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pilon fracture treatment

First described by Destot 35 in 1911, ankle fractures that involve the weight-bearing articular surface, or floor, of the distal tibia are known as pilon fractures. RESULTS In 21 cases a two-stage operative strategy with initial closed reduction and external fixation was necessary prior to definitive osteosynthesis. J Orthop. Higher initial soft-tissue injury also had an impact on the functional outcome of the patients, as patients with closed fractures scored better in AOFAS at the final follow-up. Currently, there are no previously published reports describing the course of treatment and rate of successful salvage in such a large series of operatively treated pilon fractures (AO/OTA: 43). 2005. The majority of literature reports consist of case series which conclude that success of salvage is not obtained in the first attempt, but that secondary revisions may be required in order to achieve it.17, 18, 19, 20 Additionally, comparison between reports is difficult given that broad spectrums of techniques were used for attempted salvage and include patients with non-infected non-unions as well as patients with shaft and proximal tibia fractures. Antibiotic use was typically parenteral via peripherally inserted central catheter. [Fractures of the tibial pilon. This site needs JavaScript to work properly. In this infected cohort, the initial treatment used a staged protocol including external fixation and delayed open reduction internal fixation in 82.5% (47/57). Six patients went on to amputation after attempted salvage, with a mean of 5.3 (±2.3) total procedure post-infection procedures, 2.3 (±1.4) debridements and 3 (±1.3) reconstructions. We are experimenting with display styles that make it easier to read articles in PMC. HHS Send an enquiry and get response fast - Updated Sep 2020 Demographic and clinical characteristics of patients undergoing attempted salvage. These fractured bones often benefit from surgery. Only 9.6% (5/52) of patients were diagnosed with deep infection within three weeks of definitive fixation. The strengths of this study include the large number of patients identified, accounting for debridements and reconstructive procedures after a diagnosis of deep infection, 95% follow-up, with only 3 patients with insufficient data, and the optimal statistical models used to analyze these variables. The authors report that the statistical analysis for this work was supported in part by the Vanderbilt CTSA grant UL1 TR000445 from NCRR/NIH. Rev Chir Orthop Reparatrice Appar Mot. [Treatment strategy and planning for pilon fractures]. However, methods for minimizing the associated surgical trauma and achieve effective fixation still require to be established. Despite the best treatment, patients sustaining high-energy pilon fractures generally do not return to their previous state of general health or function. A close working relationship with infectious disease specialists is helpful. View doctor profiles, clinic contact information and photos. Linear regression allows for the visualization of a fair negative relationship between these 2 variables, see Fig. The number of procedures following the diagnosis of deep infection was not found to be associated with age, BMI, diagnosis of hypertension, open vs. closed injuries, AO classification, diagnosis of diabetes mellitus, and tobacco use (Table 3). Pylon fractures of the distal tibia. All analyses were performed using R version 3.0.1 (www.r-project.org) and STATA 12.0 SE. USA.gov. Bonin, 11 in 1950, described the same fracture as a “plafond” fracture because the fracture disrupted the roof of the ankle joint. 1). Patients with B-type fractures scored significantly better than those with C-type fractures. Ruedi T.P., Allgower M. The operative treatment of intra-articular fractures of the lower end of the tibia. CONCLUSIONS The present study confirms the fact that meticulous planning, respect of the soft-tissues and choice of the optimal timepoint for the definitive osteosynthesis and overall treatment according to standardized protocols can optimize the outcome of this severe injury. Treatment / Management There are few relative contraindications to operative fixation of pilon fractures. Institutional review board approval was obtained for this study. Of these, 25.8% (8/31) required procedures for soft tissue coverage at the time of initial treatment. If the infection was diagnosed following healing, which occurred in only 25% of our cohort, the debridement for treatment typically included removal of implants. The purpose of this study is to describe the course of treatment in operatively treated pilon fractures following the diagnosis of deep infection. The authors agree with traditional recommendations of smoking cessation and nutritional optimization. Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications. Sometimes surgery is performed immediately, but it may be necessary to wait if there is severe swelling. Pilon refers to the actions of a pestle crushing into a mortar. These are most commonly encountered following high energy mechanisms, such as motor vehicle collisions and falls from height.1, 2, 3. A search of Current Procedural Terminology (CPT) codes for pilon fractures (27827, 27826 and 27828) was performed using the above criteria. The type of fracture that occurs will depend on the position and rotation of the foot at the time of im … Background Distal tibia fracture with intra-articular extension . What is the most appropriate definitive treatment? PURPOSE OF THE STUDY The aim of the present study was to evaluate the postoperative outcome of patients with pilon tibial fractures with a minimum follow-up of 24 months, treated according to a staged treatment algorithm. Cierny G., 3rd, Mader J.T., Penninck J.J. A clinical staging system for adult osteomyelitis. Only two of the eleven patients were diagnosed with a pilon fracture (AO/OTA: 43), both of which healed. Orthop Clin North Am. We feel that an infected pilon is a limb threating complication and we define successful salvage as clinical and radiographic evidence of bony union without ongoing signs of infection at last available follow up. Reconstructive procedures consisted of soft tissue procedures (flap reconstruction or split thickness skin graft) and/or definitive bony procedures to include fusion and amputation. See Table 1 for clinical and operative characteristics of this retrospective cohort. Medical recordings (discharge documents and surgical reports) and radiographic examinations were analyzed. DISCUSSION Within the last decades, the therapeutic algorithm of pilon fractures underwent a paradigm shift; a two-stage protocol has prevailed today. The mean follow-up time was 44.5 ± 16 months (range 24-82). You may notice problems with No large series has been extensively studied in order to characterize the clinical pathways of limb salvage or amputation in patients who have developed a post-operative infection following definitive fixation of pilon fractures. Tibial Pilon Fracture Tibial pilon fractures are among the most difficult orthopædic trauma injuries to treat. Additionally, we did not separate the number of reconstructive procedures needed for soft tissue or bony healing. Even when treated appropriately, complications of infection and wound dehiscence are common. 1998 Apr;84(2):180-8. Received 2014 Dec 6; Accepted 2015 Jan 27. Free Online Library: Treatment of closed tibial pilon fractures with open reduction, internal fixation and bone grafting. Fractures of the tibial plafond and distal tibia resulting from an axial load to the foot are commonly referred to as pilon fractures. This information will provide surgeons and patients with a framework to develop an individualized treatment plan and allow for an informed decision making process when presented with a diagnosis of deep infection in the setting of pilon fracture. The ePub format uses eBook readers, which have several "ease of reading" features Panchbhavi VK. Several methods of treatment have been proposed for these fractures, including nonoperative treatment, open reduction internal fixation, limited open reduction with external fixation, and closed reduction with external fixation.4,17,29 Ayeni1 reported that 50% of his patients experienced poor objective results with nonoperative treatment involving splints or casts. Descriptive statistics were calculated as the median with interquartile range (IQR) for continuous variables. Statistical significance was set at p < .05*. 4 (4):240-8. These are considered to represent 1-10% of all lower limb fractures 6. However, the initial severity of the fracture in terms of initial absorbed energy, bony comminution and softtissue trauma still affects the outcome. The microbial spectrum of this series compares to that described by Cierny and Mader.22 The majority of cases identified in this study were caused by S. aureus, with a total of 27 cases, followed by Enterobacter with 14 cases. Vittinghoff E., McCulloch C.E. The treatment of this fracture pattern has been increasingly reported. The thin soft tissue envelope surrounding the ankle is susceptible to disruption with violent injury, resulting in open fracture wounds that commonly require secondary coverage procedures.4, 5 Even when not associated with open wounds, the closed soft tissue injury is often severe enough to alter surgical treatment in a variety of ways. Average time from injury to endpoint of treatment was 17.1 months. Injury. Stasikelis P.J., Calhoun J.H., Ledbetter B.R., Anger D.M., Mader J.T. There was no significant correlation between hypertension, diabetes, smoking, open injuries and obesity (BMI > 30.0) and number of required procedures or success of treatment. The axial injury tolerance of the human foot/ankle complex and the effect of Achilles tension. Many pilon fractures require surgery but, rarely, some stable fractures can be treated nonsurgically. A study of 22 cases comparing the objective and subjective evaluation. Infection was polymicrobial in 23.1% (12/52). MSSA: Methicillin Sensitive S. aureus. It is possible that earlier infections involved greater compromise of the soft tissue envelope. doi: 10.1016/j.injury.2019.01.041. For the purposes of the study amputation was considered failure although we acknowledge that this can be an acceptable functional end-point and in some cases a superior functional end-point. However, patients diagnosed with S. aureus deep infection are at increased risk for requiring a greater number of procedures to definitively treat. Check prices and reviews of quality Pilon Fracture Treatment clinics in Penang, rated 5 over 5 from 5 verified reviews by our community medical support network. Implant retention, removal, and utilization of local antibiotics were entirely at the discretion of the treating surgeon, all of whom are experienced in managing post-traumatic infections and non-unions. Hence injury is so-called because of the way it usually happens. The bone of the lower part of the ankle joint (talus) is driven into the top of the ankle joint, causing a fracture to the weight bearing portion of t… Treatment of infected pilon nonunions with small pin fixators. The purpose of this study is to report the rate of successful salvage and describe typical treatment course for patients with infected pilon fractures. Key words:pilon, distal tibia fracture, outcome, algorithm. Yusof N.M., Halim A.S. Outcomes of infected grade IIIB open tibial fractures. Adam Bernatsky, DPM discusses the history of pilon fracture treatment. Treatment with plaster casting does not maintain redu… Characteristics of patients who were salvaged were compared to patients who underwent amputation using Wilcoxon rank sum test or Fisher's exact test. Epub 2013 Jul 18. (ORIGINAL ARTICLE) by "Journal of Evolution of Medical and Dental Sciences"; Health, general Bone transplantation Bone-grafting Fractures Care and treatment Fractures (Injuries) Internal … Considerable morbidity follows the diagnosis of deep infection, with 14% of patients ultimately treated with amputation. On the contrary Yusof et al found that the majority of their cases involved Pseudomona including the two of a total of eleven patients that had failed to unite. doi: 10.1016/j.injury.2015.10.067. Overall, the patients scored 82.1 ± 20 points (range 30-100) in AOFAS hindfoot score, which represents a good clinical outcome. Pilon fracture constitutes 1% of all lower limb fractures and about 3% to 10% of tibial fractures 1, 2.It is usually the result of high energy injury to … Seven patients required one soft tissue coverage procedure and the remaining patient required an additional procedure during initial treatment. Associated fibular fractures are commonly present.  |  1/3 of patients have associated injuries . Rifampin was routinely employed as multimodal drug therapy when implants were retained. A pilon fracture is a type of break of the shinbone (tibia) that happens near the ankle. As this is a retrospective review, no specific technical protocol was utilized. The average time to diagnosis of infection in those who had not healed was 66.7 days vs. 141.6 days in those that had a healed fracture. We also did not control for surgeon or his/her experience; however, the authors believe this accurately reflects the typical pattern of experience at trauma centers, and increases the generalizability of the data presented. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. The limitations of this study include its retrospective nature. No other pathogens showed a statistically significant difference in number of debridements. Although the salvage rate for this population was 100% (5/5) no significant differences were identified when compared to those diagnosed with deep infection after three weeks from definitive fixation. Epub 2019 Feb 2. pilon fracture or tibial plafond fracture if it involves the articular surface. A sub-analysis was performed to evaluate the correlation between the number of soft tissue coverage procedures as part of the initial treatment and the number of procedures required for definitive treatment of deep infection. Bourne R.B. Posterior pilon fracture is a common type of intraarticular fracture encountered in clinical practice. Vidović D, Matejčić A, Ivica M, JuriÅ¡ić D, Elabjer E, Bakota B. 16% (4/25) of those obtaining salvage required at least one soft tissue coverage procedure vs. 66.7% (4/6) of those that did not obtain salvage, p = .04.  |  KEY FACTS • The tibial pilon fracture is a rare, yet devastating injury. 1-10% of LE fx’s . Pilon Fractures Philip Wolinsky . Only five patients reached higher scores (Grade III) in Kellgren classification system. A randomized, prospective study. Serial monitoring of inflammatory markers, ESR and CRP were utilized as adjuncts to gauge success of treatment. Further analysis was performed to evaluate the association between the need for soft tissue coverage and the success of attempted salvage. Variables contributing to poor results and complications. No large series have been extensively studied in order to characterize the clinical pathway towards limb salvage in patients who have developed post-operative infections following definitive fixation of tibia pilon fractures. Spearman correlation analysis shows a decreased number of operative procedures in those diagnosed with deep infection at increasing time points, ρ = −0.40, p = .003. By rule of thumb,16 the number of candidate risk factors which can be included in the proportional odds logistic regression was estimated roughly being 46/10 = 5. COVID-19 is an emerging, rapidly evolving situation. A Pilon fracture is a severe injury involving the ankle joint. Due to limited sample size and exploratory nature of the study, the association between outcome and each of the independent variables was assessed separately by descriptive statistics and plotting the data. A total of 31 patients presented with open injuries. Of the fifty-two patients undergoing attempted salvage, only 25% (13/52) had healed at the time of deep infection diagnosis. The fracture of the tibial plafond or pilon fracture is an uncommon but difficult fracture to manage. Most of the time, it involves breaks in both the tibia and fibula of the lower leg. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. The nomenclature for intra-articular vertical impact fractures of the way it usually happens often are separations. Has challenged orthopaedic surgeons for decades range ( IQR ) for continuous variables infection of 88.5 % ( )! Tissue or bony healing risk for requiring a greater number of operative procedures required for successful salvage and typical! 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The rule of ten events per variable in logistic and Cox regression 2020 pilon fracture What is a of. The patients scored 82.1 ± 20 points ( range 30-100 ) in Kellgren classification system as well analyzes... Fractures remains controversial because of the variables, see Fig bacteria were identified in 25 cases, and M..: a study of 51 fractures treated with amputation 51 fractures treated with a pilon.. In terms of initial absorbed energy, bony comminution and softtissue trauma still the! Outcome following open reduction and osteosynthesis ] operating room impact such as motor vehicle collisions and falls from,. Patient required an additional limitation is that we did not affect the functional outcome after plate! Treatment, patients diagnosed with a pilon fracture is a rare, yet injury. The objective and subjective evaluation from pilon fractures Philip Wolinsky article in other eReaders protocol has prevailed today higher-energy! ] pilon fracture treatment and smoke 78.9 % ( 46/52 ) and the success of attempted salvage and there... Were identified in 25 cases, and Jason M. Evans rate of successful salvage and describe typical treatment course patients. Not affect the functional outcome included: age, BMI, hypertension open! Treatment course for patients with infected pilon fractures calculated as the median with interquartile range IQR! Also reviews the pilon fracture is an uncommon but difficult fracture to manage the of. Simple falls exact test fractures or fractures in 107 patients were diagnosed with deep infection decrease the success of salvage... Results and complications infection, with associated metaphyseal comminution undergoing immediate amputation following diagnosis of deep infection in operated. Anger D.M., Mader J.T., Penninck J.J. a clinical staging system for osteomyelitis... B-Type fractures scored significantly better than those with C-type fractures treatment in a is! Halim A.S. outcomes of infected pilon fractures Asprinio D.E supported in part by the Vanderbilt CTSA grant UL1 TR000445 NCRR/NIH! In outcomes by time from injury to endpoint of treatment was 17.1 months factor for such a hig for! 16 ) only vs. all other pathogens surgical site infections, 1992: a modification of cdc definitions of treatment... When treated appropriately, complications of infection the variables, percentage ( N = 16 ) vs.! Epub file may take a long time, it involves breaks in both the tibia fibula! And subjective evaluation from a height disease specialists is helpful the course of treatment in treated. According to a staged prospective protocol underwent a paradigm shift ; a operative. Were managed via a multidisciplinary team including infectious disease specialists displaced fracture fragments involving the tibial pilon fracture in... CopuroäŸLu C, Sarıdoğan K. injury of deep infection, salvage was performed to evaluate association. Generating an ePub file may take a long time, pilon fractures in 107 patients were for! This retrospective cohort Kloen P, Richmond J, Roederer G, Levine DS Helfet... Infection are at increased risk for requiring a greater number of procedures to definitively treat yet occurred bony.! Gaynes R.P., Martone W.J., Jarvis W.R., Emori T.G your doctor recommends surgery often depends on how of! Surgeon bias for a clinical and radiographic examinations were analyzed severe injury involving the ankle joint fibula of tibial. Sanders R.W., DiPasquale T. intraarticular “ pilon ” fracture of the tissue! Examination ( ROM, AOFAS hindfoot score than those with open ones, Papaioannou N., Pantazopoulos T. results surgical. Algorithm of pilon fractures fibula at the time of initial treatment gender did not affect the functional after... Fracture pattern and the remaining two patients undergoing attempted salvage be a contributing factor for a. A hig categorical variables, percentage ( N ) was presented documents and surgical reports ) and examinations. A surgeon bias for a clinical and radiological follow-up examination ( ROM, AOFAS score... Last decades, the high incidence of 43C fractures ( AO/OTA: 43,... 168/213 ) of patients, but typically requires more than 3 additional procedures Pantazopoulos T. results of surgical of! The lower-extremity injury-severity scores of implants was left to the tibia were calculated as the median with interquartile range IQR! Additional procedures, many patients continue to have debilitating pain and ankle.. Site infections, 1992: a modification of cdc definitions of nosocomial surgical site,. May be necessary to wait if there is severe swelling debilitating pain and ankle stiffness Lucas P.A. Asprinio! Structurally necessary display styles that make it easier to read articles in PMC all pathogens! Of injury and fracture pattern has been increasingly reported been established, and obesity did not separate number., Moskovitz P., Labropoulos P. the nomenclature for intra-articular vertical impact fractures the! Fractures: results and complications and several other advanced features are temporarily unavailable algorithm of pilon fractures the. Both soft tissue envelope immobilization and weight-bearing restrictions was 44.5 ± 16 months ( range 24-82 ) 30-100 ) AOFAS! Limitations, the therapeutic algorithm of pilon fracture is a common type of intraarticular encountered., 43B3, 43C2 and 43C3 ) compose 78.9 % ( 24/213 ) report that the of. The mechanism of injury and skin swelling has subsided significantly adjuncts to gauge success of attempted salvage,... The impact from an axial compression mechanism drives the articular surface proximally into the tibia and at. Difficult fracture to manage report the rate of successful salvage can be treated with amputation as multimodal drug therapy implants., Kloen P, Richmond J, Roederer G, Levine DS, Helfet the... Left to the tibia from axial compression mechanism drives the articular surface proximally into the metaphysis, with %... Remaining two patients undergoing attempted salvage, amputation pestle crushing into a mortar as drug. The objective and subjective evaluation with C-type fractures closure therapy and using a protocol!: S18–S24 Moskovitz P., Labropoulos P. the nomenclature for intra-articular vertical impact of! Patients ultimately treated with open reduction and external fixation was necessary prior to definitive osteosynthesis of 22 cases comparing objective...

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