C-Type Pilon Fracture – Open Reduction and Internal Fixation with Stryker AxSOS 3 Periarticular Plating System
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Pilon fractures are defined as intra-articular fractures of the distal tibial plafond and being in a load bearing joint they are serious and usually life changing fractures. The fracture is produced by a mixture of shear and compressive loads to the distal tibial metaphysis. Often such fractures are associated with other severe injuries to the ipsilateral limb, pelvis or lumbar spine.
Pilon fractures make up between 5 and 10% of all lower limb fractures and because of the energy involved are associated with a high (15 – 55%) complication rate.
Significant rotational force alone can also cause distal tibial fractures involving the plafond and these are also Pilon fractures. This mechanism though usually results in less severe soft tissue damage and less compromise to the articular surface in terms of comminution and cartilage damage.
The most frequent mechanism of injury is a fall from height though road traffic accidents also account for a good proportion of high energy Pilon fractures. This patient also sustained an ispilateral open femoral fracture which was plated on day one of the injury when a temporising external fixator was applied in a delta construct to the ankle.
In terms of operative management, the big debate is when to use ORIF or minimally invasive plate osteosynthesis (MIPO), and when to use an external fixation frame (such as an Ilizarov or other fine wire construct) as definitive treatment. It is with this in mind that there is currently a multi-centre randomised control trial comparing these two forms of treatment, funded by the NIHR (National Institute for Health Research) in the UK. This study is called the ACTIVE Trial (Articular Type C Pilon Trial Internal Vs External Fixation) being run by the York Trials unit. This patient was recruited into this trial and randomised to Internal Fixation.
In my hands and working in a unit with excellent fine wire fixation skills we treat those cases where there is very severe soft tissue damage, or where the articular surface is grossly comminuted, with a frame. Those cases where the degree of articular comminution is less severe are usually treated with plate fixation as with the case presented here.
Readers will also find of interest Chris Blundells other OrthOracle instructional technique for surgical treatment of a Pilon fracture Internal fixation of distal tibial Pilon fracture using Stryker AxSOS 3Ti plate. and also Paul Fentons technique Open reduction and internal fixation of C-type Pilon fracture using Smith and Nephew EVOS small fragment system.
Author:Mr Chris Blundell FRCS (Tr & Orth)
Institution: Northern General Hospital, Sheffield, UK
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