors that are uncon- tion. The no-touch technique and internal fi xation of severe complications after application trollable and may contribute should be used to further de- pilon fractures. J Orthop Trau- of fl aps for coverage of trau- ma. 1999; 13(2):85-91. matic soft-tissue defects about to soft tissue complications crease the rate of complications 6. Sanders DA, Sirkin M. Frac- the tibia. The Lower Extrem- include a history of smoking, in tibia pilon fractures. A gentle tures of the ankle and distal tibi- ity Assessment Project (LEAP) J Bone Joint Surg al pilon. In: Baumgaertner MR, Study Group. diabetes, and poor circula- approach to the soft tissue can Am. 2000; 82(12):1681-1691. tion. The wound breakdown result in a decrease in the com- Tornetta P III, eds. Orthopaedic Knowledge Update: Trauma 3. 12. Assal M, Ray A, Stern R. The of pilon fi xation can lead to plication rate, especially in- Rosemont, IL: American Acad- extensile approach for the op- the need for a free fl ap, and volving soft tissues, which is emy of Orthopaedic Surgeons; erative treatment of high-en- 2005:441-452. ergy pilon fractures: surgical signifi cant complications can key to a good outcome. 7. Sirkin M, Sanders R, DiPasquale technique and soft-tissue heal- J Orthop Trauma occur that include fl ap failure T, Herscovici D Jr. A staged pro- ing. . 2007; and the ultimate need for sub- REFERENCES tocol for soft tissue management 21(3):198-206. sequent amputation. 1. Helfet DL, Koval K, Pappas in the treatment of complex pi- 13. Chen L, O’Shea K, Early JS. J, Sanders RW, DiPasquale T. lon fractures. J Orthop Trauma. The use of medial and lateral Intraarticular “pilon” fracture 1999; 13(2):78-84. surgical approaches for the CONCLUSION of the tibia. Clin Orthop Relat 8. Teeny SM, Wiss DA. Open treatment of tibial plafond frac- J Orthop Trauma Res. 1994; (298):221-228. reduction and internal fi xa- tures. . 2007; With the no-touch tech- 21(3):207-211. nique, there is no retraction of 2. Kellam JF, Waddell JP. Frac- tion of tibial plafond fractures. Variables contributing to poor 14. Wolinsky P, Lee M. The distal the soft tissues, with the ex- tures of the distal tibial me- taphysis with intra-articular results and complications. approach for anterolateral plate ception of the initial placement extension—the distal tibial Clin Orthop Relat Res. 1993; fi xation of the tibia: an ana- (292):108-117. tomic study. J Orthop Trauma. of the K-wires. The use of the explosion fracture. J Trauma. 1979; 19(8):593-601. 9. Marsh JL, Weigel DP, Dirschl 2008; 22(6):404-407. no-touch technique resulted in

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