SLR - June 2013 - Trever Martin
Reference: Boraiah S, Kemp TJ, Erwteman A, Lucas PA, Asprinio DE. Outcome Following Open Reduction and Internal Fixation of Open Pilon Fractures. J Bone Joint Surg Am. 2010;92: 346-52.
Scientific Literature Review
Reviewed by: Trever Martin, DPM
Residency Program: North Colorado Medical Center Podiatric Medicine and Surgery Residency
Podiatric Relevance: Multiple treatment options exist for open pilon fractures of the distal tibia. Recovery from this injury not only requires anatomic reduction of bony fragments, but also adequate repair of damaged soft tissue. This study focuses on minimizing soft-tissue complications by using a staged protocol which also allows optimal fracture reduction. These fractures often occur as the result of a high energy mechanism, which leads to both osseous and soft-tissue injury that must be addressed.
Methods: Sixty-eight patients presenting with an open pilon fracture were identified from a prospectively maintained database of 186 consecutive patients. Fifty-nine of the sixty-eight patients, with an average age of forty-seven years, were followed for an average of thirty-four months and formed the study cohort. Within this group, there were two grade-I, three grade-II, thirty-seven grade-IIIA, and seventeen grade-IIIB open injuries. Clinical and radiographic outcomes were assessed by individuals not involved in the treatment of the patients. Functional outcome was assessed with use of the modified Mazur scoring system
Results: Fifty-two of the fifty-nine fractures healed. Six fractures had bone-grafting, and each progressed uneventfully to union. One patient required an amputation following a failed free tissue transfer. Two patients (3 percent) were deemed to have a deep wound infection and were successfully treated with a six-week course of culture-specific intravenous antibiotics. Three patients (5 percent) had a superficial wound infection that was successfully treated with oral antibiotics. The average physical component score on the Short Form-36 Version 2.0 was 40.3 points. The average mental component score (54.9 points) was better than the age-matched norm in the majority of the age groups. The average modified Mazur score was 44.8 of a possible 100, with most patients scoring in the poor range.
Conclusions: Open reduction and internal fixation of open pilon fractures was accomplished with an acceptable outcome and a low prevalence of soft-tissue complications. We believe these results can be reproduced through routine use of an individualized treatment algorithm including the use of staged procedures, meticulous soft-tissue management, liberal use of temporizing external fixation, and a patient-specific approach to fixation and soft-tissue coverage.