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Scientific Articles   |    
Outcome Following Open Reduction and Internal Fixation of Open Pilon Fractures
Sreevathsa Boraiah, MD1; Travis J. Kemp, MD1; Andrew Erwteman, BS1; Paul A. Lucas, PhD1; David E. Asprinio, MD1
1 Westchester Medical Center, New York Medical College, 19 Bradhurst Avenue, Suite 1300N, Hawthorne, NY 10532. E-mail address for S. Boraiah: bsreevathsa@rediffmail.com
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at New York Medical College and the Westchester Medical Center, Valhalla, New York

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Feb 01;92(2):346-352. doi: 10.2106/JBJS.H.01678
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

A variety of treatment options exist for open pilon fractures of the distal end of the tibia. In this study, we evaluated the use of a staged protocol designed to minimize the risk of soft-tissue complications and to allow for optimal reduction of the fracture.

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 and Short Form-36 Version 2.0 questionnaire, for thirty-eight patients who were followed for a minimum of two years.

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%) 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%) 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.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Sreevathsa Boraiah, MD
    Posted on March 02, 2010
    Drs. Boraiah and Asprinio respond to Dr. Kini
    Westchester Medical Center, Valhalla, New York

    We would like to thank Dr. Kini for his attention to our work. They inquire if there was any difference in the mean range of motion obtained in the primary versus the delayed internal fixation group. In our study, there were only nine patients in the primary fixation group, and any meaningful or statistically significant conclusions could not be drawn. The senior author’s current practice typically involves delayed internal fixation. The average duration between the temporary fixation and the definitive internal fixation was 11.3 days. Dr. Kini also inquires about the bone grafting procedures. Bone grafting was not performed during the index procedure in any case. Of the six patients who underwent bone grafting, five of them were planned staged procedures. In these cases, it was deemed that a staged bone grafting procedure would be necessary at a later stage. This decision was made during the definitive fixation procedure and reinforced during the follow up clinical visits. The average time between the definitive fixation and bone grafting was 25 weeks (Range 9-45 weeks).

    Sunil Gurpur Kini, MBBS, MS(Ortho), DNB(Ortho), MNAMS(Ortho), Dip SICOT
    Posted on February 01, 2010
    Outcome Following Open Reduction and Internal Fixation of Open Pilon Fractures
    Orthopaedics, Guru Teg Bahadur Hospital, University College of Medical Sciences, Delhi, India

    To The Editor;

    I read with interest the article by Boraiah et al. (1). The management of open pilon fractures has always been a widely debated subject in terms of optimal initial management, primary versus delayed fixation, and the timing of the index procedure. The major determinant to the initial fixation is the integrity of the soft tissue envelope. Open type C3 fractures have both articular and metaphyseal comminution, and bone loss, and they represent one of the most severe injury patterns possible (2).

    I would like the know the authors' opinion on the following:

    Was there any difference in the mean range of motion obtained in the primary versus delayed internal fixation group?

    What was the average time to conversion from the temporary construct to definitive fixation?

    What was the average time for bone grafting in their series? Is it not early for bone grafting to be done during the index procedure (assuming it would be within the first 2 weeks after injury)? In open tibial fractures with bone loss, delaying bone grafting at least 6 weeks until reepithelialization of the soft tissues is complete decreases infection risk and shortens bone healing time (3).

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. 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.

    2. Gardner MJ, Mehta S, Barei DP, Nork SE. Treatment protocol for open AO/OTA type C3 pilon fractures with segmental bone loss. J Orthop Trauma. 2008;22:451-7.

    3. Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am. 1991;73:1316–22.

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