1. Figure 4: Final AP and Lateral radiographs at 10 months post-op.
Edgardo Rodriguez, DPMŧ; Michael Bowen, DPM; Alex Cherkashin, MD; Mikhail Samchukov, MD; Stephen Frania, DPM; Paul Dayton, DPM; Gregorio Caban, DPM; Patrick Nelson, DPM
Ilizarov Method of External Fixation for the management of Pilon and Distal Tibial Fractures in the Compromised Diabetic Patient
Statement of Purpose
The purpose of this poster is to provide the foot and ankle surgeon with the surgical technique for reducing the pilon and distal tibial fractures in the compromised patient or in the face of soft tissue compromise using Ilizarov method of external fixation.
Results
According the senior author (ER), the following data has been compiled retrospectively for both pilon fractures as well as distal tibial fractures using this surgical technique:
Pilon Fractures (n= 37, mean age 57, m= 17;f= 40)
~ Mean follow up 42 month, AOFAS score
~ Combined complication rate: 13% (Infection, metal breakage, wounds dehiscence), 2 AMPUTATIONS.
Distal Tibial Fractures (n= 22, mean age 62, m= 22;f= 40)
~ Mean follow-up 28 months, AOFAS score
~ Combined complication rate: 23% (Infection, metal breakage, wounds dehiscence), 3 AMPUTATIONS.
Case Study
55-year-old female presented one hour after being involved in an MVA. Radiographs were obtained of the left ankle (Figure 1). There was an intra-articular fracture of the tibial plafond with impaction of the articular cartilage as well as comminution of the tibial dia-metaphyseal region (OTA classification 43-C1).
Case Study cont.
PMH: asthma, NIDDM, PAD
Soc Hx: Previous 20 pack year smoker.
P.E: Brisk CFT to digits, significant edema and ecchymosis to right ankle. No open fracture visualized, no tenting of the skin.
Treatment Stage 1: Patient underwent closed reduction with application of posterior splint (Figure 2).
Treatment Stage 2: Patient underwent the previous discussed surgical technique with application of Orthofix TrueLok® external fixator (Figure 3). Anatomic alignment of tibial plafond
Removal of external fixator at 12 weeks. Final weight bearing films at 10 months post-op (Figure 4). Patient was non-weight bearing for 8 weeks following fixator removal and has been in an AFO since that time.
Literature Review
Blotter et al: retrospective review of 21 patients who had diabetes and 46 randomly selected patients who did not have diabetes. Complication rate of patients with diabetes was 43% undergoing ORIF ankle fracture vs 16% complication rate without diabetes. Complications were more severe in diabetic population, including BKA.
McCormack and Leith: review of 26 diabetic patients with displaced malleolar fractures and a cohort group, overall complication rate of 42% in the diabetic patients compared with no complications in the cohort group treated non-invasively. Six of the 19 patients treated surgically developed a deep infection, and 2 patients eventually required an amputation at an unspecified level.
Schon et al: series of 13 pre-Charcot displaced ankle fractures. Four ankles were treated by closed reduction and casting or bracing (minimum, 3 m). Nine ankles underwent ORIF. The four ankles treated nonoperatively and all progressed to significant valgus deformity, non union, or both.
In comparison, nine ankles were treated by ORIF and period of various NWB protocols. Shorter NWB post-op produced one infected non-union, and the longer NWB protocol produced only one displacement that required TTC fusion.
Figure 2: Intra-op pictures of ligamentotaxis via distraction and final frame application.
Analysis and Discussion
Traditional approaches to fixation for Pilon and Distal tibial involve large ancillary incisions putting the already fragile soft tissue envelope at even more risk of complications.
The use of circular external fixation alone in a single staged procedure might help to decrease the risk of morbidity and even mortality for these patients as shown in the data presented by the senior author (13% complication rate for pilon fractures).
The relative risk for postoperative complications was 2.76 times greater in the diabetic group compared to non-diabetic control group.1
Single stage approach using external fixation allows the patient to have more mobility by allowing partial weight bearing starting on post-operative day one. It allows a skin inspection to be enacted on a daily basis.
**As with any surgical technique, the individual patient must be fully evaluated and this technique is not proposing that it be used on every pilon fracture.
Technique Guide
Materials:
Tibial block consisting of (2 full rings, and 4 threaded rods with necessary nuts and bolts), distal tibial ring, foot plate with half ring attached to the distal aspect.
Both smooth and olive wires
25lb weight.
Surgical Technique:
Patient supine, prepped and draped up past the knee. (Popliteal block pre-op for post-op analgesia)
Smooth wire is driven lateral to medial across the inferior aspect of the calcaneus and 25lb weight attached for ligamentotaxis.
The tibial block is then attached with two smooth wires at 60 degree angles on each ring, twin tensioned to 130kg and attached to the frame.
Two smoothed wires inserted through the calcaneus at 60 degree angles and tensioned to 90kg.
Midfoot opposing olive wires are then inserted, tensioned to 90kg and attached to the frame. The weight is then removed from the distraction wire.
The free floating or distal tibial ring is then positioned approximately 10mm above the ankle joint.
Next the medial tibial pilon reduction wire: Olive wire from medial to lateral on the floating ring (the olive on the medial side of the tibia) approximately 1-2 cm superior to the ankle joint. stabilization of the largest tibial pilon fragment, tension wire oposite end of the olive to 110kg.
Next the medial malleolar fragment reduction wire: An olive wire is driven from distal medial at the tip of the medial malleolus to proximal lateral through the tibia. The wire is cut flush at the olive/wire interface and buried under the skin as to reduce the fragmentThis wire is then attached to the distal tibia ring (normally requiring post to reach the wire) and tensioned from the lateral side to 90kg.
Next the lateral tibial pilon fragment reuction wire: An olive wire is driven from distal lateral to proximal medial through the fibula and tibia (again the olive remains on the lateral side) approximately 1-2 cm superior to the ankle joint. The distal end of the wire is then connected to the floating ring and tensioned to 110kg.
The ankle joint distraction is released and proper nuts are secured.
Figure 1: Closed, displaced, intra-articular tibial plafond fracture left ankle.
Figure 3: Immediate post-op radiographs with Orthofix TrueLok fixator in place.
References
1. Blotter RH, Connolly E, Wasan A, et al. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999;20:687–94.
2. McCormack RG, Leith JM. Ankle fractures in diabetics: complications of surgical management. J Bone Joint Surg Br 1998;80:689–92.
3. Schon LC, Easley ME, Weinfeld SB: Charcot neuroarthropathy of the foot and ankle. Clin Orthop 349: , 1998.
Figure 4: Final AP and Lateral radiographs at 10 months post-op.
Chicago Foot and Ankle
Deformity Correction Center
ŧ. Director, Chicago Foot and Ankle Deformity Correction Center