Sirkin, J Orthop Trauma 1999 - A Staged Protocol for Soft Tissue Management in the Treatment of Complex Pilon Fractures - Article Summary

A Staged Protocol for Soft Tissue Management in the Treatment of Complex Pilon Fractures

Sirkin, Herscovici, et al.·J Orthop Trauma·1999·415 citations·Retrospective cohort

Purpose

To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications.

Methods

Design: Retrospective.

Setting: Level 1 trauma center.

Patients:

Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C.
56 fractures were included in a retrospective analysis of a treatment protocol.
Injuries were divided into Group I, 34 closed fractures, and Group II, 22 open fractures (3 Gustilo Type 1, 6 Type II, 8 Type IIIA, and 5 Type IIIB).

The protocol consisted of immediate (within 24 hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint.
Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction.
Polytrauma patients remained hospitalized and were observed.
Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided.
Complications were defined as wound problems requiring hospitalization.
All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of 12 months.

Results

Group 1 (closed pilon): Follow-up was possible in 29 out of 30 fractures (97 percent).
Average time from external fixation to open reduction was 12.7 days.
All wounds healed.
None exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively.
17 percent (5 out of 29 patients) had partial-thickness skin necrosis.
All were treated with local wound care and oral antibiotics and healed uneventfully.
There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal.
Group II (open pilon): Follow-up was possible in 17 patients with 19 fractures (86 percent).
Average time from external fixation to formal reconstruction was 14 days (range 4 to 31 days).
By definition, all Gustilo Type IIIB fractures required flap coverage for the injury.
2 patients experienced partial-thickness wound necrosis.
These were treated with local wound care and antibiotics.
All surgical wounds healed.
There were 2 complications (10.5 percent), both deep infections.
One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection.
One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation.

Conclusions

Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.