SLR - January 2011 - Christopher J. Fatti
Reference: White et al. The Results of Early Primary Open Reduction and Internal Fixation for Treatment of OTA 43. C Type Tibial Pilon Fractures: A Cohort Study. J Orthop Trauma 2010; 24: 757-763
Scientific Literature Reviews
Reviewed by: Christopher J. Fatti, DPM
Residency Program: Yale/ DVA New England Surgical Residency Program
Podiatric Relevance:
This newly published study examines treatment protocols for high energy traumatic injuries of the ankle and distal tibia, providing evidence based medicine on an alternative technique (immediate ORIF) with associated complications for foot and ankle surgeons treating the most complicated of lower extremity fractures.
Methods:
Over a 12 year period 95 OTA (Orthopaedic Trauma Association) 43 type C pilon fractures were evaluated in a trauma level 1 center in Vancouver, British Columbia. Minimum follow up was 1 year (mean age 44). 21 were open fractures. The majority of the injuries were result of fall from height, while MVC and crush injuries were also seen. The patients were evaluated for other injuries, fractures were stabilized, and the patients proceeded to the operating room as soon as physiological conditions permitted. The strategy was immediate ORIF. A number of orthopaedic trauma surgeons or orthopaedic trainees (under direct supervision) performed all procedures. One-third tubular plates were used first most often on the fibular using a standard approach. The tibia was then addressed most often via an anteromedial or anterolateral approach based on the fracture pattern. Fractured articular segments were reduced with lag screws and anterolateral or medial bridge or buttress plates were used to stabilize the extra articular component. Most wounds were primarily closed, and open fractures were allowed to heal by secondary intention. Patients were kept non-weight bearing in plaster splints for eight to twelve weeks. Outcomes were measured primarily by presence of deep infection or wound dehiscence and secondarily by quality of fracture reduction, degree of osteoarthritis developed as evaluated radiographically by research fellow blinded of the final outcomes, and level of functionality in the affected ankle as measured by the Foot and ankle Outcome score and a patient questionnaire.
Results:
71 percent of patients underwent ORIF within 24 hours of injury and 82 percent underwent ORIF within 24 hours of admission. Six patients (6 percent) developed wound dehiscence or deep infection requiring surgical debridement within the first 40 days post operatively. This occurred in 19 percent of the open fractures and 2.7 percent of the closed fractures (both patients were diabetic). Six patients (6 percent) developed delayed or non-union requiring revision at a mean of 37 weeks after initial ORIF. This occurred in 15 percent of open fractures and 4 percent of closed fractures. 90 percent of the fractures evaluated on basis of anatomic reduction were graded as excellent. Based on the Foot and ankle outcomes scores, the level of function was better than previously reported for patients who had undergone either ORIF or external fixation of similar fractures when comparing pain, ADL score, quality of life score sport score, and symptoms score. Late follow up ( 1 year) revealed 22 percent had no evidence of arthritis, 52 percent had mild arthritis, 22 percent had moderate arthritis and 4 percent had severe arthritis.
Conclusion:
OTA type C Pilon fractures can be successfully stabilized by primary ORIF with comparable rates of infection, quality of reduction, and long term functionality outcomes to that of staged procedures.