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External FixationIn Pilon Fractures
Gillian JacksonNorth West Regional SpR Teaching
14th March 2008
•Indications•Types•How to…•Evidence
Indications“First Aid”
• Stabilise injury• Reduce soft tissue tension• Management of open wound• Analgesia• Quick
• Poly trauma• Vascular surgeons
Buy Some Time
• Allow soft tissues to settle• Further Imaging• Plan joint reconstruction/ ORIF• Order kit• Referral
• Foot and Ankle service• Trauma centre
As Definitive Treatment
• In isolation• With limited articular fixation
• Interfragmentary screws• Olive wires with frame
• +/- fibular plating • Supplement ORIF
Types
Complications
• Pin site problems• Malunion• Delayed union• Non union
How To…..
Hybrid Frame
Literature
• ORIF vs External Fixation• Spanning vs sparing• Fibular fixation• Retrospective series• Severe injuries often ex-fixed• Most studies supplement with limited
screw fixation to restore articular surface.
ORIF vs External Fixation
• Only one RCT Wyrsch 1996• 18 vs 20 patients• ORIF vs Ex-fix +limited ORIF• “Randomised surgeon” design.• No difference clinical scores at 2 years• Increased frequency/severity
complications in ORIF group.
Malunion vs Wound Problems
• Watson 2000, 107 patients. Prospective protocol
• ORIF in # with severe soft tissue - higher rates of• Non/Mal union• Severe wound complications
• Pugh 1999 60 patients• ORIF vs Spanning vs hybrid
• Ex-fixed groups increased malunion but less wound problems.
• Independent of fibular fixation or bone grafting
Fibular plating
• Williams 98• 53 monolateral ex-fix
• 22 fibula fixed,• 31 not fixed
• No difference • X-ray arthrosis• Ankle score• Complication rate
Joint spanning vs sparing
• Papadokostakis 2008 (JBJS)• Systematic review
• 15 articles 465 fractures
• Time to union 4.3 mths (both grps)• Malunion higher in spanning fixation.
• Increased plantar flexion in hybrid vs articulated
• More minor (pin site) infections in hybrids• Septic arthritis 0.6% in hybrids
Joint spanning vs sparing
• Okcu 2004 • Ilizarov vs articulated
external fixation• Retrospective 50
patients• All united• No difference functional
ankle score• Ilizarov greater ROM
• 74% vs 53% of other limb.
In Staged ORIF
• Sirkin 1999 Initial ORIF fibula + spanning Ex-fix• 56 patient series retrospective• Delayed ORIF• Minimal wound problems
• Blauth 2001• 51 patients• Primary ORIF(MIPO) vs Ex-fix vs Ex-fix and
delayed MIPO.• Delayed MIPO lowest complication rate.• Unequal numbers.
External Fixation
• Can achieve our objectives• Preserve life• Preserve leg• Straight leg• Mobile joint
• By..• Quick application• Soft tissue healing/ preservation• Articular reconstruction• Meta/diaphyseal union
• Still should be considered the first aid of choice.• Always consider in high energy/ open
injuries
• Can be your definitive treatment• With articular reconstruction.
• Move towards use in combination with delayed ORIF.