Fibular fixation in pilon f racture
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FIBULAR FIXATION IN Pilon F RACTURE. Chairiandi Siregar . Mechanism of Injury. Low Energy (Rotational Force) High Energy (Axial Loading) Motor Vehicle Coalition Fall from height Incidence of fibular fx is 85% of all pilon fx. Fracture Personality . Open vs Close ?

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FIBULAR FIXATION IN Pilon F RACTURE

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Fibular fixation in pilon f racture

FIBULAR FIXATION INPilon FRACTURE

Chairiandi Siregar


Mechanism of injury

Mechanism of Injury

  • Low Energy (Rotational Force)

  • High Energy (Axial Loading)

    • Motor Vehicle Coalition

    • Fall from height

  • Incidence of fibular fx is 85%

    of all pilon fx


Fracture personality

Fracture Personality

  • Open vs Close ?

  • Articular surface damage ?

  • Metaphysealcomminution ?

  • Diaphyseal involvement ?

  • Ipsilateral tibia or foot (talus)fracture?


Fracture morphology how many fragments

Fracture morphology: how many fragments ?

  • Anterior fraqment

  • Medial fragment

  • Posterior fragment

  • More fragment?

  • More comminution?

  • what about fibula?


Ruedi allgower classification

Ruedi-Allgower classification

I

II

III

  • Grade I

    • Minimal displacement

    • No severe joint injury

  • Grade II

    • Moderate displacement

    • Minimal comminution

  • Grade III

    • Comminution and impaction


Ao ota classification

AO/OTA classification

A : Extraarticular

B : Partial Articular

C : Complete intraarticular


Careful physical examination

(Careful) Physical Examination

  • Vascular Injury

  • Swelling

  • Fracture Blisters

    • Blood filled

    • Clear filled

  • Patient comorbidites

    • Smoking

    • Diabetic and Peripheral Vascular Disease

    • Alcoholism


Treatment options

Treatment Options

  • Plaster

  • Traction (Calcaneal)

  • ORIF Plate & Screw (Ruedi & Allgower1969)

  • 2 stage (Fibular plating + ankle spanning exfix followed by ORIF in the next 2 or 3 weeks; Patterson)

  • Definitive external fixation

  • Primary arthrodesis


Goal in pilon fx treatment

Goal in PilonFx Treatment

  • Restoring Anatomical Surface

  • Restoring Mechanical Alignment

  • Maintaining Joint Stability

  • Achieving fracture union

  • Regaining functional and pain-free weight bearing

  • Avoiding complication

FUNCTIONAL

OUTCOME !!


Normal ankle joint x ray

Normal Ankle Joint X-Ray

  • Tibiofibular overlap ~ 10mm

  • Tibiofibular clear space <5mm

  • Talar tilt


Time is important when to operate

Time is Important - When to operate ?

  • Close fx Tscherne grade ??

  • Open fx  Gustilo grade??

    DELAYED UNTIL SKIN WRINKLE SIGN is (+)


Factors involving outcome

Factors involving outcome

The Injury

  • Articular damage

  • Metaphysealcomminution

  • Diaphysealinvolvment

  • Soft tissu compromise

  • Medical comorbidities

  • Fibular fixation ??

The Surgeon

  • Atraumatic handling

  • Proper implant

  • Time of surgery


Fixation of the fibula

Fixation of The Fibula

  • Study design

    • 98 pilon fractures

    • Group A : ORIF Fibular Plating (n=50)

    • Group B : ORIF Pin fixation (n=23)

    • Group C : Treated conservatively (25)

  • Result

    • Decrease trend of malunion and ankle arthrosis

    • Better clinical outcome

    • FIBULAR FIXATION IS IMPORTANT

Lee YS, et al. Stabilisation of the fractured fibula plays an important role in the treatment of pilon fractures: a retrospective comparison of fibular fixation methods. International Orthopaedics (SICOT) (2009) 33:695-699


The advantage of fibular reduction and fixation

The advantage of fibular reduction and fixation

  • Increasing mechanical stability

  • Assissting the reduction of anterolateral articular fragment

  • Restoring the length and alignment of the tibia

  • Reduces the ankle ‘mortise’

  • Prevent lateral shift of the talus


The disadvantages of fibular fixation

The disadvantages of fibular fixation

  • Possible wound infection

  • Possible hardware removal

  • Malreduction of fibula will make the reduction of the tibia even harder


Fibular plating tibial plating

Fibular Plating + Tibial Plating


Fibular intramedullary wiring tibial plating

Fibular Intramedullary wiring + Tibial Plating


Fibular fixation tibia exfix

Fibular Fixation + Tibia ExFix


Ankle spanning exfix fibular plating

Ankle spanning exfix + Fibular Plating


Old and new

OLD AND NEW...

THANK YOU


Fibular fixation in pilon f racture

DISCUSSION ?


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