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〈 Case Report 〉 Early Tibiotalocalcaneal Arthrodesis Intramedullary Nail for Treatment of a Complex Tibial Pilon Fracture (AO/OTA 43-C) Abstract: Management of severely comminuted, complete articular tibial pilon fractures (AO/OTA 43C) remains a challenge, with few treatment options providing good clinical outcomes. Open reduction and internal fixation of the tibial plafond, tibiotalar arthrodesis, and salvage hindfoot reconstruction procedures are all associated with surgical complications and functional limitations. In this report, we present a case of a complex pilon fracture in a patient with multiple medical comorbidities and socioeconomic disadvantages that was successfully and acutely treated with a retrograde tibiotalocalcaneal hindfoot arthrodesis nail. At final follow-up examination, the patient had decreased pain, a stable plantigrade foot, and could ambulate with normal shoes without any assistive devices. Levels of Evidence: Therapeutic, Level IV: Case Series
Keywords: tibiotalocalcaneal; arthrodesis; ankle; tibial plafond; hindfoot; salvage; internal fixation
Introduction
Andrew R. Hsu, MD, and Jan P. Szatkowski, MD
soft-tissue breakdown, deep infection, hardware failure, malunion, and nonunion.1,2 The optimal treatment for definitive management of comminuted, complete articular pilon fractures is controversial and remains unknown. Ankle arthrodesis
Tibial pilon fractures are challenging injuries to treat, with frequent complications In high-energy injuries, anatomical despite recent advances in surgical approaches, reconstruction of the tibiotalar joint is techniques, implants, and 1-4 rehabilitation. In highdifficult because of the level of bone loss energy injuries, anatomical reconstruction of the and articular damage.” tibiotalar joint is difficult because of the level of for posttraumatic osteoarthritis is bone loss and articular damage.1,2 commonly performed, but acute External fixation, anatomical open tibiotalar and subtalar arthrodesis for reduction and internal fixation (ORIF), definitive management are uncommon tibiotalar arthrodesis, and hindfoot treatments.6,8,9 We believe that early reconstruction procedures have all been tibiotalocalcaneal (TTC) arthrodesis with described in the literature, with modest a retrograde intramedullary nail may be results and clinical outcomes.1,2,4-7 indicated for a select group of high-risk Complications after external fixation and patients with severe fracture ORIF include pin-tract infections,
“
DOI: 10.1177/1938640014548322. From the Department of Orthopaedic Surgery, Rush University Medical Center (ARH), and the Department of Orthopaedic Surgery, John H. Stroger, Jr Hospital of Cook County (JPS), Chicago, Illinois. Address correspondence to: Andrew R. Hsu, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St, Suite #300, Chicago, IL 60612; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
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comminution, poor bone quality, compromised soft-tissue envelopes, multiple comorbidities, and/or socioeconomic disadvantages to provide a stable, plantigrade foot for early weight bearing with decreased soft-tissue injury. In this report, we present a case of a homeless, drug-addicted patient with multiple medical comorbidities who sustained a complete articular pilon fracture (AO/OTA 43-C) with anterior bone loss after a fall from height. The patient was initially treated with a temporizing joint-spanning external fixator for soft-tissue compromise followed by a TTC nail 2 weeks after initial injury. The patient was able to bear weight on the operative extremity early on after surgery and, at the most recent follow-up, had decreased pain, could ambulate without an assistive device in normal shoes, and was satisfied with her clinical and functional outcome.
Case Report A 58-year-old homeless African American woman presented to the emergency department with severe left ankle pain after jumping out of a second story window while fleeing from an assailant. The patient had altered mental status and tested positive for cocaine toxicity. She was agitated, combative, and unable to follow commands on initial examination. She had moderate pain with ankle range of motion with diffuse swelling over the left lower extremity, without blister formation. Gross motor and sensation were intact, dorsalis pedis and posterior tibial pulses were palpable, and compartments were compressible with no evidence of compartment syndrome. There were no open lesions or lacerations indicating an open fracture. The patient’s past medical history was positive for seizures, stroke, osteoporosis, hypertension, cocaine abuse, and a right eye infection requiring complete eye excision. She smoked one pack of cigarettes per day and was taking antiseizure medications at the time of injury. Plain radiographs of the left ankle revealed a closed, comminuted complete
Figure 1. Initial anteroposterior (A) and lateral (B) radiographs of the left ankle showing a closed, comminuted, complete articular pilon fracture with anterior cortex bone loss and anteromedial dislocation of the talus in the tibiotalar joint.
articular pilon fracture (AO/OTA 43-C) with loss of anterior cortex, poor bone quality, and anteromedial dislocation of the talus in the tibiotalar joint (Figures 1A and 1B). The patient was placed into a short-leg splint for immobilization for several hours until her mental status improved and she was deemed to be alert and oriented to person, place, and time. She was then interviewed completely, and informed consent was obtained. In the interim period, the emergency department obtained a CT scan to further evaluate the fracture. Although the fracture was impacted with anterior tibiotalar dislocation, the CT scan further clarified the extent of anterior bone loss (>50%) and articular comminution (Figures 2A-2C). The patient was brought to the operating room for closed reduction under general anesthesia and application of a joint-spanning external fixator in a delta-frame configuration to stabilize the fracture and reduce soft-tissue compromise (Figures 3A and 3B). Two proximal tibial pins were placed along with 2 calcaneal pins for increased stability and rotational control, with adequate restoration of ankle alignment.
The patient was kept in the hospital for pain control, physical therapy, and management of her multiple medical problems. On hospital day 7, the patient developed large fracture blisters over the medial, lateral, and posterior malleoli that were treated with soft dressings and antimicrobial wound care. The risks and benefits of and alternatives to surgical interventions, including ORIF, definitive external fixation, and tibiotalar and TTC arthrodesis, were discussed in full with the patient. The patient clearly indicated that she would likely be unable to comply with any weight-bearing precautions, pin-site and/or associated external fixator care, or postoperative therapy, given her lack of social support and living situation. As a result, the primary goal was to obtain a stable, plantigrade foot that could be weight bearing early on with decreased soft-tissue dissection and postoperative rehabilitation. The patient ultimately elected to undergo a retrograde TTC arthrodesis intramedullary nail on hospital day 16. The patient chose to defer spinal anesthesia or a regional block by anesthesia because of personal concerns
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Figure 2. Preoperative coronal (A), sagittal (B), and axial CT (C) cuts of the tibial plafond showing the extent of articular comminution and >50% anterior bone loss.
Figure 3. Anteroposterior (A) and lateral (B) radiographs of the left ankle after closed reduction under anesthesia and placement of an external fixator on the day of presentation.
regarding the procedure. In the operating room under general anesthesia, an anterolateral incision was made across the tibiotalar joint in line with the fourth metatarsal. A large amount of fibula comminution was found, and all of the bone was saved and used as autologous bone graft for the ankle arthrodesis. The majority of the tibiotalar articular surface was delaminated as a result of the initial injury, and the remaining cartilage was
formally removed and underlying bone prepared with k-wires and osteotomes. The tibiotalar and subtalar joints were pinned into place, and the ankle was positioned into neutral flexion, 5° of valgus, and 10° of external rotation. A 200 × 10 mm retrograde TTC arthrodesis nail was inserted that included a built in 5° valgus bend at the ankle (T2 Ankle Arthrodesis Nail, Stryker, Mahwah, NJ; Figures 4A and 4B). Isolated subtalar
preparation was performed using intramedullary reaming. A talus screw was placed along with 2 tibia screws and 2 multiplanar calcaneus screws. Compression was achieved through the tibiotalar and subtalar joints through the mechanism of the TTC nail. A medium hemovac drain was placed along with a short-leg splint for temporary immobilization and wound protection. The patient had gross motor and sensation intact after surgery but unfortunately elected to leave the hospital against medical advice on postoperative day 1 for stated personal and social reasons that she would not elaborate on. As a result, the drain was removed, and the patient was given a CAM (controlled ankle motion) boot for ambulation that she was able to use with the assistance of crutches. The patient could not be contacted after leaving the hospital because of her homeless status and lack of telephone or nearby friends or relatives. Incisional sutures were removed by the emergency department approximately 2 weeks after surgery when the patient presented for a refill of her pain medications. The patient returned to the orthopedic clinic 3 months after surgery weight bearing as tolerated in her CAM boot without the need for crutches. Her incisions were clean, dry, and intact, and she had mild, occasional pain with ambulation with no limitations in her stated activities of daily living. She was able to ambulate approximately 3 blocks prior to stopping because of pain and had some difficulty on uneven terrain and inclines. On exam, she ambulated with an antalgic gait and had no ankle or hindfoot motion because of her TTC fusion. She had a stable ankle-hindfoot with good alignment and a plantigrade foot. Her total AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Score was 69. Radiographs showed good ankle and subtalar alignment with hardware intact and initial consolidation of the arthrodesis across the formally prepared tibiotalar joint and reamed subtalar joint (Figures 5A and 5B). At the most recent follow-up 17 months following the
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Figure 4. Postoperative anteroposterior (A) and lateral (B) radiographs on postoperative day 1 demonstrating good alignment of a retrograde tibiotalocalcaneal intramedullary arthrodesis nail, with fibula comminution serving as autologous bone graft at the tibiotalar joint.
procedure, the patient had no pain, was ambulating independently with normal shoes, was satisfied with her overall outcome, and had an AOFAS AnkleHindfoot score of 79.
Discussion
Figure 5. Postoperative anteroposterior (A) and lateral (B) radiographs 3 months after surgery show good ankle and subtalar alignment with hardware intact and initial consolidation of the arthrodesis across the hindfoot.
Tibial pilon fractures have a high rate of complications and posttraumatic arthritis, with often modest clinical outcomes cited in the literature.1-4,6 Early stabilization with an external fixator followed by staged definitive treatment with ORIF to achieve anatomical articular restoration and fixation has become a mainstay of treatment.1,2,4 External fixation devices are often large, poorly tolerated, and have complications, including pin-tract infections. Infection is a common, early postoperative complication after ORIF that may require further surgical intervention, including revision arthrodesis or amputation.10,11 In a review of 51 tibial pilon fractures, including closed and open injuries, Blauth et al4 found that patients treated with a 2-stage procedure consisting of primary reduction and articular reconstruction with minimally invasive osteosynthesis and short-term external fixation followed by secondary stabilization with limited incisions had greater ankle range of motion, decreased pain, and improved return to work compared with 1-stage procedures. Harris et al1 reported a series of 79 pilon fractures that were treated with either limited articular reduction and external fixation (16) or ORIF (63) approximately 8 days after injury. In the early postoperative period, there were 2 superficial wound infections and 3 deep infections, whereas in the late postoperative period, there were 2 nonunions and 4 malunions. Also, 31 fractures (39%) went on to develop posttraumatic arthritis at the 2-year follow-up. Marsh et al5 have reported that 15% of patients have persistent pain at the 2-year follow-up after external fixation and/or ORIF of pilon fractures. In a follow-up study, the authors noted a 35-point decrease in SF (Short Form)-36 scores at the 5- to 11-year follow-up,
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with 70% of patients having severe tibiotalar arthritis. Complex, complete articular fractures are challenging in regard to treatment options, timing of surgical intervention, rehabilitation, and disposition. Early ankle arthrodesis should be reserved for severely comminuted fractures with poor bone quality. However, high-risk patients requiring early stability and weight bearing may be suitable for early hindfoot arthrodesis with an intramedullary TTC nail. There are various techniques of ankle arthrodesis for the early treatment of difficult pilon fractures.9,12 Published techniques include external fixators,13,14 cannulated blade plates,6,15 Ilizarov fixators with bone transport,16 and antegrade intramedullary nailing.17 Bozic et al6 described 15 cases of nonreconstructable pilon fractures treated with primary ankle arthrodesis using a fixed-angle blade plate at an average of 20 weeks after initial injury. Stable arthrodesis was achieved in all patients at an average of 15 weeks, with 1 case of hardware breakage. No secondary arthrodesis procedures were performed, and all patients were ambulating independently at 39 weeks after surgery. Niikura et al17 described 2 patients with nonreconstructable tibial pilon fractures treated with tibiotalar arthrodesis using an antegrade intramedullary nail from the proximal tibia. Both patients were pain free and could ambulate independently at the follow-up at >1 year, but the long-term effects of knee pain commonly associated with tibial intramedullary were unknown. Intramedullary nailing has the potential advantages of decreased soft-tissue dissection, decreased implant bulk in comparison with plates, load sharing, and lower rates of infection. In the present case, use of a retrograde TTC intramedullary nail sacrificed the subtalar joint through a limited joint preparation, thus shortening the extremity by approximately 1 cm, increasing the likelihood of early osteoarthritis in adjacent joints and impairing normal ankle hindfoot motion gait mechanics.18-20 However, early
Foot & Ankle Specialist
hindfoot stability was achieved with decreased soft-tissue dissection. Our patient fortunately did not have any postoperative complications such as wound breakdown, infection, or hindfoot instability. She was able to ambulate immediately in a CAM boot without having to undergo non–weight-bearing precautions and extensive rehabilitation. It is important to note that this decision for immediate ambulation was chosen by the patient and did not follow the advice of the surgical team. The goal of the procedure was to provide a stable plantigrade foot for ambulation in place of preserving ankle and subtalar motion, given the patient’s complex medical and socioeconomic status. Our patient had decreased pain, independent ambulation, and an AOFAS Ankle-Hindfoot score of 79 at the latest follow-up, indicating an acceptable clinical and functional result. We believe that additional indications for early TTC nailing in the treatment of complete articular pilon fractures may include severely impacted fragility fractures, obese diabetic patients, and patients in resource-limited environments who cannot comply with standard rehabilitation protocols. However, future studies are required to evaluate these potential indications and the risks and benefits of each and the individual circumstances for each patient. Overall, management of comminuted pilon fractures in patients with multiple comorbidities is challenging, and each treatment plan must be tailored to the individual needs of the patient, factoring in articular comminution, bone loss, and socioeconomic issues. External fixation, ORIF, and tibiotalar fusion are all established treatment options, with early retrograde TTC nailing representing a potential alternative technique in specific patient populations.
Conclusions In the case described here, we were able to achieve stable fixation of a complex, complete articular pilon fracture using temporary external fixation with early retrograde TTC arthrodesis nailing. The patient was satisfied with
her treatment and had decreased pain and independent ambulation at final follow-up. This case demonstrates a previously unreported treatment option in the acute setting for a difficult pilon fracture in a patient with multiple comorbidities and socioeconomic disadvantages. It is important to inform patients before surgery of long-term functional limitations as a result of TTC arthrodesis despite improvements in stability and pain. The potential consequences of deep infection, nonunion, or hardware failure after early TTC nail for pilon fractures are a limitation of the procedure that needs to be investigated in the future along with a larger series of patients.
References 1. Harris AM, Patterson BM, Sontich JK, Vallier HA. Results and outcomes after operative treatment of high-energy tibial plafond fractures. Foot Ankle Int. 2006;27:256-265. 2. Marsh JL, Weigel DP, Dirschl DR. Tibial plafond fractures: how do these ankles function over time? J Bone Joint Surg Am. 2003;85-A:287-295. 3. Wyrsch B, McFerran MA, McAndrew M, et al. Operative treatment of fractures of the tibial plafond: a randomized, prospective study. J Bone Joint Surg Am. 1996;78:16461657. 4. Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma. 2001;15:153-160. 5. Marsh JL, Bonar S, Nepola JV, Decoster TA, Hurwitz SR. Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am. 1995;77:1498-1509. 6. Bozic V, Thordarson DB, Hertz J. Ankle fusion for definitive management of nonreconstructable pilon fractures. Foot Ankle Int. 2008;29:914-918. 7. Ruedi TP, Allgower M. Fractures of the lower end of the tibia into the ankle joint. Injury. 1969;1:92-99. 8. Thordarson DB. Fusion in posttraumatic foot and ankle reconstruction. J Am Acad Orthop Surg. 2004;12:322-333. 9. Zelle BA, Gruen GS, McMillen RL, Dahl JD. Primary arthrodesis of the tibiotalar joint in severely comminuted high-energy pilon fractures. J Bone Joint Surg Am. 2014;96:e91.
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10. Kline AJ, Gruen GS, Pape HC, Tarkin IS, Irrgang JJ, Wukich DK. Early complications following the operative treatment of pilon fractures with and without diabetes. Foot Ankle Int. 2009;30:1042-1047. 11. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures: variables contributing to poor results and complications. Clin Orthop Relat Res. 1993;292:108-117. 12. Beaman DN, Gellman R. Fracture reduction and primary ankle arthrodesis: a reliable approach for severely comminuted tibial pilon fracture [published online May 21, 2014]. Clin Orthop Relat Res. doi:10.1007/ s11999-014-3683-x.
13. Kenzora JE, Simmons SC, Burgess AR, Edwards CC. External fixation arthrodesis of the ankle joint following trauma. Foot Ankle. 1986;7:49-61. 14. Stiehl JB, Dollinger B. Primary ankle arthrodesis in trauma: report of three cases. J Orthop Trauma. 1988;2:277-283. 15. Morgan SJ, Thordarson DB, Shepherd LE. Salvage of tibial pilon fractures using fusion of the ankle with a 90 degrees cannulated blade-plate: a preliminary report. Foot Ankle Int. 1999;20:375-378. 16. Feibel RJ, Uhthoff HK. Primary Ilizarov ankle fusion for nonreconstructable tibial plafond fractures [in English, German]. Oper Orthop Traumatol. 2005;17:457-480.
17. Niikura T, Miwa M, Sakai Y, et al. Ankle arthrodesis using antegrade intramedullary nail for salvage of nonreconstructable tibial pilon fractures. Orthopedics. 2009;32(8):pii. 18. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis: long-term follow-up with gait analysis. J Bone Joint Surg Am. 1979;61: 964-975. 19. Chou LB, Mann RA, Yaszay B, et al. Tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2000;21:804-808. 20. Rammelt S, Pyrc J, Agren PH, et al. Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study. Foot Ankle Int. 2013;34:1245-1255.
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〈 Case Report 〉 Early Tibiotalocalcaneal Arthrodesis Intramedullary Nail for Treatment of a Complex Tibial Pilon Fracture (AO/OTA 43-C) Abstract: Management of severely comminuted, complete articular tibial pilon fractures (AO/OTA 43C) remains a challenge, with few treatment options providing good clinical outcomes. Open reduction and internal fixation of the tibial plafond, tibiotalar arthrodesis, and salvage hindfoot reconstruction procedures are all associated with surgical complications and functional limitations. In this report, we present a case of a complex pilon fracture in a patient with multiple medical comorbidities and socioeconomic disadvantages that was successfully and acutely treated with a retrograde tibiotalocalcaneal hindfoot arthrodesis nail. At final follow-up examination, the patient had decreased pain, a stable plantigrade foot, and could ambulate with normal shoes without any assistive devices. Levels of Evidence: Therapeutic, Level IV: Case Series
Keywords: tibiotalocalcaneal; arthrodesis; ankle; tibial plafond; hindfoot; salvage; internal fixation
Introduction
Andrew R. Hsu, MD, and Jan P. Szatkowski, MD
soft-tissue breakdown, deep infection, hardware failure, malunion, and nonunion.1,2 The optimal treatment for definitive management of comminuted, complete articular pilon fractures is controversial and remains unknown. Ankle arthrodesis
Tibial pilon fractures are challenging injuries to treat, with frequent complications In high-energy injuries, anatomical despite recent advances in surgical approaches, reconstruction of the tibiotalar joint is techniques, implants, and 1-4 rehabilitation. In highdifficult because of the level of bone loss energy injuries, anatomical reconstruction of the and articular damage.” tibiotalar joint is difficult because of the level of for posttraumatic osteoarthritis is bone loss and articular damage.1,2 commonly performed, but acute External fixation, anatomical open tibiotalar and subtalar arthrodesis for reduction and internal fixation (ORIF), definitive management are uncommon tibiotalar arthrodesis, and hindfoot treatments.6,8,9 We believe that early reconstruction procedures have all been tibiotalocalcaneal (TTC) arthrodesis with described in the literature, with modest a retrograde intramedullary nail may be results and clinical outcomes.1,2,4-7 indicated for a select group of high-risk Complications after external fixation and patients with severe fracture ORIF include pin-tract infections,
“
DOI: 10.1177/1938640014548322. From the Department of Orthopaedic Surgery, Rush University Medical Center (ARH), and the Department of Orthopaedic Surgery, John H. Stroger, Jr Hospital of Cook County (JPS), Chicago, Illinois. Address correspondence to: Andrew R. Hsu, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St, Suite #300, Chicago, IL 60612; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
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comminution, poor bone quality, compromised soft-tissue envelopes, multiple comorbidities, and/or socioeconomic disadvantages to provide a stable, plantigrade foot for early weight bearing with decreased soft-tissue injury. In this report, we present a case of a homeless, drug-addicted patient with multiple medical comorbidities who sustained a complete articular pilon fracture (AO/OTA 43-C) with anterior bone loss after a fall from height. The patient was initially treated with a temporizing joint-spanning external fixator for soft-tissue compromise followed by a TTC nail 2 weeks after initial injury. The patient was able to bear weight on the operative extremity early on after surgery and, at the most recent follow-up, had decreased pain, could ambulate without an assistive device in normal shoes, and was satisfied with her clinical and functional outcome.
Case Report A 58-year-old homeless African American woman presented to the emergency department with severe left ankle pain after jumping out of a second story window while fleeing from an assailant. The patient had altered mental status and tested positive for cocaine toxicity. She was agitated, combative, and unable to follow commands on initial examination. She had moderate pain with ankle range of motion with diffuse swelling over the left lower extremity, without blister formation. Gross motor and sensation were intact, dorsalis pedis and posterior tibial pulses were palpable, and compartments were compressible with no evidence of compartment syndrome. There were no open lesions or lacerations indicating an open fracture. The patient’s past medical history was positive for seizures, stroke, osteoporosis, hypertension, cocaine abuse, and a right eye infection requiring complete eye excision. She smoked one pack of cigarettes per day and was taking antiseizure medications at the time of injury. Plain radiographs of the left ankle revealed a closed, comminuted complete
Figure 1. Initial anteroposterior (A) and lateral (B) radiographs of the left ankle showing a closed, comminuted, complete articular pilon fracture with anterior cortex bone loss and anteromedial dislocation of the talus in the tibiotalar joint.
articular pilon fracture (AO/OTA 43-C) with loss of anterior cortex, poor bone quality, and anteromedial dislocation of the talus in the tibiotalar joint (Figures 1A and 1B). The patient was placed into a short-leg splint for immobilization for several hours until her mental status improved and she was deemed to be alert and oriented to person, place, and time. She was then interviewed completely, and informed consent was obtained. In the interim period, the emergency department obtained a CT scan to further evaluate the fracture. Although the fracture was impacted with anterior tibiotalar dislocation, the CT scan further clarified the extent of anterior bone loss (>50%) and articular comminution (Figures 2A-2C). The patient was brought to the operating room for closed reduction under general anesthesia and application of a joint-spanning external fixator in a delta-frame configuration to stabilize the fracture and reduce soft-tissue compromise (Figures 3A and 3B). Two proximal tibial pins were placed along with 2 calcaneal pins for increased stability and rotational control, with adequate restoration of ankle alignment.
The patient was kept in the hospital for pain control, physical therapy, and management of her multiple medical problems. On hospital day 7, the patient developed large fracture blisters over the medial, lateral, and posterior malleoli that were treated with soft dressings and antimicrobial wound care. The risks and benefits of and alternatives to surgical interventions, including ORIF, definitive external fixation, and tibiotalar and TTC arthrodesis, were discussed in full with the patient. The patient clearly indicated that she would likely be unable to comply with any weight-bearing precautions, pin-site and/or associated external fixator care, or postoperative therapy, given her lack of social support and living situation. As a result, the primary goal was to obtain a stable, plantigrade foot that could be weight bearing early on with decreased soft-tissue dissection and postoperative rehabilitation. The patient ultimately elected to undergo a retrograde TTC arthrodesis intramedullary nail on hospital day 16. The patient chose to defer spinal anesthesia or a regional block by anesthesia because of personal concerns
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Figure 2. Preoperative coronal (A), sagittal (B), and axial CT (C) cuts of the tibial plafond showing the extent of articular comminution and >50% anterior bone loss.
Figure 3. Anteroposterior (A) and lateral (B) radiographs of the left ankle after closed reduction under anesthesia and placement of an external fixator on the day of presentation.
regarding the procedure. In the operating room under general anesthesia, an anterolateral incision was made across the tibiotalar joint in line with the fourth metatarsal. A large amount of fibula comminution was found, and all of the bone was saved and used as autologous bone graft for the ankle arthrodesis. The majority of the tibiotalar articular surface was delaminated as a result of the initial injury, and the remaining cartilage was
formally removed and underlying bone prepared with k-wires and osteotomes. The tibiotalar and subtalar joints were pinned into place, and the ankle was positioned into neutral flexion, 5° of valgus, and 10° of external rotation. A 200 × 10 mm retrograde TTC arthrodesis nail was inserted that included a built in 5° valgus bend at the ankle (T2 Ankle Arthrodesis Nail, Stryker, Mahwah, NJ; Figures 4A and 4B). Isolated subtalar
preparation was performed using intramedullary reaming. A talus screw was placed along with 2 tibia screws and 2 multiplanar calcaneus screws. Compression was achieved through the tibiotalar and subtalar joints through the mechanism of the TTC nail. A medium hemovac drain was placed along with a short-leg splint for temporary immobilization and wound protection. The patient had gross motor and sensation intact after surgery but unfortunately elected to leave the hospital against medical advice on postoperative day 1 for stated personal and social reasons that she would not elaborate on. As a result, the drain was removed, and the patient was given a CAM (controlled ankle motion) boot for ambulation that she was able to use with the assistance of crutches. The patient could not be contacted after leaving the hospital because of her homeless status and lack of telephone or nearby friends or relatives. Incisional sutures were removed by the emergency department approximately 2 weeks after surgery when the patient presented for a refill of her pain medications. The patient returned to the orthopedic clinic 3 months after surgery weight bearing as tolerated in her CAM boot without the need for crutches. Her incisions were clean, dry, and intact, and she had mild, occasional pain with ambulation with no limitations in her stated activities of daily living. She was able to ambulate approximately 3 blocks prior to stopping because of pain and had some difficulty on uneven terrain and inclines. On exam, she ambulated with an antalgic gait and had no ankle or hindfoot motion because of her TTC fusion. She had a stable ankle-hindfoot with good alignment and a plantigrade foot. Her total AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Score was 69. Radiographs showed good ankle and subtalar alignment with hardware intact and initial consolidation of the arthrodesis across the formally prepared tibiotalar joint and reamed subtalar joint (Figures 5A and 5B). At the most recent follow-up 17 months following the
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Figure 4. Postoperative anteroposterior (A) and lateral (B) radiographs on postoperative day 1 demonstrating good alignment of a retrograde tibiotalocalcaneal intramedullary arthrodesis nail, with fibula comminution serving as autologous bone graft at the tibiotalar joint.
procedure, the patient had no pain, was ambulating independently with normal shoes, was satisfied with her overall outcome, and had an AOFAS AnkleHindfoot score of 79.
Discussion
Figure 5. Postoperative anteroposterior (A) and lateral (B) radiographs 3 months after surgery show good ankle and subtalar alignment with hardware intact and initial consolidation of the arthrodesis across the hindfoot.
Tibial pilon fractures have a high rate of complications and posttraumatic arthritis, with often modest clinical outcomes cited in the literature.1-4,6 Early stabilization with an external fixator followed by staged definitive treatment with ORIF to achieve anatomical articular restoration and fixation has become a mainstay of treatment.1,2,4 External fixation devices are often large, poorly tolerated, and have complications, including pin-tract infections. Infection is a common, early postoperative complication after ORIF that may require further surgical intervention, including revision arthrodesis or amputation.10,11 In a review of 51 tibial pilon fractures, including closed and open injuries, Blauth et al4 found that patients treated with a 2-stage procedure consisting of primary reduction and articular reconstruction with minimally invasive osteosynthesis and short-term external fixation followed by secondary stabilization with limited incisions had greater ankle range of motion, decreased pain, and improved return to work compared with 1-stage procedures. Harris et al1 reported a series of 79 pilon fractures that were treated with either limited articular reduction and external fixation (16) or ORIF (63) approximately 8 days after injury. In the early postoperative period, there were 2 superficial wound infections and 3 deep infections, whereas in the late postoperative period, there were 2 nonunions and 4 malunions. Also, 31 fractures (39%) went on to develop posttraumatic arthritis at the 2-year follow-up. Marsh et al5 have reported that 15% of patients have persistent pain at the 2-year follow-up after external fixation and/or ORIF of pilon fractures. In a follow-up study, the authors noted a 35-point decrease in SF (Short Form)-36 scores at the 5- to 11-year follow-up,
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with 70% of patients having severe tibiotalar arthritis. Complex, complete articular fractures are challenging in regard to treatment options, timing of surgical intervention, rehabilitation, and disposition. Early ankle arthrodesis should be reserved for severely comminuted fractures with poor bone quality. However, high-risk patients requiring early stability and weight bearing may be suitable for early hindfoot arthrodesis with an intramedullary TTC nail. There are various techniques of ankle arthrodesis for the early treatment of difficult pilon fractures.9,12 Published techniques include external fixators,13,14 cannulated blade plates,6,15 Ilizarov fixators with bone transport,16 and antegrade intramedullary nailing.17 Bozic et al6 described 15 cases of nonreconstructable pilon fractures treated with primary ankle arthrodesis using a fixed-angle blade plate at an average of 20 weeks after initial injury. Stable arthrodesis was achieved in all patients at an average of 15 weeks, with 1 case of hardware breakage. No secondary arthrodesis procedures were performed, and all patients were ambulating independently at 39 weeks after surgery. Niikura et al17 described 2 patients with nonreconstructable tibial pilon fractures treated with tibiotalar arthrodesis using an antegrade intramedullary nail from the proximal tibia. Both patients were pain free and could ambulate independently at the follow-up at >1 year, but the long-term effects of knee pain commonly associated with tibial intramedullary were unknown. Intramedullary nailing has the potential advantages of decreased soft-tissue dissection, decreased implant bulk in comparison with plates, load sharing, and lower rates of infection. In the present case, use of a retrograde TTC intramedullary nail sacrificed the subtalar joint through a limited joint preparation, thus shortening the extremity by approximately 1 cm, increasing the likelihood of early osteoarthritis in adjacent joints and impairing normal ankle hindfoot motion gait mechanics.18-20 However, early
Foot & Ankle Specialist
hindfoot stability was achieved with decreased soft-tissue dissection. Our patient fortunately did not have any postoperative complications such as wound breakdown, infection, or hindfoot instability. She was able to ambulate immediately in a CAM boot without having to undergo non–weight-bearing precautions and extensive rehabilitation. It is important to note that this decision for immediate ambulation was chosen by the patient and did not follow the advice of the surgical team. The goal of the procedure was to provide a stable plantigrade foot for ambulation in place of preserving ankle and subtalar motion, given the patient’s complex medical and socioeconomic status. Our patient had decreased pain, independent ambulation, and an AOFAS Ankle-Hindfoot score of 79 at the latest follow-up, indicating an acceptable clinical and functional result. We believe that additional indications for early TTC nailing in the treatment of complete articular pilon fractures may include severely impacted fragility fractures, obese diabetic patients, and patients in resource-limited environments who cannot comply with standard rehabilitation protocols. However, future studies are required to evaluate these potential indications and the risks and benefits of each and the individual circumstances for each patient. Overall, management of comminuted pilon fractures in patients with multiple comorbidities is challenging, and each treatment plan must be tailored to the individual needs of the patient, factoring in articular comminution, bone loss, and socioeconomic issues. External fixation, ORIF, and tibiotalar fusion are all established treatment options, with early retrograde TTC nailing representing a potential alternative technique in specific patient populations.
Conclusions In the case described here, we were able to achieve stable fixation of a complex, complete articular pilon fracture using temporary external fixation with early retrograde TTC arthrodesis nailing. The patient was satisfied with
her treatment and had decreased pain and independent ambulation at final follow-up. This case demonstrates a previously unreported treatment option in the acute setting for a difficult pilon fracture in a patient with multiple comorbidities and socioeconomic disadvantages. It is important to inform patients before surgery of long-term functional limitations as a result of TTC arthrodesis despite improvements in stability and pain. The potential consequences of deep infection, nonunion, or hardware failure after early TTC nail for pilon fractures are a limitation of the procedure that needs to be investigated in the future along with a larger series of patients.
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