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FIBULAR FIXATION IN Pilon F RACTURE

FIBULAR FIXATION IN Pilon F RACTURE. Chairiandi Siregar . Mechanism of Injury. Low Energy (Rotational Force) High Energy (Axial Loading) Motor Vehicle Coalition Fall from height Incidence of fibular fx is 85% of all pilon fx. Fracture Personality . Open vs Close ?

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FIBULAR FIXATION IN Pilon F RACTURE

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  1. FIBULAR FIXATION INPilon FRACTURE Chairiandi Siregar

  2. Mechanism of Injury • Low Energy (Rotational Force) • High Energy (Axial Loading) • Motor Vehicle Coalition • Fall from height • Incidence of fibular fx is 85% of all pilon fx

  3. Fracture Personality • Open vs Close ? • Articular surface damage ? • Metaphysealcomminution ? • Diaphyseal involvement ? • Ipsilateral tibia or foot (talus)fracture?

  4. Fracture morphology: how many fragments ? • Anterior fraqment • Medial fragment • Posterior fragment • More fragment? • More comminution? • what about fibula?

  5. Ruedi-Allgower classification I II III • Grade I • Minimal displacement • No severe joint injury • Grade II • Moderate displacement • Minimal comminution • Grade III • Comminution and impaction

  6. AO/OTA classification A : Extraarticular B : Partial Articular C : Complete intraarticular

  7. (Careful) Physical Examination • Vascular Injury • Swelling • Fracture Blisters • Blood filled • Clear filled • Patient comorbidites • Smoking • Diabetic and Peripheral Vascular Disease • Alcoholism

  8. Treatment Options • Plaster • Traction (Calcaneal) • ORIF Plate & Screw (Ruedi & Allgower1969) • 2 stage (Fibular plating + ankle spanning exfix followed by ORIF in the next 2 or 3 weeks; Patterson) • Definitive external fixation • Primary arthrodesis

  9. Goal in PilonFx Treatment • Restoring Anatomical Surface • Restoring Mechanical Alignment • Maintaining Joint Stability • Achieving fracture union • Regaining functional and pain-free weight bearing • Avoiding complication FUNCTIONAL OUTCOME !!

  10. Normal Ankle Joint X-Ray • Tibiofibular overlap ~ 10mm • Tibiofibular clear space <5mm • Talar tilt

  11. Time is Important - When to operate ? • Close fx Tscherne grade ?? • Open fx  Gustilo grade?? DELAYED UNTIL SKIN WRINKLE SIGN is (+)

  12. Factors involving outcome The Injury • Articular damage • Metaphysealcomminution • Diaphysealinvolvment • Soft tissu compromise • Medical comorbidities • Fibular fixation ?? The Surgeon • Atraumatic handling • Proper implant • Time of surgery

  13. Fixation of The Fibula • Study design • 98 pilon fractures • Group A : ORIF Fibular Plating (n=50) • Group B : ORIF Pin fixation (n=23) • Group C : Treated conservatively (25) • Result • Decrease trend of malunion and ankle arthrosis • Better clinical outcome • FIBULAR FIXATION IS IMPORTANT Lee YS, et al. Stabilisation of the fractured fibula plays an important role in the treatment of pilon fractures: a retrospective comparison of fibular fixation methods. International Orthopaedics (SICOT) (2009) 33:695-699

  14. The advantage of fibular reduction and fixation • Increasing mechanical stability • Assissting the reduction of anterolateral articular fragment • Restoring the length and alignment of the tibia • Reduces the ankle ‘mortise’ • Prevent lateral shift of the talus

  15. The disadvantages of fibular fixation • Possible wound infection • Possible hardware removal • Malreduction of fibula will make the reduction of the tibia even harder

  16. Fibular Plating + Tibial Plating

  17. Fibular Intramedullary wiring + Tibial Plating

  18. Fibular Fixation + Tibia ExFix

  19. Ankle spanning exfix + Fibular Plating

  20. OLD AND NEW... THANK YOU

  21. DISCUSSION ?

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