Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Abstract

Fractures of the tibial plafond affect the weightbearing articular surface and comprise < 1% of all lower extremity fractures [1]. Patients tend to have significantly decreased quality of life with a high rate of complications, leading to poor results [8, 12]. These fractures remain a challenge for orthopaedic surgeons because they commonly are associated with wound complications, more so than other orthopaedic trauma procedures [8, 11]. To try to minimize the frequency of wound complications that had been observed with early open reduction internal fixation (ORIF), some surgeons treat these injuries with staged surgical procedures in which the first intervention involves a bridging external fixation and the second procedure involves an open approach to perform definitive internal fixation when soft tissue rest has occurred [7, 10, 12, 14]. This staged approach improved outcomes and decreased complications, and may be the most commonly used approach. However, in an attempt to decrease wound complications with higher energy injuries resulting in significant soft tissue damage, some surgeons support limited internal fixation of the articular surface through small or percutaneous incisions with application of Ilizarov or circular external fixation [4, 6]. Additionally, multiple studies [2, 3, 5, 9] show equivalent clinical and functional outcomes using circular external fixation for definitive management of tibial plafond fractures. In short, there are many ways to treat this challenging injury, and no consensus treatment algorithm has been established. To take a deeper dive into this important controversy, I am joined by two experts on the topic: Michael T. Archdeacon MD, the Peter J. Stern Professor and Chairman of the Department of Orthopaedic Surgery at the University of Cincinnati College of Medicine, and John K. Sontich MD, the Chief of Orthopaedic Trauma Surgery at University Hospitals Cleveland Medical Center. Dr. Archdeacon also serves as the Medical Director of Operative Services and Director of the Division of Musculoskeletal Traumatology at the University of Cincinnati Medical Center and Executive Board member of the Orthopaedic Trauma Association (OTA). Dr. Sontich is the former President of the Limb Lengthening Reconstruction Society and spent time learning Ilizarov techniques in Kurgan, Siberia. Joshua K. Napora MD: What are the best indications for circular external fixation in the treatment of pilon fractures, and how should other concerns—such as anticipating a possible free-flap or concomitant ipsilateral hindfoot or midfoot fractures—influence the decision? John K. Sontich MD: The best indication for definitive treatment of pilon fractures using wire ring external fixation are high-energy trauma with intraarticular extension and severe soft tissue injuries. This could include Type I-III open fractures but also closed Tscherne 2-3 injuries where the soft tissue is also compromised. The goals for treatment start with minimizing soft tissue surgical trauma, restoring the articular surface, and reducing the metaphyseal/diaphyseal junction using the struts provided by ring fixation. Although the plating techniques and approaches have improved over the past decade, using a metal plate under compromised soft tissue still risks infection and wound complications. Using ring fixation to prevent further compromise can reduce the risk of the Type IIIA to IIIB conversion. This conversion is more likely to occur when an open wound is compromised by surgical trauma, which could cause soft tissue coverage—complex flaps, in some patients. This puts the patient one anastomosis failure away from a below-knee amputation. Another good indication for ring fixation might be a patient who has a comorbid condition that results in poor wound-healing potential, such as someone with diabetes. They may have peripheral neuropathy, impaired circulation, and difficulty complying with weightbearing restrictions. The addition of the foot ring with wire fixation of the foot spans the ankle to the lower leg ring with distraction and neutral dorsiflexion. This technique protects the articular repair, stabilizes the soft tissue envelope around the ankle and can become a weightbearing frame that is particularly useful in neuropathic patients who need to mobilize but can’t maintain weightbearing restrictions. I believe that open fractures with extensive distal tibial bone loss often are best treated with bone transport and fixation of the articular surface distally. This brings in new bone and can substantially reduce the time and increase the healing potential. Patients with additional hindfoot or forefoot injuries make treatment more complicated; in those situations, limb salvage may be at stake. If the talus is fractured, I prefer ORIF and a bridging foot frame to protect the repair. If the calcaneus is fractured, I prefer percutaneous screw fixation across the subtalar joint and bridging fixation of the foot including the calcaneus to protect it. Lastly, I currently bridge all of my wire ring pilon fractures (even without foot fractures) with a foot frame in neutral dorsiflexion and slight traction across the ankle to protect the joint and prevent contractures. Michael T. Archdeacon MD: Dr. Sontich brings up some good points regarding the potential benefits of ring fixation for complex pilon fractures. In particular, the comments regarding bone loss and the ability to perform bone transport in these circumstances deserves both recognition and acknowledgement. In these scenarios, particularly in patients with peripheral vascular disease, uncontrolled diabetes, and/or peripheral neuropathy, the ring fixator is likely the best option. However, not every pilon fracture needs nor should have a ring fixator. Staged surgical reconstruction and meticulous soft tissue management have improved our ability to perform ORIF with fewer wound complications and infections, even in the patient with an open fracture. Without question, some complex injuries are best managed with ring fixators, but devastating complications can occur even with that approach. Given that nearly every long-term frame construct (more than 3 months) will have some pin-site issues, if not substantial soft tissue complications, the surgeons should be mindful of the high likelihood of complications and repeat surgical procedures, particularly in patients with complex comorbid conditions such as aortic stenosis, end-stage chronic obstructive pulmonary disease, and/or high-risk cardiovascular disease. In these patients, repeat surgical interventions put the patient at higher risk for mortality. Additionally, the management of a circular frame is complex, and socioeconomic factors can influence the outcomes. For example, in a homeless patient, lack of follow-up or access to a clean environment to maintain the frame can lead to deep infection and even amputation. Finally, although the concept of allowing full weightbearing in patients with ring fixators and foot frames sounds good in theory, not all patients are able to bear weight in these frames. The theory does not always translate into reality. Dr. Napora:Given that there is evidence for the efficacy of a ring fixator in treating the some tougher pilon fractures[4, 6, 13], why take a chance with an open reduction and plate fixation in those situations? Dr. Archdeacon: All definitive treatment choices for complex pilon fractures have their associated risks and benefits, including nonoperative treatment. The surgeon should consider several issues when making a definitive treatment plan. The injury and management of the soft tissue envelope is paramount to reducing the risk of complications including infection and wound breakdown. However, fracture reduction and definitive stabilization also requires thoughtful consideration. Certainly, ring fixators have a role in the treatment of complex pilon fractures. They can be less traumatic to compromised soft tissues at the time of definitive fixation, but pin tract infections are extremely common with ring fixators. This may be considered the “price of doing business” when using a ring fixator, but it should not be underestimated. Parenteral or oral antibiotics, repeat surgery for wound debridement or pin exchange, or modification of the fixator are not minor issues in the eyes of the patient. Regardless of the technique used for stabilizing the articular block to the shaft, ORIF will almost always be performed for the intraarticular components. Less-invasive techniques can be used to “slide” definitive fixation plates in the submuscular or subcutaneous plane. This carries some risk, but these techniques are associated with fewer perioperative wound complications than were the more extensive ORIF techniques of the 1980s. Finally, complex pilon fractures often are open injuries. If adequately debrided and a clean wound can be obtained, definitive plate fixation can be performed at the initial surgery with little risk of wound complications or infection. Ring fixation at the initial debridement can be challenging. As I mentioned, all treatment options have risks. Surgeons need to use the techniques they are most comfortable with while minimizing the risk and maximizing the benefit for the patient. Dr. Sontich: High-energy, comminuted, soft tissue–compromised pilon fractures pose a challenge even to the experienced trauma surgeon. The goal is to end up with the best functional outcome with the lowest risk for complications in the most expedient and cost-effective manner. The most important variables to guide plating versus ring fixation are soft tissue damage, bone loss, and host comorbidities. There are numerous studies that support wire ring fixation of pilon fractures [2-6, 9] but the most extensive direct comparison by Watson et al. [13] contains 107 patients treated for pilon fractures by an experienced surgeon in both techniques. They found that C3 pilon fractures treated with ORIF had more nonunions, malunions, reoperations, and wound infections than the external fixation cohort despite the ORIF group having less initial soft tissue trauma. Avoiding soft tissue stripping with limited arthrotomies for the articular surface reduction and reduction of the metaphysis to diaphysis using the ring fixator produces less surgical trauma and reduces complications. The higher energy the injury and the unhealthier the patient, the more likely I will use ring fixation for definitive treatment. I use plating techniques for most low-energy injuries in healthy patients. Better plating techniques, staged surgery, and anatomically designed locked plates certainly have improved the outcome for these patients in the last 15 years. The cost of the implants and the ease of postoperative care is an advantage to plating techniques. Excellent results can be expected with staged plating and respect of the soft tissue envelope. Plating the tibia under an open traumatic wound can easily become a nidus for infection when that wound fails to heal. Plating can easily become overly aggressive during the approach because the larger the incision, the easier the reduction. Biological preservation should trump absolute stability and anatomic radiographs. Dr. Napora:Given that tools like hexapod struts and computer software correction make circular fixation more accessible to orthopaedic surgeons who are comfortable with high-energy trauma, what parameters should cause a surgeon to consider getting a deformity specialist (as opposed to “just” a trauma specialist) involved in the treatment of a particular fracture? Dr. Sontich: The orthopaedic trauma surgeon should know how to apply a static ring fixator. The commitment of understanding hexapod computer software has been largely left to the deformity specialist. The best scenario would be to have one traumatologist in the group be familiar with deformity correction using computer assistance and have a good understanding of distraction osteogenesis techniques. The orthopaedic trauma surgeon without deformity experience should still feel comfortable with wires and tensioning, stability of frames, cross-sectional anatomy, and standard acute reduction techniques for most pilon fractures. The trauma surgeon should use a trauma-type ring frame with good fixation block techniques on both sides of the fracture. The trauma frame should include the use of reducible trauma connecting struts between the rings. This usually includes a universal hinge at each end of the strut and a mechanism that allows lengthening and shortening as part of the strut. This allows for acute reduction in length, angulation, rotation, and translation on the operating table for acute pilon fractures. The deformity specialist should get involved when the primary surgeon does not feel comfortable with the computer program linked to the hexapod frame. In certain circumstances, such as delayed reduction, the hexapod frame can be invaluable for gradual correction. It is particularly useful in restoring length and translation and can be managed on an outpatient basis and readjusted by the patient at home. Residual or postoperative corrections can be accomplished by reprograming with computer assistance until the desired result is obtained. Occasionally, an open fracture can be closed by temporarily bending the reduction into the defect using the frame, closing the wound, and gradually straightening the leg with computer assistance once the skin is healed. This can help avoid free flaps but should be done with slow deformity correction rather than acutely. Lastly, when acute shortening and lengthening or transport is used to treat extensive bone loss, the technique employs a distant osteotomy and bone lengthening and is probably better left to the surgeon with more experience in deformity correction. Dr. Archdeacon: In the end, the fracture or trauma surgeon who manages complex pilon fractures needs to be comfortable with a variety of techniques. When the indications or patient circumstances require a super-subspecialist, it is helpful to have a member of the team who is both comfortable and proficient with hexapod ring fixators. Dr. Napora:Are there ever fractures you don’t think you can manage with a plate, and if so, what do those look like? Does timing after injury impact this? Dr. Archdeacon: There definitely are pilon fractures that are not amenable to plate fixation. The two most common scenarios in my experience are the extremely compromised soft tissue envelope and the severely comminuted meta-diaphyseal fracture where plate fixation may not provide adequate stability for the prolonged healing time. Ring fixation may offer a safer alternative than plate fixation for patients with a severely compromised soft tissue envelope such as fractures with large soft tissue deficits, severely contaminated injuries, and those fractures with associated circumferential burns or hemorrhagic fracture blisters. When considering bone defects or severely comminuted meta-diaphyseal segments, the surgeon must determine if the bone is even viable and has the potential to heal. At times, these fractures are so extensive that they are destined to nonunion. In these circumstances, ring fixation may provide the opportunity for bone transport. Surgeons treating complex pilon fractures need to have a variety of tools available to manage these injuries. There is no “one-size-fits-all” approach to these injuries. The surgeon must weigh the advantages and disadvantages of all techniques, and if necessary, engage colleagues for assistance if the most reasonable plan is not within their skill set. Dr. Sontich: There certainly are situations when I believe that ring fixation is the better option. Type IIIA injuries are a good indication for ring fixators. The wound heals primarily without plate contamination, so a free flap is avoided. The wires must not be placed in compromised tissue, and a bridge foot frame needs to be included, which stabilizes the soft tissue of the ankle. If the wound obviously needs a free flap from the injury, then I bridge the ankle with spanning frame, reduce the articular surface with screws, and allow plastic surgery space to provide soft tissue coverage. Six weeks after the flap, I apply the ring fixator and fine tune the reduction of the metaphysis with a hexapod frame. I know at this point that the flap is viable and the fracture is not infected. Plating before the free flap is an alternate technique, but a delay in coverage or partial flap loss can result in plate contamination and infection. If the soft tissue is closed but sustained a crush, abrasions, or burns even after a staged delay, I believe that standard surgical approaches are similarly contraindicated and ring fixation is a better option. Bone loss, seen often in open fractures, can result in nonunions. In these instances, a bone transport from the beginning, using ring fixation and a proximal tibia transport, is biologically beneficial, results in a mechanically stable bone, and decreases the overall healing time. Patients with poorly controlled diabetes, vascular disease, kidney or liver disease, those going through chemotherapy, or those who smoke are at particular risk for infection and wound-healing complications, and open plating across the metaphysis adds surgical trauma. These patients likely are better treated with ring fixators. Lastly, timing of the definitive treatment is important. Regardless of my choice for definitive treatment, I temporarily bridge intraarticular pilon fractures, wait for the swelling to improve, and stage the definitive surgery. I study the traction CT scans and determine my approach to the articular reduction and time the surgery with the soft tissue in mind.