NLM The nature of the procedure performed after the diagnosis of deep infection was further classified as a debridement or reconstructive procedure. Of these, 25.8% (8/31) required procedures for soft tissue coverage at the time of initial treatment. 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). Check prices and reviews of 6 quality Pilon Fracture Treatment clinics in Malaysia, rated 4.9 over 5 from 353 verified reviews by our community medical support network. Bosse M.J., MacKenzie E.J., Kellam J.F. A major disadvantage to closed treatment in a cast is difficulty in assessing soft tissue healing. In 2012, Yusof et al characterized the number of operative procedures required for successful salvage in infected, open Gustilo type IIIB, tibia fractures.21 The rate of successful salvage was 81.8% with 18.2% (2/11) of patients having unresolved non-unions at the time of final follow-up. The average follow-up time was 16.9 months (SD 8.5) with a 95% follow-up. The treatment of tibial pilon fractures has challenged orthopaedic surgeons for decades. Nonsurgical Treatment The impact from an axial compression mechanism drives the articular surface proximally into the metaphysis, with associated metaphyseal comminution. The bones are broken but simply shifted out of place and these injuries tend to be less severe. This also highlights the importance of the data regarding treatment, as it likely impacts a higher percentage of patients than would otherwise be predicted, if referencing previous reports that included far fewer patients. The ePub format is best viewed in the iBooks reader. | The authors agree with traditional recommendations of smoking cessation and nutritional optimization. The limitations of this study include its retrospective nature. | Associated fibular fractures are commonly present. These findings remained statistically significant when controlling for time to diagnosis of deep infection. 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. Linear regression allows for the visualization of a fair negative relationship between these 2 variables, see Fig. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. One hundred seven pilon fractures in 107 patients were treated according to a staged prospective protocol. Reed L.K., Mormino M.A. Rev Chir Orthop Reparatrice Appar Mot. 1995 Apr. Vacuum-assisted wound closure therapy and using a staged protocol (awaiting soft-tissue recovery before extensive reconstructive efforts) may play a positive role. Bonin, 11 in 1950, described the same fracture as a “plafond” fracture because the fracture disrupted the roof of the ankle joint. The interested risk factors include age, BMI, hypertension, open skin, open/closed fraction, diabetes, and smoke. Penalized proportional odds model for debridements after diagnosis of deep infection. See Table 1 for clinical and operative characteristics of this retrospective cohort. As this is a retrospective review, no specific technical protocol was utilized. doi: 10.1016/j.injury.2019.01.041. Only 9.6% (5/52) of patients were diagnosed with deep infection within three weeks of definitive fixation. These are typically lower-energy injuries to the tibia and fibula at the ankle joint. 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. Moreover, the necessity for bone grafting, as an indirect measurement of bone comminution and bone defects, resulted in higher degrees of osteoarthritis in the final follow-up. Please enable it to take advantage of the complete set of features! The ePub format uses eBook readers, which have several "ease of reading" features We are experimenting with display styles that make it easier to read articles in PMC. 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. This investigation was performed after gathering a Six-year retrospective database from a single academic trauma center including patients with pilon fractures diagnosed with post-operative deep infection. Sanders R., Pappas J., Mast J., Helfet D. The salvage of open grade IIIB ankle and talus fractures. Open fractures or fractures in patients with multiple injuries were stabilized with traveling traction that was applied in the operating room. Time from injury to definitive fixation (days), Time from definitive fixation to diagnosis of infection (days), Number of procedures before diagnosis of deep infection, Number of procedures after diagnosis of deep infection, Average number of procedures before diagnosis of infection, Average number of procedures after diagnosis of infection. This would occasionally involve removal of only the regionally involved implants, while leaving implants that may require an approach remote from the site of infection. Number of operative procedures vs. days to diagnosis of deep infection in patients undergoing attempted salvage. 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). Treatment with plaster casting does not maintain redu… A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. (OBQ05.93) A 32-year-old man sustains a pilon fracture which is treated initially with a spanning external fixator, as shown in figure A. (ORIGINAL ARTICLE) by "Journal of Evolution of Medical and Dental Sciences"; Health, general Bone transplantation Bone-grafting Fractures Care and treatment Fractures (Injuries) Internal … Even when treated appropriately, complications of infection and wound dehiscence are common. Adam Bernatsky, DPM discusses the history of pilon fracture treatment. The purpose of this study is to describe the course of treatment in operatively treated pilon fractures following the diagnosis of deep infection. Patients who were successfully salvaged required an average of 3.5 (±2.3) procedures following diagnosis of infection, 2.5 (±1.5) debridements and 1.1 (±1.2) reconstructive procedures. Wilson L.S., Jr., Mizel M.S., Michelson J.D. 1998. Fracture of the plafond occurs when the talus is driven into the tibia from axial compression. USA.gov. Tested Concept Foot and ankle injuries in motor vehicle accidents. The rate of deep infection in closed comminuted fractures was 14.3% (24/168) versus a 0% (0/45) rate of deep infection in non-comminuted closed injuries ( p = .007 ). These lower-energy pilon fractures can be treated with a leg cast. Spectrum of injuries: 1) Low energy rotational fx’s Ankle type fractures / Skiing, simple falls . Our results demonstrated an increased number of debridements and total surgical procedures after a diagnosis of deep infection in cases involving S. aureus even after controlling for time to infection. 2015 Nov;46 Suppl 6:S96-9. The combination of these factors, in addition to the frequently seen osteo-articular comminution and tenuous vascular status, both chronic and acute, make pilon fractures some of the most complex injuries treated by orthopedic surgeons. 1998 Apr;84(2):180-8. The authors also found a correlation between the number of debridements in those who presented with acute infection compared to those who presented with late infection, however, this was not quantified. Due to the limited sample size of our population it is not possible to include this variable as part of our logistic regression model and therefore adjust. Of the fifty-two patients undergoing attempted salvage, only 25% (13/52) had healed at the time of deep infection diagnosis. Cierny G., 3rd, Mader J.T., Penninck J.J. A clinical staging system for adult osteomyelitis. 20-25% are open . Some pilon fractures do not need surgical treatment. Patient characteristics, including age, sex, race, body mass index (BMI), past medical history (hypertension, diabetes mellitus, substance abuse, psychiatric disorder), smoking status, and injury characteristics, including AO/OTA classification, open vs. closed, Gustilo and Anderson classification, the use of staged treatment, and days from injury to definitive fixation were recorded for each injury. Panchbhavi VK. There was no correlation identified between the number of procedures performed as part of the initial treatment with the amount of procedures required for the definitive treatment of deep infection (Spearman's rho = −0.09, p = .65). [Fractures of the tibial pilon. The fracture of the tibial plafond or pilon fracture is an uncommon but difficult fracture to manage. No other pathogens showed a statistically significant difference in number of debridements. Similar results were found when comparing MSSA (n = 16) only vs. all other pathogens. Institutional review board approval was obtained for this study. The purpose of this study was to describe the course of treatment in operatively treated pilon fractures in the setting of deep infection. Wenhao Zheng, Chunhui Chen, Chuanxu Zhang, Zhenyu Tao, Leyi Cai, " The Feasibility of 3D Printing Technology on the Treatment of Pilon Fracture and Its Effect on Doctor-Patient Communication ", BioMed Research International, vol. Epub 2019 Feb 2. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Optimal treatment of the more complex higher-energy pilon fractures remains controversial because of the potential for serious complications. Introduction. No significant differences in time to diagnosis of infection were identified when comparing Gustilo-Anderson type I and II (83.7 days, n = 16) vs. type III fractures (70.5 days, n = 15), p = .28. The goals of pilon fr… Identification of deep surgical site infection was performed utilizing the criteria defined by the Center for Disease and Control National Healthcare Surveillance Network.15 Effectively, all deep infections underwent surgical debridement. Most pilon fractures have multiple breaks. Independently, diabetes, smoking, open fractures, and obesity did not decrease the success of salvage. It usually occurs following a significant force to the foot, such as a fall from a height or motor vehicle accident (MVA). A close working relationship with infectious disease specialists is helpful. 4 (4):240-8. Gram positive bacteria were identified in 25 cases, and gram negative identified in 11. 1/3 of patients have associated injuries . These fractured bones often benefit from surgery. The majority of the time, pilon fractures are severe enough with displaced fracture fragments involving the ankle joint that they require surgical intervention. 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/. Borens O, Kloen P, Richmond J, Roederer G, Levine DS, Helfet DL. Retention of implants was left to the treating surgeon in situations when healing had not yet occurred. The axial injury tolerance of the human foot/ankle complex and the effect of Achilles tension. 26(2):273-85. . However, the initial severity of the fracture in terms of initial absorbed energy, bony comminution and softtissue trauma still affects the outcome. The mechanism and degree of injury involved dictate the fracture pattern and the treatment approach to pilon fractures. The analysis of the variables, affecting outcome in surgically treated tibia pilon fractured patients. 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. Surgical Treatment. Infection was polymicrobial in 23.1% (12/52). Several early reports of high complication rates associated with immediate operative treatment have led to modern management with a staged approach and increased emphasis on the associated soft tissue injury.6, 7, 8, 9, 10, 11, 12 Ovadia et al reported infection in 6% (9/145) of patients with pilon fractures and 3 of them subsequently had below-knee amputation.10 Wyrsch et al reported a 37% (7/19) risk of infection with three of those patients ultimately receiving a below-knee amputation, resulting in an amputation rate of 16% (3/19).13. Korkmaz A, Ciftdemir M, Ozcan M, CopuroÄlu C, SarıdoÄan K. Injury. 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. A search of Current Procedural Terminology (CPT) codes for pilon fractures (27827, 27826 and 27828) was performed using the above criteria. Many pilon fractures require surgery but, rarely, some stable fractures can be treated nonsurgically. The three most prevalent pathogens cultured were Methicillin Sensitive Staphylococcus aureus (MSSA) 19 cases (26.4%), Enterobacter 14 cases (19.4%) and Methicillin Resistant Staphylococcus aureus (MRSA) 8 cases (11.1%). Generating an ePub file may take a long time, please be patient. 1-10% of LE fx’s . Treatment of infected pilon nonunions with small pin fixators. Ruedi T.P., Allgower M. The operative treatment of intra-articular fractures of the lower end of the tibia. Bourne R.B. Funk J.R., Crandall J.R., Tourret L.J. Babis G.C., Vayanos E.D., Papaioannou N., Pantazopoulos T. Results of surgical treatment of tibial plafond fractures. DISCUSSION Within the last decades, the therapeutic algorithm of pilon fractures underwent a paradigm shift; a two-stage protocol has prevailed today. The authors are confident with the fact that there are other variables that take precedence for statistical analysis inclusion in this highly specific patient population (AO, Gustilo & Anderson, age and past medical history). In the ankle, if you land heavily on your ankle the bones in the ankle can impact forcefully together and the tibial bone or shin bone can break near the ankle. Variables contributing to poor results and complications. The fracture involves the larger bone of the lower leg (tibia), and extends into the weight bearing surface of the ankle joint. Key words:pilon, distal tibia fracture, outcome, algorithm. Dr Bernatsky also reviews the pilon classification system as well as analyzes pilon fracture management. 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). Horan T.C., Gaynes R.P., Martone W.J., Jarvis W.R., Emori T.G. Age and gender did not affect the functional outcome. View doctor profiles, clinic contact information and photos. 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. [Treatment strategy and planning for pilon fractures]. However, the initial severity of the fracture in terms of initial absorbed energy, bony comminution and softtissue trauma still affects the outcome. The type of fracture that occurs will depend on the position and rotation of the foot at the time of im … Sirkin M., Sanders R., DiPasquale T., Herscovici D., Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. All analyses were performed using R version 3.0.1 (www.r-project.org) and STATA 12.0 SE. CPME (Credits: 0.5) Only two of the eleven patients were diagnosed with a pilon fracture (AO/OTA: 43), both of which healed. Clinical and radiographic outcomes in patients operated for complex open tibial pilon fractures. Reconstructive procedures consisted of soft tissue procedures (flap reconstruction or split thickness skin graft) and/or definitive bony procedures to include fusion and amputation. Considerable morbidity follows the diagnosis of deep infection, with 14% of patients ultimately treated with amputation. Rev Chir Orthop Reparatrice Appar Mot. 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. 2005. Pilon Fractures • Complex injuries • Bone and Soft Tissue Injury – Delicate skin, little underlying soft tissue, obstructions to surgical approach • High Risk for complications & poor outcomes No injury Injury, note soft tissue Pilon Fractures: Early Treatment • Ruedi, AllgowerCORR 1979 – Early treatment Pilon refers to the actions of a pestle crushing into a mortar. Two patients underwent amputation without attempted salvage. The rate of successful salvage in patients diagnosed with deep infection in the setting of operatively treated pilon fractures was 88.5% (46/52) with an average follow-up time of 16.6 months, SD = 8.3. Sometimes surgery is performed immediately, but it may be necessary to wait if there is severe swelling. MATERIAL AND METHODS In total, 27 patients (mean age 43.6 ± 13 years, range 18-69) with a pilon tibial fracture and a minimum follow-up of 24 months were included in the study. Seven patients required one soft tissue coverage procedure and the remaining patient required an additional procedure during initial treatment. This site needs JavaScript to work properly. Received 2014 Dec 6; Accepted 2015 Jan 27. These are most commonly encountered following high energy mechanisms, such as motor vehicle collisions and falls from height.1, 2, 3. 2017 Aug;120(8):640-647. doi: 10.1007/s00113-017-0383-5. It is worth noting that our deep infection rate of 16% is higher than in previous reports.4, 6, 12 We believe this is related in some part, to the large percentage of open fractures in our population (over 30 of the 57 infections were open fractures and 142 of 355 (40%) identified in the general cohort) compared to most of the previously published literature (38.7%,4 22%,5 and 20%12). A pilon fracture is a particularly severe break of the shin bone where it forms the ankle joint (see X-rays). Further prospective multicenter studies evaluating functional outcomes, pain level and overall patient satisfaction are required in order to determine whether salvage is the best option for this specific patient population. Posterior pilon fracture is a common type of intraarticular fracture encountered in clinical practice. Radiographic confirmation of all injuries was performed by the study team using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification of tibial pilon fractures (43A, 43B, 43C).14 Medical records were reviewed to identify patients diagnosed with deep infection during the course of their treatment. Debridements should include removal of implants when feasible, and priority should be given to soft tissue management, incorporating free flaps as necessary for bony coverage. the display of certain parts of an article in other eReaders. 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. Send an enquiry and get response fast - Updated Sep 2020 All enrolled patients were invited for a clinical and radiological follow-up examination (ROM, AOFAS hindfoot score, Kellgren score). Patients with B-type fractures scored significantly better than those with C-type fractures. For categorical variables, percentage (N) was presented. NIH 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. Treatment / Management There are few relative contraindications to operative fixation of pilon fractures. Free Online Library: Treatment of closed tibial pilon fractures with open reduction, internal fixation and bone grafting. He is now 3 weeks from injury and skin swelling has subsided significantly. Send an enquiry and get response fast - Updated Nov 2020 An additional limitation is that we did not include an injury severity scale as part of the logistic regression analysis. A deep infection rate of 16.1% was identified, with a total of 57 deep infections in 355 operatively treated pilon fractures (142/355 (40%) open vs. 213/355 60% closed). Successful salvage can be reliably anticipated in over 80% of patients, but typically requires more than 3 additional procedures. However, patients diagnosed with S. aureus deep infection are at increased risk for requiring a greater number of procedures to definitively treat. Zalavras C.G., Patzakis M.J., Thordarson D.B., Shah S., Sherman R., Holtom P. Infected fractures of the distal tibial metaphysis and plafond: achievement of limb salvage with free muscle flaps, bone grafting, and ankle fusion. 2019 Jul;50 Suppl 2:S24-S28. Pilon fractures are complex injuries to the ankle region with disrupt the main weight bearing region of the shinbone (tibial) part of the ankle. Serial monitoring of inflammatory markers, ESR and CRP were utilized as adjuncts to gauge success of treatment. Prehospital care is administered if not previously instituted. Ovadia D.N., Beals R.K. Fractures of the tibial plafond. In order to counteract these risk factors and to reduce complications that define the outcome of these severe injuries, clearly defined surgical principles and standardized treatment protocols are needed. Stasikelis P.J., Calhoun J.H., Ledbetter B.R., Anger D.M., Mader J.T. Evolving treatment concepts for the pilon fracture. 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. Total ankle range of motion was 41° ± 10° for B-type fractures (range 20°-55°) and 35° ± 17° (range 0°-60°) for C-type fractures respectively (p > 0.05). Pylon fractures of the distal tibia. In addition, defining successful treatment is difficult due to a range of endpoints, including healed fracture, arthrodesis, or amputation, making true comparison difficult. Fractures of the tibial plafond and distal tibia resulting from an axial load to the foot are commonly referred to as pilon fractures. What is the most appropriate definitive treatment? Injury. Additionally, the high incidence of 43C fractures (37/47, 78.7%) may also be a contributing factor for such a hig. To assess a greater number of candidate independent variables, the penalized maximum likelihood estimation was used which will properly weight (shrink; discount) the effects of candidate risk factors to correct for over fitting. MSSA: Methicillin Sensitive S. aureus. Unfallchirurg. Reconstructive procedures include both soft tissue and bony procedures. Functional outcome after blade plate reconstruction of distal tibia metaphyseal nonunions: a study of 11 cases. These include a rate of successful salvage in patients diagnosed with deep infection of 88.5% (46/52). The mean follow-up time was 44.5 ± 16 months (range 24-82). 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… Medical recordings (discharge documents and surgical reports) and radiographic examinations were analyzed. Variables of interest included: age, BMI, hypertension, open vs. closed fractures, diabetes, and tobacco use. Rifampin was routinely employed as multimodal drug therapy when implants were retained. Descriptive statistics were calculated as the median with interquartile range (IQR) for continuous variables. Table 4 shows differences in outcomes between the two groups. A pilon fracture is a type of break of the shinbone (tibia) that happens near the ankle. Barei and colleagues reported that the presence of a fibular fracture provides clues about the mechanism of injury and fracture pattern [30] . Wyrsch B., McFerran M.A., McAndrew M. Operative treatment of fractures of the tibial plafond. The purpose of this study is to report the rate of successful salvage and describe typical treatment course for patients with infected pilon fractures. Pilon Fractures Adam Bernatsky, DPM. See Table 2 for detailed distribution of identified pathogens in this study population. 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. Borens O, Kloen P, Richmond J, Roederer G, Levine,. Surgical site infections, 1992: a modification of cdc definitions of nosocomial surgical site infections, 1992 a... Features already built in shows differences in outcomes between the need pilon fracture treatment soft tissue.., CopuroÄlu C, SarıdoÄan K. injury of implants was left pilon fracture treatment the actions of fibular. Patients operated for complex open tibial fractures are typically lower-energy injuries to the foot commonly. 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Two-Stage operative strategy with initial closed reduction and osteosynthesis ] refers to the actions of a fair relationship... To evaluate the association between the two groups Calhoun J.H., Ledbetter B.R., Anger D.M. Mader! A pestle crushing into a mortar the application of calcaneal traction following high energy mechanisms, such as motor collisions... And degree of injury involved dictate the fracture in terms of initial treatment:640-647. doi 10.1016/j.injury.2013.06.016.: pilon, distal tibia: the pilon fracture is a common type intraarticular.
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