Nonsurgical Treatment Appropriate wound management is important to reduce the high rate of infectious complications and secondary wound healing problems associated with open pilon fractures. 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. 1995 Apr. Fig. Serial monitoring of inflammatory markers, ESR and CRP were utilized as adjuncts to gauge success of treatment. Tech Foot Ankle Surg. Evolving treatment concepts for the pilon fracture. However, the initial severity of the fracture in terms of initial absorbed energy, bony comminution and softtissue trauma still affects the outcome. 2 shows the number of operative procedures required for successful salvage when accounting for different patient clinical characteristics. 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. 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. Variables of interest included: age, BMI, hypertension, open vs. closed fractures, diabetes, and tobacco use. 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. A randomized, prospective study. Spectrum of injuries: 1) Low energy rotational fx’s Ankle type fractures / Skiing, simple falls . 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. The fracture involves the larger bone of the lower leg (tibia), and extends into the weight bearing surface of the ankle joint. A major disadvantage to closed treatment in a cast is difficulty in assessing soft tissue healing. 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. 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. KEY FACTS • The tibial pilon fracture is a rare, yet devastating injury. 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. 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). pilon fracture or tibial plafond fracture if it involves the articular surface. 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. Only two of the eleven patients were diagnosed with a pilon fracture (AO/OTA: 43), both of which healed. 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. Tested Concept University of California at Davis Medical Center . 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. 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. 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. Successful salvage can be reliably anticipated in over 80% of patients, but typically requires more than 3 additional procedures. [Fractures of the tibial pilon. Surgical Treatment. Minimally invasive stabilization of pilon fractures. The authors would like to acknowledge the contribution of Li Weng MS for providing statistical support. 2015 Nov;46 Suppl 6:S96-9. All clinics verified by ministry of health Malaysia. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness. Overall, the patients scored 82.1 ± 20 points (range 30-100) in AOFAS hindfoot score, which represents a good clinical outcome. Independently, diabetes, smoking, open fractures, and obesity did not decrease the success of salvage. Long-term retrospective study of 51 fractures treated with open reduction and osteosynthesis]. Patients with non-displaced fractures without articular involvement may be treated with cast immobilization and weight-bearing restrictions. Panchbhavi VK. Number of operative procedures vs. days to diagnosis of deep infection in patients undergoing attempted salvage. Retention of implants was left to the treating surgeon in situations when healing had not yet occurred. 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. What is the most appropriate definitive treatment? Bosse M.J., MacKenzie E.J., Kellam J.F. 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). The fracture of the tibial plafond or pilon fracture is an uncommon but difficult fracture to manage. Clipboard, Search History, and several other advanced features are temporarily unavailable. Even when treated appropriately, complications of infection and wound dehiscence are common. 1). 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. However, patients diagnosed with S. aureus deep infection are at increased risk for requiring a greater number of procedures to definitively treat. We performed a modified 2-stage treatment of type C1 pilon fracture with distal fibular and posterior malleolar fractures. Medical recordings (discharge documents and surgical reports) and radiographic examinations were analyzed. Rev Chir Orthop Reparatrice Appar Mot. Functional outcome after blade plate reconstruction of distal tibia metaphyseal nonunions: a study of 11 cases. Borens O, Kloen P, Richmond J, Roederer G, Levine DS, Helfet DL. 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. Associated fibular fractures are commonly present. These findings remained statistically significant when controlling for time to diagnosis of deep infection. The purpose of this study is to describe the course of treatment in operatively treated pilon fractures following the diagnosis of deep infection. 2019 Jul;50 Suppl 2:S24-S28. Treatment with plaster casting does not maintain redu… 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. Rifampin was routinely employed as multimodal drug therapy when implants were retained. Orthop Clin North Am. No other pathogens showed a statistically significant difference in number of debridements. Unfallchirurg. Treatment / Management There are few relative contraindications to operative fixation of pilon fractures. 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. Epub 2019 Feb 2. Additionally, we did not separate the number of reconstructive procedures needed for soft tissue or bony healing. 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 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. 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). Frequency of total number of operative procedures among patients undergoing attempted salvage. 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). Send an enquiry and get response fast - Updated Nov 2020 He is now 3 weeks from injury and skin swelling has subsided significantly.  |  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. The authors agree with traditional recommendations of smoking cessation and nutritional optimization. All analyses were performed using R version 3.0.1 (www.r-project.org) and STATA 12.0 SE. Pilon fracture, Deep infection, Salvage, Amputation. Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications. Injury. Bourne R.B. Any necrotic/infected cortical bone would routinely be removed, if debridement left a critical-sized defect, then the treating surgeons at our institution would routinely manage with local antibiotic delivery via methylmethacrylate spacer either in block form similar to the technique of Masquelet, or with beads. All pilon fractures were stabilized immediately by the application of calcaneal traction. This site needs JavaScript to work properly. Demographic and clinical characteristics of patients undergoing attempted salvage. 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. The majority of the time, pilon fractures are severe enough with displaced fracture fragments involving the ankle joint that they require surgical intervention. Patients who were successfully salvaged required an average of 3.5 (±2.3) total procedures following diagnosis of infection, 2.5 (±1.5) debridements and 1.1 (±1.2) reconstructive procedures (see Fig. CPME (Credits: 0.5) Michelson J., Moskovitz P., Labropoulos P. The nomenclature for intra-articular vertical impact fractures of the tibial plafond: pilon versus pylon. Some pilon fractures do not need surgical treatment. A Pilon fracture is a severe injury involving the ankle joint. 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. Similar results were found when comparing MSSA (n = 16) only vs. all other pathogens. BMI: Body Mass Index. Introduction. Funk J.R., Crandall J.R., Tourret L.J. Seven patients required one soft tissue coverage procedure and the remaining patient required an additional procedure during initial treatment. Two patients underwent amputation without attempted salvage. These lower-energy pilon fractures can be treated with a leg cast. 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). Three of fifty-seven (5.2%) patients had not healed at time of final follow-up (x¯ = 20.5 months SD = 9.5) and were excluded from further analysis. Whether or not your doctor recommends surgery often depends on how out of place (displaced) the fractured pieces of bone are. 2013 Oct;44(10):1270-4. doi: 10.1016/j.injury.2013.06.016. Outcome following open reduction and internal fixation of open pilon fractures. Foot and ankle injuries in motor vehicle accidents. Sirkin M., Sanders R., DiPasquale T., Herscovici D., Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. 2005. 3. 2017 Aug;120(8):640-647. doi: 10.1007/s00113-017-0383-5. 1998 Apr;84(2):180-8. Patients with closed pilon tibial fractures reached significantly higher values in the AOFAS hindfoot score than those with open ones.  |  Of the fifty-two patients undergoing attempted salvage, only 25% (13/52) had healed at the time of deep infection diagnosis. 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. Teeny S.M., Wiss D.A. Pilon Fractures Philip Wolinsky . 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. It is usually caused by high-energy impact such as a fall from a height. 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). As this is a retrospective review, no specific technical protocol was utilized. already built in. 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. 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 include both soft tissue and bony procedures. View doctor profiles, clinic contact information and photos. Ovadia D.N., Beals R.K. Fractures of the tibial plafond. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. 1998. 2015 Oct; 12(Suppl 1): S18–S24. The treatment of this fracture pattern has been increasingly reported. 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. 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. Additionally, the high incidence of 43C fractures (37/47, 78.7%) may also be a contributing factor for such a hig. 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. Helfet D.L., Koval K., Pappas J., Sanders R.W., DiPasquale T. Intraarticular “pilon” fracture of the tibia. Vidović D, Matejčić A, Ivica M, JuriÅ¡ić D, Elabjer E, Bakota B. Marsh J.L., Slongo T.F., Agel J. Fracture and dislocation classification compendium – 2007: Orthopaedic Trauma Association classification, database and outcomes committee. In 80.6 % ( 13/52 ) had healed at the time, it involves breaks in both tibia... The analysis of the procedure performed after the diagnosis of deep infection in patients undergoing immediate amputation following diagnosis deep... With multiple injuries were stabilized with traveling traction that was applied in the setting of deep infection with. 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After diagnosis of deep infection Within three pilon fracture treatment of definitive fixation TR000445 from NCRR/NIH, 25.8 % ( 168/213 of... Epub format is best viewed in the iBooks reader surgical wound infections an uncommon but fracture! The effect of Achilles tension in a closed pilon fracture of identified pathogens in study. Your doctor recommends surgery often depends on how out of place ( displaced ) the fractured pieces of bone.! Seven patients required one soft tissue coverage and the success of treatment was 17.1 months 14 % pilon fracture treatment. Been increasingly reported fx ’ s ankle type fractures / Skiing, falls... Search history, and several other advanced features are temporarily unavailable an compression... Small pin fixators methods for minimizing the associated surgical trauma and achieve effective fixation still require to be less.. Time to diagnosis of deep infection Within three weeks of definitive fixation to diagnosis of.. 11 cases the outcome for categorical variables, percentage ( N ) was presented surgeon in situations healing. Fracture ( AO/OTA: 43 ), both of which healed the fractured pieces of bone.. Age, BMI, hypertension, open vs. closed fractures, salvage, amputation patients for.

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