Definitive Plates Overlapping Provisional External Fixator Pin Sites

Abstract

Objectives The purpose of this study was to compare the infection risk when internal fixation plates either overlap or did not overlap previous external fixator pin sites in patients with bicondylar tibial plateau fractures and pilon fractures treated with a two-staged protocol of acute spanning external fixation and later definitive internal fixation. Design Retrospective comparison study. Setting Two level I trauma centers. Patients/Participants A total of 85 OTA type 41C bicondylar tibial plateau fractures and 97 OTA type 43C pilon fractures treated between 2005 to 2010. Radiographs were evaluated to determine the positions of definitive plates in relation to external fixator pin sites and patients were grouped into an “overlapping” group and a “non-overlapping” group. Intervention Fifty patients had overlapping pin sites and 132 did not. Main Outcome Measure Presence of a deep wound infection Results Overall, 25 patients developed a deep wound infection. Of the 50 patients in the “overlapping” group, 12 (24%) developed a deep infection, compared to 13 (10%) of the 132 patients in the “non-overlapping” group (p = 0.033). Conclusions Placement of definitive plate fixation overlapping previous external fixator pin sites significantly increases the risk of deep infection in the two-staged treatment of bicondylar tibial plateau and pilon fractures. Surgeons must make a conscious effort to place external fixator pins outside of future definitive fixation sites to reduce the overall incidence of deep wound infections. Additionally, consideration must be given to the relative benefit of a spanning external fixator in light of the potential for infection associated with their use.

Definitive Fixation of Tibial Plateau Fractures

“…23 Recent studies, in an effort to provide objective data to find an answer, reported conflicting results. 24,25 In a small cohort comparison study, Laible and colleagues 24 did not find an increased infection rate in tibial plateau fractures fixed with plates that overlapped with pin-sites. Shah and colleagues 25 found the opposite, finding an increased infection rate with plate, pin-site overlap.…”

“…24,25 In a small cohort comparison study, Laible and colleagues 24 did not find an increased infection rate in tibial plateau fractures fixed with plates that overlapped with pin-sites. Shah and colleagues 25 found the opposite, finding an increased infection rate with plate, pin-site overlap. However, the authors had a more heterogeneous study cohort, including both tibial plafond and plateau fractures.…”

“…However, the authors had a more heterogeneous study cohort, including both tibial plafond and plateau fractures. 25 While we await larger studies for a definitive answer based on objective data, we recommend trying to place pin-sites outside of the zone of fixation. However, that goal should not outweigh achieving stability, length, and alignment.…”

Fratture esposte meta-epifisarie distali di femore e meta-epifisarie prossimali di tibia

“…Il rischio infettivo è infatti più alto nelle sintesi interne dopo applicazione di fissatore esterno, in particolare nelle sintesi interne con placche o chiodi posizionati nel sito di infissione delle pins. Questo fenomeno sembra anche tempo-dipendente, perché si verifica con più probabilità in fissatori posizionati da più di 2 settimane o in presenza di una secrezione dalle pin che indica un'alta probabilità di infezione [27]. Il timing e la modalità della conversione dalla fissazione esterna all'osteosintesi interna restano ancora da definire, e dipendono dalle condizioni generali del paziente, dallo stato delle parti molli, dalla persistenza dell'infezione valutata con parametri clinici, biologici e strumentali (febbre, VES, PCR, esami colturali, scintigrafia con leucociti marcati, PET-TAC, RMN).…”

“…fino a più di 100 gg.) [27]. In casi selezionati, la persistenza di un'infezione e le condizioni generali del paziente non consentono la conversione, per cui il trattamento con fissatore esterno resta quello definitivo, con maggiore incidenza di pseudoartrosi, viziose consolidazioni e rigidità articolari, in particolar modo per le fratture del femore distale (Fig.…”