The anterior approaches that have been described for open reduction internal fixation of multifragmentary pilon fractures are designed to reconstruct the comminuted and impacted anterior articular ...surface onto a stable posterior column. Thus, reduction of the posterior column, particularly proper length, is critical. There are differing opinions of how best to surgically approach the posterior pilon fracture. There is also no clear indication as to the timing of both anterior and posterior reconstructions. Our objectives were (1) to develop a more midline posterior approach that might provide better visualization of the posterior aspect of the posterior column and juxtametaphyseal/diaphyseal parts of the tibia, first on the cadaver and then with patients, and (2) to use this as part of a combined posterior and anterior approach during the same anesthesia for complex tibial pilon fractures (AO/OTA 43-C) in a preliminary study of 6 patients.
Posterior pilon variant ankle fractures (PPVF) are a unique subtype of posterior malleolar fractures which have been a source of controversy and confusion in recent years. There has not been a ...thorough literature review previously written on the topic. Database searches of PubMed and Embase were conducted from inception until June 2023. The key words included “pilon variant,” “posterior pilon variant,” and “posterior pilon” fractures. Outcomes were evaluated by union time, rates of delayed union, nonunion, malunion, and complication. A total of 15 articles relevant to surgical repair of pilon variant fractures were included in the literature review. The unique mechanism of injury has been reported to involve both rotational and axial forces, leading to involvement of the posterior and medial aspects of the distal tibia. Pilon variant fractures can be suspected by several characteristics on radiographs and have a high confirmation rate via CT images. Multiple systems have been proposed to classify this fracture pattern, but there is no consensus on the ideal classification system. Surgically, direct fixation has shown better short-term clinical outcomes versus indirect fixation or no fixation. PPVF have a distinct fracture pattern involving the posterior and medial columns of the distal tibial plafond, and results from a mechanism intermediate to rotational and axial forces. These fractures are more severe than tri-malleolar fractures due to increased rates of articular impaction and incongruity. Future classification systems should focus on joint surface area and the tibial pilon column involved to avoid confusion with less severe posterior malleolar fractures.
Pilon fractures are intra-articular injuries involving the tibial plafond and have a wide range of complexity. The timing and type of fixation in these injuries is dictated by soft tissue status and ...energy imparted to the distal tibial plafond. We had a unique clinical situation in which axial loading of the talus caused severe comminution of the tibial plafond and fracture of the distal third of the fibula. Further action of these forces caused displacement of the fibular segment into dorsum of the foot along with part of the articular surface of the tibial plafond without causing any external wound. This case was challenging because displacement of the distal fibula resulted in disruption of important syndesmotic and lateral ankle ligaments. Fibular segment was without any soft tissue attachment and was reimplanted in the ankle mortise like a free fibula graft. Near normal ankle biomechanics were achieved in this case through anatomic reduction of the articular surface, reimplantation of the fibula in the ankle mortise, and repair of syndesmotic and lateral ankle ligaments. There was satisfactory clinical and radiological outcome on follow-up of more than 4 years. To our knowledge, this is the only case in Standard English literature where in the case of pilon fracture, the fibula had displaced in the foot without external wound.
To determine patient-specific and injury-specific factors that may predict infection and other adverse clinical results in the setting of tibial pilon fractures.
Retrospective chart review.
Level 1 ...academic trauma center.
Two hundred forty-eight patients who underwent operative treatment for tibial pilon fractures between 2010 and 2020.
External fixation and/or open reduction and internal fixation.
Fracture-related infection rates and specific bacteriology, risk factors associated with development of a fracture-related infection, and predictors of adverse clinical results.
Two hundred forty-eight patients were enrolled. There was an infection rate of 21%. The 3 most common pathogens cultured were methicillin-resistant Staphylococcus aureus (20.3%), Enterobacter cloacae (16.7%), and methicillin-resistant Staphylococcus aureus (15.5%). There was no significant difference in age, sex, race, body mass index, or smoking status between those who developed an infection and those who did not. Patients with diabetes mellitus ( P = 0.0001), open fractures ( P = 0.0043), and comminuted fractures (OTA/AO 43C2 and 43C3) ( P = 0.0065) were more likely to develop a fracture-related infection. The presence of a polymicrobial infection was positively associated with adverse clinical results ( P = 0.006). History of diabetes was also positively associated with adverse results ( P = 0.019).
History of diabetes and severe fractures, such as those that were open or comminuted fractures, were positively associated with developing a fracture-related infection after the operative fixation of tibial pilon fractures. History of diabetes and presence of a polymicrobial infection were independently associated with adverse clinical results.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
BackgroundPatients with psychiatric comorbidities represent a significant subset of those sustaining pilon fractures. The purpose of this study is to examine the association of psychiatric ...comorbidities (PC) in patients with pilon fractures and clinical outcomes. MethodsA multi-institution, retrospective review was conducted. Inclusion/exclusion criteria were skeletally mature patients with a tibia pilon fracture (OTA Type 43B/C) who underwent definitive fracture fixation utilizing open reduction internal fixation (ORIF) with a minimum of 24 weeks of follow-up. Patients were stratified into two groups for comparison: PC group and no PC group. ResultsThere were 103 patients with pilon fractures that met the inclusion/exclusion criteria of this study. Of these patients, 22 (21.4%) had at least one psychiatric comorbidity (PC) and 81 (78.6%) did not have psychiatric comorbidities (no PC). There was a higher percentage of female patients (PC: 59.1% vs no PC: 25.9%, p=0.0.005), smokers (PC: 40.9% vs no PC: 16.0%, p=0.02), and drug users (PC: 22.7% vs no PC: 8.6%, p=0.08) amongst PC patients. Fracture comminution (PC: 54.5% vs no PC: 32.1%, p=0.05) occurred more frequently in PC patients. The PC group had a higher incidence of weightbearing noncompliance (22.7% vs 7.5%, p=0.04) and reoperation (PC: 54.5% vs no PC: 29.6%, p=0.03). ConclusionPatients with psychiatric comorbidities represent a significant percentage of pilon fracture patients and appear to be at higher risk for postoperative complication. Risk factors that may predispose patients in the PC group include smoking/substance use, weightbearing noncompliance, and fracture comminution. Level of Evidence: III.
Objective
The incidence of posterior pilon variant fractures has been underestimated. The purpose was to study the characteristics of posteromedial (PM) and posterolateral (PL) fragments in CT ...imaging of posterior pilon variant fractures, and to provide help for clinical diagnosis and treatment.
Methods
CT imaging data of 109 cases of posterior pilon variant fractures in our hospital from January 2013 to December 2020 were retrospectively analyzed. According to Mason and Molloy classification, PM fragments were further divided into pilon subtypes and avulsed subtypes. The largest actual area of fragments in axial and sagittal were selected as the study plane, and the maximum axial lengths of
X
,
Y
and
Z
,
α
angle,
β
angle, fragment area (S1–7) and fragment area ratio (FAR1-4), interfragmentary (IF) angle, and back of tibia (BT) angle were measured.
Results
A total of 109 cases were included in this study, 61 of whom were pilon subtypes 90.16% were supination-external rotation (SER) injuries. 48 cases were avulsed subtypes 81.25% were pronation-external rotation (PER) injuries. Pilon subtypes were larger than avulsed subtypes in
X
,
Y
,
Z
,
α
2
Angle,
β
2
Angle, fragment area and ratio, and IF and BT angle (
P
< 0.05). There was no difference between
α
1
and β
1
angle (
P
> 0.05).
Conclusion
The morphology of pilon subtype was larger than that of avulsion subtype. According to fragment size, morphology, and injury mechanism, two fragments of pilon subtype should be anatomic reduction and fixation. However, the PL fragment of avulsion subtype should to be fixed, while PM fragment may only need conservative treatment.
Management of Pilon Fractures Kugach, Kelly A; Leong, Wesley Maurice; Clements, John Randolph
Clinics in podiatric medicine and surgery
41, Številka:
3
Journal Article
Recenzirano
Pilon fractures are complex injuries that can be difficult to treat and lead to severe complications if not managed appropriately. A thorough examination for polytraumatic injuries, neurovascular ...status, and skin condition should be done. A variety of approaches can be chosen based on fracture pattern, including staging, incisional approach, and no-touch technique. This article discusses various ways to manage pilon fractures.
To assess the medium-term functional and radiological outcomes, as well as injury mechanisms, fracture patterns and demographics of typical pilon fractures and pilon variant fractures treated based ...on the four-column theory in adults.
A retrospective comparative study was performed. Demographics of typical pilon and pilon variant fractures, injury mechanisms, OTA/AO classification, Rüedi-Allgöwer and the four-column classification were analyzed for the cohort. Radiographic ankle arthrosis (modified Kellgren-Lawrence 3/4), Burwell Charnley Score, and AOFAS score were also analyzed.
There were 142 pilon fractures met the inclusion and exclusion criteria for this study, of which 77(54.23%) were females and 65 (45.77%) were males, with an average of 48 (range, 18-86)years. One hundred twenty-five posterior columns fractured in 142 pilon fractures, and the posterior columns were most prone to fractures. Ninety cases of posterior pilon fractures in 142 pilon fractures were single posterior column fractures with or without medial or lateral malleolar fractures. The average age (51, range, 18-86 years) of low-energy pilon fractures was older than the average age (42, range, 19-66 years) of high-energy pilon fractures significantly. The average time (5, range, 0-17 days) from injury to definitive internal fixation of the low-energy group was shorter than the average time (9, range, 0-21 days) from injury to definitive internal fixation of the high-energy group significantly. The average of AOFAS (87, range, 56-100) of the low-energy group is higher than the average of AOFAS (82, range, 47-100) of the high-energy group significantly. There were more male patients and more die-punch or intercalary fractures in high energy groups significantly. There were more medial and lateral malleolar fractures in low-energy groups. Compared with the non-multiple column group, the multiple-column group had more Rüedi-Allgöwer type III cases, more modified Kellgren-Lawrence 3/4 cases and lower AOFAS score significantly. However, the numbers of Burwell Charnley Score type 1 and 2 cases were not significantly different between the two groups.
Kinds of pilon variants should be recognized. Outcomes of high-energy pilon fractures were worse than low-energy pilon fractures. The four-column theory can be applied to typical pilon fracture and pilon variants in adults.
Las fracturas de pilón tibial son poco comunes; sin embargo, se consideran de alta complejidad. En general, se producen por mecanismos de trauma de alta energía, como fuerzas axiales sobre el ...astrágalo, lo que provoca impacto en la tibia y su fractura. Estas fracturas están asociadas con una grave afectación de los tejidos blandos, lo que las predispone a complicaciones. Por tanto, se debe tener un manejo meticuloso de estos tejidos, lo que representa un desafío para su fijación, dado que en múltiples ocasiones dificultan su abordaje. A pesar de los avances quirúrgicos y los protocolos por etapas, así como la introducción del uso de la fijación externa provisional en el período agudo, hasta lograr un adecuado estado de los tejidos blandos, se ha reducido la tasa de infecciones y complicaciones. Sin embargo, su pronóstico continúa siendo deficiente.
Die septische Pseudarthrose einer Pilon tibiale Fraktur stellt eine schwerwiegende Komplikation dar. Nur ein konsequentes Vorgehen mit mehrfachen Eingriffen und ein langer Heilungsverlauf versprechen ...einen nachhaltigen Heilungserfolg. Im Folgenden wird ein aktuelles und praktikables Konzept zur Therapie einer septischen Pseudarthrose des Pilon tibiale vorgestellt, dass in unserer Klinik etabliert durchgeführt wird und mit dem bei konsequenter Durchführung viele dieser komplexen Patienten mit einem guten klinischen Ergebnis geheilt werden können. Die Kernpunkte des Konzeptes bilden die Pseudarthrosenresektion, das Erreichen der Infektfreiheit mittels lokaler und systemischer antiinfektiver Therapie und die befundabhängige Rekonstruktion. Abhängig vom Grad des Verlustes der Knochensubstanz beschreiben die Autoren die lokale Defektauffüllung, bei Notwendigkeit in Kombination mit erneuter osteosynthetischer Versorgung oder primärer Arthrodese. Bei langstreckigen Knochenverlusten besteht die Möglichkeiten zum Knochensegmenttransport mittels verschiedener Verfahren zur Defektfüllung oder in die sekundäre Arthrodese.
10.1016/j.fuspru.2024.02.002
Septic non-union of a tibial pilon or plafond fracture is a serious complication. Only a consistent procedure with multiple interventions and a long process promises a sustainable success. In the following, a current and practicable therapeutical concept of a septic non-union of the tibial pilon is presented, which is carried out in an established manner in our clinic and which, if carried out consistently, many of these complex patients can be healed with a good clinical result. The key points of the concept are radical bone and soft-tissue resection followed by local and systemic anti-infective therapy, and reconstruction of bone and soft tissue loss. Depending on the degree of bone loss, the authors describe local defect filling, if necessary, in combination with osteosynthetic treatment or primary arthrodesis. In the case of long-distance bone loss, there is the possibility of bone segment transport. Therefore, different techniques are presented, followed by docking-procedure or secondary arthrodesis depending on the condition of the joint.
