Edgardo Rodriguez, DPMŧ; Michael Bowen, DPM; Alex Cherkashin, MD; Mikhail Samchukov, MD; Stephen Frania, DPM; Paul Dayton, DPM; Gregorio Caban, DPM; Patrick Nelson, DPM
Statement of Purpose
Results
The purpose of this poster is to provide the foot and ankle surgeon with the surgical technique for reducing the pilon
and distal tibial fractures in the compromised patient or in the face of soft tissue compromise using Ilizarov method of
external fixation.
According the senior author (ER), the following data has been compiled retrospectively
for both pilon fractures as well as distal tibial fractures using this surgical technique:
Literature Review
Blotter et al: retrospective review of 21 patients who had diabetes and 46 randomly selected patients who did not have diabetes.
Complication rate of patients with diabetes was 43% undergoing ORIF ankle fracture vs 16% complication rate without diabetes.
Complications were more severe in diabetic population, including BKA.
Case Study
55-year-old female presented one hour after being involved in an MVA. Radiographs were
obtained of the left ankle (Figure 1). There was an intra-articular fracture of the tibial plafond
with impaction of the articular cartilage as well as comminution of the tibial dia-metaphyseal
region (OTA classification 43-C1).
Pilon Fractures (n= 37, mean age 57, m= 17;f= 40)
~ Mean follow up 42 month, AOFAS score 85.04.
~ Combined complication rate: 13% (Infection, metal breakage,
wounds dehiscence), 2 AMPUTATIONS.
Distal Tibial Fractures (n= 22, mean age 62, m= 22;f= 40)
McCormack and Leith: review of 26 diabetic patients with displaced malleolar fractures and a cohort group, overall complication rate of
42% in the diabetic patients compared with no complications in the cohort group treated non-invasively. Six of the 19 patients treated
surgically developed a deep infection, and 2 patients eventually required an amputation at an unspecified level.
~ Mean follow-up 28 months, AOFAS score 92.13.
Schon et al: series of 13 pre-Charcot displaced ankle fractures. Four ankles were treated by closed reduction and casting or bracing
(minimum, 3 m). Nine ankles underwent ORIF. The four ankles treated nonoperatively and all progressed to significant valgus deformity,
non union, or both.
In comparison, nine ankles were treated by ORIF and period of various NWB protocols. Shorter NWB post-op produced one infected
non-union, and the longer NWB protocol produced only one displacement that required TTC fusion.
Figure 2: Intra-op pictures of ligamentotaxis via distraction and final
frame application.
Analysis and Discussion
Technique Guide
Materials:
• Traditional approaches to fixation for Pilon and Distal tibial involve large
ancillary incisions putting the already fragile soft tissue envelope at even more
risk of complications.
- Tibial block consisting of (2 full rings, and 4 threaded rods with necessary nuts and bolts), distal tibial ring, foot plate with half ring
attached to the distal aspect.
- Both smooth and olive wires
- 25lb weight.
• The use of circular external fixation alone in a single staged procedure might
help to decrease the risk of morbidity and even mortality for these patients as
shown in the data presented by the senior author (13% complication rate for
pilon fractures).
Surgical Technique:
- Patient supine, prepped and draped up past the knee. (Popliteal block pre-op for post-op analgesia)
- Smooth wire is driven lateral to medial across the inferior aspect of the calcaneus and 25lb weight attached for ligamentotaxis.
Figure 1: Closed, displaced, intra-articular tibial plafond fracture left ankle.
- The tibial block is then attached with two smooth wires at 60 degree angles on each ring, twin tensioned to 130kg and attached to the
frame.
• The relative risk for postoperative complications was 2.76 times greater in
the diabetic group compared to non-diabetic control group.1
- Two smoothed wires inserted through the calcaneus at 60 degree angles and tensioned to 90kg.
- Midfoot opposing olive wires are then inserted, tensioned to 90kg and attached to the frame. The weight is then removed from the
distraction wire.
- The free floating or distal tibial ring is then positioned approximately 10mm above the ankle joint.
- Next the medial tibial pilon reduction wire: Olive wire from medial to lateral on the floating ring (the olive on the medial side of the tibia)
approximately 1-2 cm superior to the ankle joint. stabilization of the largest tibial pilon fragment, tension wire oposite end of the olive to
110kg.
- Next the medial malleolar fragment reduction wire: An olive wire is driven from distal medial at the tip of the medial malleolus to
proximal lateral through the tibia. The wire is cut flush at the olive/wire interface and buried under the skin as to reduce the fragmentThis
wire is then attached to the distal tibia ring (normally requiring post to reach the wire) and tensioned from the lateral side to 90kg.
-Next the lateral tibial pilon fragment reuction wire: An olive wire is driven from distal lateral to proximal medial through the fibula and tibia
(again the olive remains on the lateral side) approximately 1-2 cm superior to the ankle joint. The distal end of the wire is then connected
to the floating ring and tensioned to 110kg.
- The ankle joint distraction is released and proper nuts are secured.
~ Combined complication rate: 23% (Infection, metal breakage,
wounds dehiscence), 3 AMPUTATIONS.
Case Study cont.
PMH: asthma, NIDDM, PAD
Soc Hx: Previous 20 pack year smoker.
P.E: Brisk CFT to digits, significant edema and ecchymosis to right ankle. No open fracture
visualized, no tenting of the skin.
Figure 3: Immediate post-op radiographs with Orthofix TrueLok fixator in
place.
• Single stage approach using external fixation allows the patient to have more
mobility by allowing partial weight bearing starting on post-operative day one.
It allows a skin inspection to be enacted on a daily basis.
**As with any surgical technique, the individual patient must be fully evaluated
and this technique is not proposing that it be used on every pilon fracture.
Treatment Stage 1: Patient underwent closed reduction with application of posterior splint
(Figure 2).
Treatment Stage 2: Patient underwent the previous discussed surgical technique with
application of Orthofix TrueLok® external fixator (Figure 3). Anatomic alignment of tibial
plafond
Removal of external fixator at 12 weeks. Final weight bearing films at 10 months post-op
(Figure 4). Patient was non-weight bearing for 8 weeks following fixator removal and has been
in an AFO since that time.
References
1. Blotter RH, Connolly E, Wasan A, et al. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes
mellitus. Foot Ankle Int 1999;20:687–94.
2. McCormack RG, Leith JM. Ankle fractures in diabetics: complications of surgical management. J Bone Joint Surg Br 1998;80:689–92.
3. Schon LC, Easley ME, Weinfeld SB: Charcot neuroarthropathy of the foot and ankle. Clin Orthop 349:116-131, 1998.
Figure 4: Final AP and Lateral radiographs at 10 months post-op.
Chicago Foot and Ankle
Deformity Correction Center
ŧ.
Director, Chicago Foot and
Ankle Deformity Correction Center