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AO Trauma NA Fellows Webinar Pilon Strategies for Success and Avoiding Complications

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AO Trauma North America


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1-Sentence-Summary

The AO Trauma NA Fellows Webinar on Pilon fractures delves into the complexities of managing these injuries, emphasizing staged surgical approaches, meticulous soft tissue management, and the critical importance of precise fracture reduction and fixation techniques to enhance outcomes and minimize complications.

Favorite Quote from the Author

the soft tissue trumps everything because if you say hey I don't I don't really care I'm going to do the approach that I want and see what happens that's going to end up in a baloney amputation.

💨 tl;dr

This webinar dives into managing pilon fractures, emphasizing the importance of understanding X-rays, soft tissue health, and staged management. Key strategies include careful fracture reduction, using CT scans for planning, and ensuring secure fixation of articular fragments. Patience and ongoing learning are crucial for successful outcomes.

💡 Key Ideas

  • Focus on pilon fractures and the management strategies involved, particularly understanding X-rays and soft tissue injuries related to fracture patterns.
  • Staged management is critical, with stage one involving external fixation to restore length, alignment, and rotation, influencing surgical approaches and implant selection.
  • Importance of thorough fracture reduction techniques (closed or open) to ensure successful patient outcomes and avoid complications during external fixation.
  • Utilize CT scans for better assessment of open fractures and surgical planning, especially for complex injuries.
  • Healthy soft tissue envelope is crucial for successful healing and closure; assess soft tissue condition before surgery.
  • Every articular fragment requires secure fixation; offloading and protecting the fixation post-surgery is essential.
  • Surgical approach decisions should consider both skeletal injuries and soft tissue condition to avoid complications.
  • Dual column plating is important for maintaining reduction in complex fractures with significant bone loss.
  • Emphasize patience and thoroughness in managing complex injuries rather than rushing for immediate results.
  • Engage in ongoing learning and discussions about pilon fractures to improve surgical skills and patient outcomes.

🎓 Lessons Learnt

  • Understand Injury Management Guidelines: Always analyze X-rays and fracture patterns, and consider soft tissue injuries during initial management.

  • Prioritize Soft Tissue Condition: Soft tissue health is paramount; it often dictates surgical approaches and impacts outcomes.

  • Careful Fracture Reduction: Take time to ensure proper reduction of fractures, ensuring alignment on both AP and lateral views before leaving the OR.

  • Utilize Appropriate Imaging: Always get CT scans for open injuries to aid in planning and managing subsequent treatments effectively.

  • Engage in Thorough Debridement: Initial debridement is crucial to remove nonviable tissue and set the foundation for successful fracture management.

  • Plan Surgical Approaches Mindfully: Choose surgical access routes carefully to avoid complicating future management and ensure adequate soft tissue evaluation.

  • Consider Fibula's Role: Address the fibula accurately in treatment; its stability is crucial for overall fracture management.

  • Postoperative Planning is Essential: Establish a clear postoperative plan early on, as complex injuries can significantly affect recovery.

  • Adopt a Hybrid Approach When Necessary: Combining external fixation with intramedullary devices can enhance stability in complex fractures.

  • Continuous Learning and Mentorship: Engage with mentors and education organizations to improve skills and knowledge in surgical practices.

🌚 Conclusion

Mastering pilon fracture management requires a blend of technical skills, thorough assessment, and continuous education. Prioritizing soft tissue condition and careful planning can significantly enhance surgical success and patient recovery.

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In-Depth

Worried about missing something? This section includes all the Key Ideas and Lessons Learnt from the Video. We've ensured nothing is skipped or missed.

All Key Ideas

Webinar on Pilon Fractures

  • The webinar focuses on pilon fractures and the thought processes involved in their management.
  • Importance of understanding injury X-rays and the predictable nature of soft tissue injuries based on fracture patterns.
  • Discussion of staged management, particularly stage one involving external fixation to restore length, alignment, and rotation.
  • Emphasis on the influence of fracture pattern and soft tissue injury on surgical approach and implant selection.
  • The goal is to empower stage one treatment to facilitate a smoother stage two procedure.

Fracture Treatment Considerations

  • Be thoughtful in the way that we reduce the fracture, whether it's closed or open, to ensure successful patient treatment.
  • Errors can occur when applying an external fixer, such as leaving a patient short, particularly if the fibula is intact.
  • Understanding the talo-fibular relationships is crucial for achieving adequate fracture reduction.
  • The tailor must be centered under the pond on both AP and lateral views before leaving the operating room.
  • There are methods to make the definitive fixation stage more efficient and soft tissue friendly.
  • Fixing the fibula requires understanding the fracture and how it affects the position of the chaput and the vulgus.
  • If fixing the fibula, it must be done perfectly to avoid challenges in stage two of the procedure.
  • A meary implant can provide skeletal stability with minimal biological cost, especially for certain fracture patterns.
  • Soft tissue condition influences the choice of surgical approach and fixation method.
  • Reducing a shaft fracture early is easier and can be accomplished through soft tissue friendly techniques.

Surgical Approaches to Fractures

  • The soft tissue is amenable to surgical approaches even in compromised situations, allowing for effective fracture reduction.
  • CT scans are crucial for understanding open fractures and guiding surgical interventions to avoid reopening wounds.
  • Accessing and reconstructing fractures through open wounds can prevent the need for additional surgeries on those wounds, enhancing patient outcomes.
  • Initial surgery on open fractures is critical for optimal outcomes, aiming to stabilize and reduce fractures effectively.

Key Considerations in Surgical Management

  • Understand the fracture to avoid needing to backtrack on decisions made during surgery.
  • The importance of a healthy soft tissue envelope for successful closure and healing.
  • Use low-profile implants in the context of open wounds.
  • Patience and thoroughness are critical in managing complex injuries, rather than seeking immediate success.
  • The fibula can be beneficial or problematic depending on how it is managed.
  • Pre-operative CT scans can provide crucial information for early decision-making.
  • Evaluating soft tissue injuries, including their severity and need for future coverage, is essential before surgery.
  • Identifying skin at risk and other complications (like blisters) is vital for determining the patient's management plan.

Considerations for Surgical Decision-Making

  • Understanding previous incisions and hardware placement is crucial for decision-making in patient management.
  • Consider whether the fibula injury is comminuted or simple and its impact on treatment decisions.
  • Long-term management of the patient should be a factor in determining the type of intervention.
  • The stability of the injury (length stable vs. transverse) influences the use of intramedullary implants.
  • Preoperative CT scans are essential for assessing open injuries and planning definitive management.
  • The choice of surgical approach (anterior lateral vs. anterior medial) can affect future treatment options and complications.

Pilon Fractures Management Insights

  • Understanding different surgical approaches (posterior lateral, direct lateral, posterior medial, direct medial) is crucial for management of pilon fractures.
  • Engaging in higher-level discussions and case applications enhances learning in the context of pilon fractures.
  • Atypical pilon fractures present unique challenges and require careful consideration of factors like bone stock and energy distribution in the injury.
  • Patient discussions post-surgery are critical, especially for complex pilon fractures that can lead to significant life changes.
  • The relationship between the talus and fibula in pilon fractures is important, particularly when considering the difficulty of separating the talus from an intact fibula.

Anterior Plafond Injury Insights

  • The anterior plafond injury can be deceptively simple, but it's actually complex and concerning when pulverized bone is involved.
  • Intrinsic stability during fracture reduction and fixation is critical for maintaining reduction, especially with powdered bone.
  • Recognizing and planning for marginal impaction in posterior segments is essential when evaluating CT scans of these injuries.
  • If the Tais is not contained in anterior escape injuries, it leads to a higher risk of post-traumatic arthritis and treatment failure.
  • Anterior escape plafond injuries require specific strategies to address potential pitfalls and optimize patient outcomes.

Surgical Considerations for Articular Fragments

  • Every single articular fragment requires an implant for secure fixation, as they are small and fragile.
  • Offloading and protection of the fixation post-surgery is critical to prevent complications.
  • The use of a ring fixator could allow weight-bearing for patients, promoting mobility compared to a static fixation.
  • Fragment-specific fixation and anatomic reduction are essential for successful outcomes in these injuries.
  • A gastroc recession may help in offloading the affected area post-operation.
  • There’s a risk of avascular necrosis of the anterior fragments during the revascularization process post-surgery.
  • The choice of surgical approach (anterolateral vs. direct anterior vs. anteromedial) is influenced by both skeletal and soft tissue injuries.
  • Respecting the extensor retinaculum during surgery is crucial to avoid tendon bowstringing.

Surgical Considerations in Orthopedic Procedures

  • The importance of experimenting with z-plasty for the extensor retinaculum to facilitate closure after incision.
  • Anterolateral approach can provide better access through different intervals offered by the skin incision.
  • Midfoot control is crucial, especially in patients with a fixed acinus, to avoid putting excessive pressure on fixation.
  • Advancing the bases in pilon fracture treatment may be more effective than aiming for complex solutions.
  • The surgeon's mentality should embrace additional measures, like prolonged fixation, if they genuinely improve patient outcomes.
  • The role of definitive acute fixation is highly dependent on the soft tissue envelope in the case of a tibial shaft fracture plus a pilon injury.

Fracture Management Considerations

  • The injury has two components: a shaft fracture best treated with a nail and an articular injury with a segmental fibula fracture.
  • Importance of assessing soft tissue condition and energy of the injury before acute fixation.
  • A push towards early definitive management of pilon fractures may not be appropriate for complex cases.
  • The decision to fix the fibula during surgery can vary based on the fracture's nature and soft tissue condition.
  • Using a medullary device for distal fractures while minimizing soft tissue damage is a consideration.
  • A hybrid construct approach can be effective, combining external fixation and medullary implants for complex fractures.

Fracture Management Strategies

  • Looking for functional reduction, indirect reduction, length alignment, and rotation in fracture management.
  • A flexible implant like a Meary nail can control fractures and provide secondary bone healing.
  • The complexity of closed nailing in the presence of a pleon fracture can complicate alignment and salvage options.
  • Creating a bone tube through the metaphyseal transition simplifies nailing and pleon management.
  • Acute compartment syndrome is a rare concern after pilon fractures, especially with metadiaphyseal and diaphyseal extensions.
  • The use of intracortical screws as clamp replacements can help maintain bony contact and promote union during open clamping of fractures.
  • Mixing primary and secondary bone healing strategies can be confusing but is manageable with proper techniques.

Key Considerations in Managing Soft Tissue Injuries

  • The importance of thorough and adequate debridement to set up for success in managing soft tissue injuries.
  • The role of accurately assessing and addressing the trajectory of pins and fracture deformities in treatment.
  • The necessity of considering a mini fragment implant for maintaining reduction in cases with medial open wounds.
  • The significance of fixing the fibula to resist valgus failure in skeletal injuries.
  • The need for careful and intentional application of external fixators (x-fix) as if they are definitive management for the patient.
  • The impact of soft tissue condition on surgical approach choices and access to injuries.

Considerations in Surgical Approaches for Injuries

  • Every injury presents unique nuances, necessitating a careful assessment of the skeletal injury and soft tissue condition before determining the surgical approach.
  • Soft tissue injuries often dictate surgical decisions; ignoring them can lead to severe complications like amputation.
  • An anterolateral approach may be required when the initial preferred method is obstructed by soft tissue damage, even if it's not the optimal choice.
  • Dual column plating is crucial for maintaining reduction and preventing non-union in complex fractures with significant bone loss or comminution.
  • The timing for placing medial column support should consider the contamination level of the medial wound, with options for delayed intervention based on the injury's cleanliness.

Surgical Insights and Learning Opportunities

  • Early implant acceptance is complicated by progressive mosis or extreme contamination.
  • Closing the medial wound on day one with a plate and fibula fixation facilitates better healing and reduces wound breakdown risk.
  • Anatomic reduction of simple medial fractures allows for better length adjustment on the lateral side.
  • Osteotomy, whether early or late, presents challenges in practice despite theoretical benefits; preventative measures are emphasized instead.
  • The webinars aim to provide valuable learning and foster friendships to enhance patient care.
  • Encouragement to join AO for ongoing learning and improvement in surgical skills post-fellowship.

All Lessons Learnt

Injury Management Guidelines

  • Understand the injury X-rays and fracture pattern.
  • Be mindful of soft tissue injuries in acute management.
  • Stage one should include a thoughtful external fixation procedure.
  • Set yourself up for success in stage two.

Fracture Treatment Considerations

  • Be thoughtful in the way that we reduce the fracture.
  • Never leave the operating room without the tailor centered under the pond on both the AP and lateral view.
  • Understand the fibula's role in fracture treatment.
  • Consider soft tissue recovery when planning definitive fixation.
  • Fixing the fibula requires precision.
  • Use a medullary implant for additional stability with minimal biological cost.
  • Early reduction is easier and can be done through soft tissue-friendly techniques.

Fracture Management Guidelines

  • Get CT scans for open fractures preop
  • Access through open wounds for fracture reduction
  • First day access is crucial
  • Avoid reopening wounds if possible

Surgical Guidelines for Open Wound Treatment

  • Fix part of the fracture through the open wound only if necessary.
  • Complete and thorough debridement is essential.
  • Use low-profile implants for open wounds.
  • Be patient and thoughtful in your approach.
  • Understand the role of the fibula in treatment.
  • Pre-exfix CT can provide valuable information.
  • Evaluate the soft tissues and injury severity thoroughly.
  • Assess if the injury is likely to need soft tissue coverage.
  • Identify skin at risk during evaluation.

Surgical Considerations

  • Understand previous incisions and hardware impact: Before deciding on a treatment plan, consider how any past surgeries or hardware might affect your current decisions and future management.
  • Evaluate long-term management needs: Determine if the patient requires long-term management. If you're unsure about definitive treatment, reconsider your approach to avoid complicating future care.
  • Assess injury complexity: Be clear on whether the injury is comminuted or simple, as this will influence your ability to achieve proper alignment and rotation during treatment.
  • Consider length stability: When using intramedullary implants, assess if there's significant comminution or shear injuries that could lead to complications like shortening, impacting definitive fixation.
  • Avoid burning bridges: Ensure you have adequate imaging (like a preop CT) to guide your surgical approach, as poor decisions in the initial intervention can hinder future treatment options.
  • Utilize CT scans for open injuries: Always obtain a CT scan for open injuries to better plan your intervention and manage subsequent stages effectively.
  • Plan approaches carefully: Think through your surgical approach (anterior lateral vs. anterior medial) before proceeding, as it affects your management and future interventions.

Surgical Approach Considerations

  • Avoid Burning Bridges with Initial Approaches: It's crucial to carefully consider your first surgical approach to avoid complicating future management steps.
  • Engage in Q&A During Discussions: Active participation in discussions can clarify confusing points and enhance understanding of complex cases.
  • Pay Attention to Patient-Specific Factors: Recognizing unique characteristics like foot structure (e.g., cavus foot) can influence treatment strategies and outcomes.
  • Postoperative Planning is Vital: Establish a clear postoperative plan early, as pylon fractures can significantly impact a patient's life and recovery.
  • Understand the Energy Distribution in Fractures: Acknowledge that the localized energy distribution in atypical pylon fractures may complicate treatment and increase failure risks.

Clinical Guidelines for Injury Management

  • Always plan for marginal impaction when reviewing CT scans.
  • Containing the Tais in anterior escape injuries is critical.
  • Use structural substitutes for filling metal voids in fractures.

Surgical Considerations for Articular Fragments

  • Every articular fragment needs secure fixation.
  • Unloading and protection are essential for recovery.
  • Consider using a ring fixator for weight bearing.
  • Protect the fixation area postoperatively.
  • Think about gastroc recession for offloading.
  • Address potential avascular necrosis.
  • Choose the surgical approach based on injury specifics.
  • Respect the extensor retinaculum to avoid complications.

Surgical Techniques and Considerations

  • Experiment with Z-plasty for extensor retinaculum: If you haven't seen a Z-plasty, get into a cadaver lab and practice or consult experienced staff to improve your skills.
  • Use midfoot control for fixation: Employ a caor pin for dorsal flexion as it provides better control and stability than other fixation methods, especially in challenging cases.
  • Manage patient expectations with complex injuries: It's important to communicate to the patient that their injury is unique and may require additional interventions, even if it feels burdensome for both the surgeon and the patient.
  • Be adaptable with fixation strategies: Assess the soft tissue envelope of injuries to determine the appropriateness of definitive acute fixation, as it can vary based on each case.

Surgical Considerations for Fracture Management

  • Always assess soft tissue condition and energy involved before acute fixation. This is crucial to avoid complications during surgery.
  • Don’t rush into early definitive management for complex fractures. It's better to stage management if you're not confident in achieving a good outcome quickly.
  • Be cautious with fibula fixation decisions. Sometimes it's better to be patient with segmental fractures unless they are clearly transverse and manageable.
  • A hybrid construct may be necessary. Using external fixation alongside a medullary device can provide better stability in complex fracture cases.
  • Always evaluate the need for additional imaging, like a CT scan, to understand fracture patterns better before deciding on the surgical approach.

Surgical Recommendations for Bone Healing

  • Use a flexible implant like a Meary nail for secondary bone healing.
  • Consider a hybrid approach for reduction.
  • Be cautious with closed nail procedures on complex fractures.
  • Create a bone tube for straightforward nailing.
  • Avoid early open reduction internal fixation in certain fractures.
  • Use intracortical screws as clamp replacements.
  • Evaluate soft tissue wounds before choosing surgical approaches.

Surgical Management Considerations

  • Thorough Debridement is Crucial: Stage one should involve an appropriate debridement to remove nonviable tissue, which sets the foundation for successful management.
  • Understand Displacement Vectors: When applying an external fixator (xfix), it's essential to comprehend the displacement vectors to avoid complications like soft tissue necrosis.
  • Consider Mini Fragment Implants: In cases of open wounds and potential fixation failure, using a mini fragment implant can help maintain reduction on the medial side, aiding in better outcomes.
  • Fix the Fibula: Addressing the fibula in cases of significant valgus can help resist future failures and stabilize the overall structure.
  • Take Time with External Fixators: Applying an xfix should not be rushed; each application should be treated as definitive management, as circumstances may prevent later interventions.
  • Assess Soft Tissue Impact on Surgical Approaches: Always consider the condition of soft tissue when determining surgical approaches, as it significantly affects accessibility and outcomes.

Surgical Considerations in Fracture Management

  • Soft tissue considerations trump skeletal injury plans. Always prioritize the condition of the soft tissues over your preferred surgical approach to avoid severe complications like amputation.
  • Dual column support is crucial in complex fractures. For cype fractures with significant bone loss or comminution, implementing a dual column plating strategy is important for maintaining reduction and preventing non-union.
  • Delaying medial column fixation can be beneficial. If there’s an open medial wound, consider waiting until the wound has healed or dried up before placing medial column support to reduce infection risks.
  • Assess wound contamination before intervention timing. The cleanliness of an open wound impacts whether to proceed with immediate fixation or to wait for multiple debridements, so evaluate the wound's condition carefully.

Surgical Insights

  • Early implant acceptance is crucial: If the wound is not adequately debed, it can lead to complications like infection or wound breakdown. Closing the medial wound on day one with the fibula fix can promote healing.
  • Utilizing simple fractures effectively: For a simple medial fracture, achieving anatomic alignment allows for better length adjustment on the lateral side, reducing reliance on a comminuted fibula.
  • Osteotomy considerations: Performing an osteotomy for offloading the anterior pond is complex and may not yield beneficial results. It's often more practical to pursue simpler solutions.
  • Value of mentorship and collaboration: Engaging with mentors and peers in fellowships can enhance skills and knowledge, ultimately improving patient care.
  • Continuous learning is essential: Joining organizations like AO can encourage ongoing education and skill improvement in surgical practices.

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