4 (4):240-8. The nature of the pilon fracture has caused evolution of treatment methods and its historically high rate of complication and poor outcome continue to direct choice of treatment. (ORIGINAL ARTICLE) by "Journal of Evolution of Medical and Dental Sciences"; Health, general Bone transplantation Bone-grafting Fractures Care and treatment Fractures (Injuries) Internal … BMI: Body Mass Index. A major disadvantage to closed treatment in a cast is difficulty in assessing soft tissue healing. We are experimenting with display styles that make it easier to read articles in PMC. 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. View doctor profiles, clinic contact information and photos. 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. 26(2):273-85. . Please enable it to take advantage of the complete set of features! As this is a retrospective review, no specific technical protocol was utilized. 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. Free Online Library: Treatment of closed tibial pilon fractures with open reduction, internal fixation and bone grafting. Korkmaz A, Ciftdemir M, Ozcan M, Copuroğlu C, Sarıdoğan K. Injury. Named "pilon" (from the French word for "hammer") because of the hammer-like way in which the talus drives into the weight-bearing surface of the distal tibia, these fractures are uncommon, making up only about 1% of fractures of the lower extremities. 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). 2013 Oct;44(10):1270-4. doi: 10.1016/j.injury.2013.06.016. Additionally, the high incidence of 43C fractures (37/47, 78.7%) may also be a contributing factor for such a hig. 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. Barei and colleagues reported that the presence of a fibular fracture provides clues about the mechanism of injury and fracture pattern [30] . Two patients underwent amputation without attempted salvage. Institutional review board approval was obtained for this study. Antibiotic use was typically parenteral via peripherally inserted central catheter. 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. The total number of procedures, including procedures for debriding and of reconstructive nature, was also higher in this group, 5.1 (SD = 2.5) vs. 2.7 (SD = 1.7), p = .013. Reconstructive procedures consisted of soft tissue procedures (flap reconstruction or split thickness skin graft) and/or definitive bony procedures to include fusion and amputation. 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 pilon. University of California at Davis Medical Center . 2019 Jul;50 Suppl 2:S24-S28. Silluzio N, De Santis V, Marzetti E, Piccioli A, Rosa MA, Maccauro G. Injury. The analysis of the variables, affecting outcome in surgically treated tibia pilon fractured patients. DISCUSSION Within the last decades, the therapeutic algorithm of pilon fractures underwent a paradigm shift; a two-stage protocol has prevailed today. Injury. 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. 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 … Fracture of the plafond occurs when the talus is driven into the tibia from axial compression. 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. Funk J.R., Crandall J.R., Tourret L.J. 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. Nonsurgical Treatment These fractured bones often benefit from surgery. Of these, 25.8% (8/31) required procedures for soft tissue coverage at the time of initial treatment. Treatment with plaster casting does not maintain redu… It is possible that earlier infections involved greater compromise of the soft tissue envelope. Exploration of an association between microbial culprit and number of post-infection debridements showed that deep infections caused by S. aureus (MRSA = 5 & MSSA = 16) required an average of 3.1 (SD = 1.6) debridements compared to deep infections caused by other pathogens (n = 25) requiring an average of 1.9 (SD = 1.1) debridements, p = .004. 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. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness. Successful salvage can be reliably anticipated in over 80% of patients, but typically requires more than 3 additional procedures. Deep infections caused by other pathogens required a total of 1.9 (SD = 1.1) debridement procedures vs. 3.4 (SD = 1.6) debridements in the MSSA group. Only five patients reached higher scores (Grade III) in Kellgren classification system. Attempted salvage was performed in fifty-two of the fifty-four patients with the remaining two patients undergoing immediate amputation following diagnosis of deep infection. All patients were managed via a multidisciplinary team including infectious disease specialists. Sometimes surgery is performed immediately, but it may be necessary to wait if there is severe swelling. Etienne Destot introduced the term tibial pilon in 1991 where pilon is a French word for pharmacist’s pestle that has a similar shape to the area of distal tibia metaphysis extending 5cm from ankle joint 2. Teeny S.M., Wiss D.A. Relaxing the rule of ten events per variable in logistic and Cox regression. 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/. However, the initial severity of the fracture in terms of initial absorbed energy, bony comminution and softtissue trauma still affects the outcome. These are typically lower-energy injuries to the tibia and fibula at the ankle joint. 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. Orthop Clin North Am. 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. All patients fifteen years or older treated definitively with ORIF of pilon fractures at our institution between January 1, 2006 and December 31, 2011 were identified from an institutional billing database. 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. 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. Reed L.K., Mormino M.A. We performed both univariate analysis and the penalized multivariable proportional odds model and both indicated that there is not enough evidence to identify an association between risk factors and the outcome. 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. Adam Bernatsky, DPM discusses the history of pilon fracture treatment. 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). Fig. All clinics verified by ministry of health Malaysia. Even when treated appropriately, complications of infection and wound dehiscence are common. 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. pilon fracture or tibial plafond fracture if it involves the articular surface. RESULTS In 21 cases a two-stage operative strategy with initial closed reduction and external fixation was necessary prior to definitive osteosynthesis. 2017 Aug;120(8):640-647. doi: 10.1007/s00113-017-0383-5. 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. The average follow-up time was 16.9 months (SD 8.5) with a 95% follow-up. Patients with non-displaced fractures without articular involvement may be treated with cast immobilization and weight-bearing restrictions. Pilon Fractures Adam Bernatsky, DPM. 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). Pilon Fracture What is a Tibial Pilon fracture? This series serves as a framework for discussions regarding anticipated success of and course of treatment, helping align patient and surgeon expectations, and provides surgeons and patients a framework for discussions regarding optimal, individualized treatment. Pilon fractures are complex injuries to the ankle region with disrupt the main weight bearing region of the shinbone (tibial) part of the ankle. Surgical Treatment. Pilon fracture, Deep infection, Salvage, Amputation. NLM A pilon fracture is a particularly severe break of the shin bone where it forms the ankle joint (see X-rays). The authors agree with traditional recommendations of smoking cessation and nutritional optimization. Of the thirty-one open fractures, salvage was obtained in 80.6% (25/31) of patients. 1995 Apr. Sirkin M., Sanders R., DiPasquale T., Herscovici D., Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. Foot and ankle injuries in motor vehicle accidents. You may notice problems with Variables of interest included: age, BMI, hypertension, open vs. closed fractures, diabetes, and tobacco use. Panchbhavi VK. 1998. Infection was polymicrobial in 23.1% (12/52). HHS doi: 10.1016/j.injury.2015.10.067. Appropriate wound management is important to reduce the high rate of infectious complications and secondary wound healing problems associated with open pilon fractures. Functional outcome after blade plate reconstruction of distal tibia metaphyseal nonunions: a study of 11 cases. Wilson L.S., Jr., Mizel M.S., Michelson J.D. Helfet D.L., Koval K., Pappas J., Sanders R.W., DiPasquale T. Intraarticular “pilon” fracture of the tibia. Spectrum of injuries: 1) Low energy rotational fx’s Ankle type fractures / Skiing, simple falls . Most of the time, it involves breaks in both the tibia and fibula of the lower leg. The ePub format is best viewed in the iBooks reader. These are most commonly encountered following high energy mechanisms, such as motor vehicle collisions and falls from height.1, 2, 3. Send an enquiry and get response fast - Updated Sep 2020 The purpose of this study was to describe the course of treatment in operatively treated pilon fractures in the setting of deep infection. For categorical variables, percentage (N) was presented. View doctor profiles, clinic contact information and photos. 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. COVID-19 is an emerging, rapidly evolving situation. Overall, the patients scored 82.1 ± 20 points (range 30-100) in AOFAS hindfoot score, which represents a good clinical outcome. Bosse M.J., MacKenzie E.J., Kellam J.F. Outcome following open reduction and internal fixation of open pilon fractures. Rev Chir Orthop Reparatrice Appar Mot. Optimal treatment of the more complex higher-energy pilon fractures remains controversial because of the potential for serious complications. A search of Current Procedural Terminology (CPT) codes for pilon fractures (27827, 27826 and 27828) was performed using the above criteria. MSSA: Methicillin Sensitive S. aureus. Considerable morbidity follows the diagnosis of deep infection, with 14% of patients ultimately treated with amputation. Unfallchirurg.  |  Additionally, the total number of surgeries related to the study injury were accounted for and further subdivided into number of operative procedures before and after the diagnosis of deep infection. The secondary aim of this paper was to look for risk factors that associated with number of operative procedures (debridements and reconstructive procedures) after the diagnosis of deep infection among 46 salvaged patients. The mechanism and degree of injury involved dictate the fracture pattern and the treatment approach to pilon fractures. What is the most appropriate definitive treatment? 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. 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. 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. The treatment of this fracture pattern has been increasingly reported. 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. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. Generating an ePub file may take a long time, please be patient. An additional limitation is that we did not include an injury severity scale as part of the logistic regression analysis. Average time from injury to endpoint of treatment was 17.1 months. 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… Acknowledging the limitations, the authors can support the following treatment recommendations. The ePub format uses eBook readers, which have several "ease of reading" features All analyses were performed using R version 3.0.1 (www.r-project.org) and STATA 12.0 SE. 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. Vidović D, Matejčić A, Ivica M, JuriÅ¡ić D, Elabjer E, Bakota B. 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. 3. Some pilon fractures do not need surgical treatment. Retention of implants was left to the treating surgeon in situations when healing had not yet occurred. Reconstructive procedures include both soft tissue and bony procedures. 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. Differences in outcomes by time from definitive fixation to diagnosis of infection. Given nearly 20% of the infections in our series included gram negative organisms, consideration should be given to initiating broader empiric treatment to include coverage for both Staphylococcus and Enterobacter species, with transition to organism specific therapy directed by intraoperative culture results. Only 9.6% (5/52) of patients were diagnosed with deep infection within three weeks of definitive fixation. The interested risk factors include age, BMI, hypertension, open skin, open/closed fraction, diabetes, and smoke. Guidelines for treatment of these complications have not been established, and currently there exists wide variation in management. Linear regression allows for the visualization of a fair negative relationship between these 2 variables, see Fig. 1/3 of patients have associated injuries . 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).

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