Bad Ankle with Soft Tissue Injuries: Fix them all Now! Dont Wait! - - PowerPoint PPT Presentation

Bad Ankle with Soft Tissue Injuries: Fix them all Now! Don’t Wait!

BOB ZURA, MD OSET 2017 LAS VEGAS

Disclosures

• Consultant:

– Smith-Nephew – Bioventus – Cardinal Health

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Case

Case

Case

Case

Case:

This is really about soft tissue

• Yes – you can wait, but….

– Easier if wound vac – What if you closed the skin

• Wait until it heals?
• Re-open?
• What options does the soft tissue envelope/injury give you?
• The question is:

– Is it safe to the soft tissues to fix early?

Assumption – the open fracture is adequately clean and does not require redebridement.

Immediate internal fixation of open ankle fractures.

J Orthop Trauma. 1988.

Wiss DA, Gilbert P, Merritt PO, Sarmiento A.

• 76 open ankles treated with immediate fixation
• Seventy-two percent of the patients had a satisfactory result
• Deep infection occurred in 5% of the patients
• We believe immediate internal fixation is the treatment of

choice for displaced open ankle fractures, but this form of treatment does have a significant rate of complications.

Treatment of open ankle fractures. Immediate internal fixation versus closed immobilization and delayed fixation.

Clin Orthop Relat Res. 1989. Bray TJ, Endicott M, Capra SE.

• Thirty-one open ankle fractures

– 15 delayed – 16 immediate

• One case in each group became infected
• Functional scores at follow-up examination were the same
• immediate showed less impairment of range of motion but had a greater

incidence of chronic ankle swelling

• Significant shorter LOS for immediate
• Faster recovery with no more infection

Open ankle fractures. The indications for immediate

• pen reduction and internal fixation.Review article

Clin Orthop Relat Res. 1993. Johnson EE, Davlin LB.

• 22 open ankles treated with immediate fixation
• There were six Grade I (27%), 15 Grade II (68%), and one Grade

III (5%) injuries.

• Excellent results were achieved in 14 patients (64%); good

results in five (23%), and poor results in three (13%).

• There were no deep infections or nonunions.
• Immediate debridement, irrigation, reduction, and internal

fixation of open ankle fractures is clearly indicated in Grade I and clean Grade II open injuries.

Does this apply to “modern” literature?

The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study.

White TO, Guy P, Cooke CJ, Kennedy SA, Droll KP, Blachut PA, O'Brien PJ. JOT 2010

• 95 pilons
• Primary ORIF was performed within 24 hours in 70% of cases and within 48 hours in 88%.

–

Six patients developed a deep wound infection or dehiscence that required surgical débridement, four after open fractures (four of 21 [19%]) and two after closed fractures (two of 74 [2.7%]).

• Provided surgery is performed expeditiously by experienced orthopaedic trauma surgeons,

most tibial pilon fractures can be stabilized by primary ORIF within a safe and effective

• perative window with relatively low rates of wound complications, a high quality of reduction,

and functional outcomes that compare favorably with the published results for all other reported surgical treatments of these severe injuries.

• Comparison of Early and Delayed Open

Reduction and Internal Fixation for Treating Closed Tibial Pilon Fractures.

• Tang X1, Liu, Tu CQ, Li J, Li Q, Pei FX.
• If soft tissue conditions are acceptable, early ORIF for treating

closed type C pilon fractures can be safe and effective, with:

– similar rates of wound complication – fracture union – good functional recovery but shorter operative time, union time, and hospital stay.

• These results favorably compare with delayed ORIF treatment.

• Complications and early results after
• perative fixation of 68 pilon fractures of

the distal tibia.

• Lomax, Singh, N Jane, C Senthil.
• Fixation of these complex fractures in subspecialist units can

achieve overall low rates of wound complications, with definitive fixation of selected fractures within 48 h of initial presentation achieving comparable results to those fixed in a delayed fashion.

• However, this injury continues to have a significant overall

complication rate with a high chance of developing early posttraumatic arthritis and of requiring further surgery.

Summary

• These are soft tissue injuries
• Must adequately debride and irrigate open fractures
• In open injuries – ok (and I think preferable) to fix early

– No need to revisit incisions

• Personalize the treatment to each case
• It is SAFE to fix these early in experienced hands
• Complications will still occur as these are devastating injuries

Early is ok, ok with open fractures?

• Look to the tibia
• We know we can fix early if low grade and clean

Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?

Duyos, Oscar A. MD; Beaton-Comulada, David MD; Davila-Parrilla, Ariel MD; Perez-Lopez, Jose Carlos MD; Ortiz, Krystal BS; Foy-Parrilla, Christian MD; Lopez-Gonzalez, Francisco MD

• Open tibial shaft fractures should be débrided within 24 hours

after injury.

• Primary reamed intramedullary nailing appears to be a

reasonable option for the management of Gustilo-Anderson types 1 and 2 open tibial shaft fractures.

Thank You!