Crystal L. Ramanujam, John J. Stapleton, Scott E. Sexton
Revisional Surgery of Pilon Fractures
Introduction
Indications and Contraindications
Preoperative Considerations
Clinical Cases
Case 1
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Revisional Surgery of Pilon Fractures
Pilon fractures are complex injuries involving the articular weight-bearing surface of the distal tibia, also known as the tibial plafond, and they constitute 1%–10% of all lower extremity fractures with many presenting as open fractures.1 These fractures typically have 2 mechanisms of injury: (1) high-energy axial load injuries of the distal tibial plafond which are associated with a higher incidence of intra-articular and soft tissue injury, and (2) low-energy rotational pilon fractures which are frequently associated with less articular injury and chondral impaction.2
Open reduction with internal fixation, typically plates and screws, to restore the articular surface requires extensive incisions and soft tissue dissection but can lead to increased infection rates and soft tissue complications. To reduce complications, minimally invasive plate osteosynthesis techniques have been utilized to indirectly reduce the fractures and percutaneously apply locking compression plates for fixation.3 Combined with independent screw fixation for simple articular fractures, intramedullary nail (IMN) placement has been used to restore the overall alignment of the distal tibia reliably without adversely affecting the soft tissues in the zone of injury.4 Better outcomes have been reported via treatment through staged procedures consisting of acute spanning external fixation to allow for the soft tissue insult to resolve followed by delayed definitive open reduction and internal fixation.1,5 Acute ankle arthrodesis is a viable option in the setting of severe nonreconstructable comminution, osteopenia, peripheral neuropathy, and arthritis in patients with poor healing potential.1
Overall outcomes of pilon fractures depend on the severity of the trauma, quality of the surgical reduction, and stability of the fixation. Active smoking status at the time of definitive fixation of the pilon fracture has been found to increase the risk of complications due to microvascular pathology.6 Similar to ankle fractures in diabetic patients, pilon fractures in diabetic patients have higher complication rates than those treated in nondiabetic patients, particularly infection and nonunion/delayed union requiring reoperation.7,8 Since pilon fractures often present with a significant degree of periarticular comminution, metaphyseal bone loss, and substantial injury to the soft tissues surrounding the ankle, postoperative complications and sequela may require revisional surgery. Ankle arthrodesis has become a frequent option for revisional surgery in the setting of complicated pilon fractures.
The goals for revisional surgical treatment of pilon fractures are to restore anatomical alignment with a healthy soft tissue envelope. Indications for surgical management include but are not limited to wound-healing complications, hardware complications, malunion, nonunion, delayed union, soft tissue and/or bone infection not amenable to conservative treatment with use of antibiotic therapy and local wound care, and posttraumatic arthritis. Contraindications to revisional surgery for pilon fractures may include the presence of medical comorbidities that cannot be optimized safely for surgical intervention, nonreconstructable peripheral arterial disease, poor bone stock that cannot accommodate surgical reconstruction, severe patient noncompliance, patient’s refusal of reoperation, and those cases in which a proximal amputation may be the best option for management. For diabetic patients with severe peripheral neuropathy, uncontrolled hyperglycemia, peripheral arterial disease, and multiple comorbidities, lower extremity bracing may be considered for asymptomatic, plantigrade, and stable nonunions as opposed to revisional surgery.
A thorough history and clinical examination is critical for planning to determine any medical comorbidities which may need to be optimized preoperatively and to investigate any prior surgical intervention(s) which may contribute to the revisional surgical approach. Standard blood tests for laboratory analysis including glycosylated hemoglobin should be obtained. Local factors to consider include extent of bone loss, existing bone stock, severity of compromised soft-tissue envelope, presence of infection, location and type of retained hardware, residual deformity, and peripheral neuropathy.
Staged reconstructions are recommended especially in cases of chronic infection/osteomyelitis. For ankle arthrodesis, to achieve successful fusion in the setting of local infection, radical debridement(s), removal of hardware, and use of local antibiotic-impregnated cement beads/spacers should be considered. For definitive arthrodesis, adequate bone contact, possible bone grafting, stable fixation, and minimal compromise of the marginal blood supply are necessary. It is important to avoid introducing foreign bodies at the site of infection and therefore external fixation should be highly considered. Antibiotic-coated IMN can also be considered if acute shortening and bone contact can be achieved. For soft tissue defects, negative pressure wound therapy is helpful for wound bed preparation followed by plastic surgical techniques such as skin grafting, orthobiologics, local and pedicle flaps, and muscle flaps for closure. In cases of large soft tissue loss, free tissue transfer might be necessary.
This is a patient who presented to our outpatient clinic with a history of a distal tibia pilon fracture and broken hardware at approximately 8 months since the time of the index procedure. Patient’s laboratory analysis was within normal limits and without any indications of a localized infection, and his radiographs were consisted of a distal tibia metaphyseal septic nonunion (Figure 26.1A and B). Patient’s clinical examination did not reveal any clinical signs of infection and all incisions were healed appropriately. Patient underwent revisional surgery that consisted of 1-stage removal of the tibia hardware, repair of the tibia nonunion augmented with autogenous bone graft harvested from the proximal tibia, and revisional open reduction and internal fixation with dual plating of the pilon fracture. The fibula hardware was left intact at the time of revisional surgery. The patient was kept non–weight bearing for 3 months and then progressed to weight-bearing status as tolerated in a high-tide orthotic walking boot for an additional 4 weeks. Patient returned to normal shoe gear and activities at 4 months postoperatively since the revisional surgery (Figure 26.1C and D).