Management of High-Energy Tibial Pilon Fractures

Abstract

ä Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.ä Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.ä Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.ä Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.ä Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.ä The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.Tibial pilon fractures in younger patient populations are frequently devastating high-energy intra-articular injuries and pose a difficult clinical problem in both academic and community practices. Representing approximately 5% to 7% of all tibial fractures 1-4 , pilon fractures are impaction injuries of the weightbearing surface of the distal tibia 5-8 . These most frequently occur in men in their fourth and fifth decades via an axial loading mechanism from motor vehicle trauma or a fall from a height 1,5-10 . The term "pilon" was first described in 1911 by Destot, due to the injury mechanism being analogous to a mortar and "pestle." 11 Extensive soft-tissue trauma is predictable and increases the risk of surgical complications (e.g., infection, nonunion, malunion), as well as the need for secondary intervention, including revision procedures and/or amputation 6,[12][13][14] . Despite treatment advances over the past several decades, long-term functional outcomes reveal persistent disability and the development of posttraumatic arthritis [15][16][17] , thereby negatively impacting the quality of life [18][19][20][21] . As many as ‡50% of patients may develop posttraumatic arthritis within 4 years after the injury 14,16 , and pilon fractures are among the worst musculoskeletal injuries for both functional and healthrelated outcomes 1,15,22 . In this article, an evidence-based critical discussion of the evaluation, classification, management, and strategies for optimization of these injuries is presented. Initial Management Clinical EvaluationTibial pilon fractures secondary to high-energy trauma are often accompanied by trauma to the head, spine, chest, or abdomen Disclosure: ...