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.