SLR - February 2015 - Rikhil Patel
Reference: Kiner DW, Johnson MD, Nowotarski PJ. PPrimary Bladed Plate Arthrodesis for Unreconstructable Distal Tibia Fractures. Techniques in Foot & Ankle Surgery, Volume 12, Number 4, December 2013.Scientific Literature Review
Reviewed By: Rikhil Patel, DPM
Residency Program: Phoenixville Hospital
Podiatric Relevance: Distal tibial fractures present a difficult task of surgical intervention due to their high complication rate and extent of injury to the joint surface and surrounding soft tissue. The majority of cases require an external fixture be applied initially in order to allow soft tissue injury and edema to recover. Subsequent open procedures follow to reconstruct articular surfaces and reduce fractures by internal fixation. These fracture may still lead to post traumatic arthritis, pain, and disability. Factors such as prolonged soft tissue healing and complex articular fracture patterns make arthrodesis of the ankle a viable option. The authors of this study provide a possible “one and done” procedure by introducing a primary arthrodesis earlier in the patient’s treatment course in order to lessen the likelihood of post operative complications.
Methods: A retrospective analysis was performed of 12 patients from January 2002 to June 2011. All patients with pilon fractures in the authors’ cohort were initially reduced using pin-to-bar external fixation within the first 24 hours of presentation with the forefoot fixated in a neutral position to avoid equinus contracture. If the patient had a concurrent stable transverse fracture of the fibula, an IM rod was placed within the fibula. A CT scan was then performed to assess the patient's articular surface of the ankle and severity of injury. The patients were placed on bedrest with the affected foot to overhang the bed surface.
When the time came for primary arthrodesis, the existing external fixture was utilized to position the foot and ankle. Positioning was achieved with the patient supine and then rechecked once the patient was turned to a prone position. The posterior illiac crest and/or femur was also prepped in anticipation for graft donor site if needed. Incision was made posteriorly and the distal attachment of the FHL to the fibula was released and taken medially. Once adequate exposure was obtained, all ankle joint cartilage was denuded. Next, a guide pin for the cannulated blade plate was inserted. Bone harvesting was performed and all patients in this study were grafted to fill any bony voids. The holes in the blade plate guide were then subsequently drilled as it is centered axially on the distal tibia. The blade was then inserted over the guide wire and the handle of the guide was used to make adjustments under fluoroscopy. The first screw was placed into the most distal hole of the plate posterior and was aimed at the distal tip of the horizontal portion of the blade plate. The external fixator was then loosened to allow for compression with placement of the subsequent screws. Compression was achieved either by eccentric drilling or by an external tensioning device. The patient’s ankle was then splinted and then kept NWB for three months.
Results: The twelve patients in the study were followed and outcome measures were assessed using the short form-36 Foot Function Index (SF-36, FFI) and the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. The average age of the nine males and three females was 37.8 years old. All fractures were AO C3 fractures with seven being open fractures. Mean time from injury to definitive blade plate fusion was 66.25 days. Mean time from injury to weight bearing was 4.1 months. Mean AOFAS hindfoot score after 10 month follow-up was 57.3, mean FFI was 61.7 with SF-36 scores of 27.9 and 44.7 respectively for physical and mental components. Twenty five percent of the patents required acute surgical interventions due to infection, nonunion, or broken plate.
Conclusion: Primary fusion may be the most beneficial option to provide the patient with a functional limb after a pilon fracture. The literature shows a 55 percent deep infection rate, 6 percent osteomyelitis, and overall 55 percent complication rate with early ORIF. The authors conclude, after external fixation, the introduction of a fusion blade plate may allow for better restoration of bony anatomy. The blade plate procedure allows for the STJ to be spared and in this study allowed 75 percent of the cohort one definitive surgery after initial external fixation.