Rapid reference review in orthopedic trauma : pivotal papers by David J. Hak MD MBA

By David J. Hak MD MBA

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17 (44%) were Rüedi-Allgöwer-type III fractures. ORIF group ▷ 3 open fractures ≫ All treated with emergent irrigation and débridement and ORIF within 5 hours of injury ▷ 16 closed fractures ≫ ORIF performed within 48 hours unless blisters or severe swelling ≫ Average time from injury to operative fixation: 5 days (3 hours to 17 days) External fixation group ▷ 7 open fractures ▷ 13 closed fractures Average follow-up: 39 months (25 to 51 months) Results ▶ The complications after ORIF tended to be more severe, and amputation was performed in 3 of these cases ▷ ORIF group ≫ 7 patients had 15 major complications requiring 28 additional operations ≫ 6 wound breakdowns requiring free flap coverage ≫ 6 deep infections or osteomyelitis ≫ 3 amputations ▷ External fixation group ≫ 4 patients had 4 major complications requiring 5 additional operations ≫ 1 partial nerve injury caused by external fixation pin resulting in mild reflex sympathetic dystrophy 40 Chapter 4 1 deep infection and failed skin graft requiring free flap ≫ 1 loss of reduction requiring treatment with thin wire fixator ≫ 1 pin tract infection subsequently resulting in ankle joint infection requiring 2 débridements and developing spontaneous tibiotalar fusion Clinical Score (higher score indicated better outcome) ▷ Patient questionnaire that evaluated pain and functional outcome ▷ Surgeon evaluation of gait and ROM Clinical Score at the most recent follow-up showed no significant difference between the 2 groups ▷ 61 points in ORIF group ▷ 72 points in external fixation group Clinical Scores were worse for type II and type III fractures regardless of the type of treatment.

Journal Information: J Orthop Trauma. 2010;24(12):757–763. ▶ While most surgeons have advocated a staged approach to fixation of tibial pilon fractures, this group of surgeons reported on a single-stage urgent ORIF of these injuries. C) treated between January 1993 and May 2005 ▷ Primary ORIF was deemed not possible in 20 cases and was treated with initial external fixation ≫ 4 cases were due to local soft-tissue factors ≫ 8 cases were due to delayed tertiary transfers ≫ 4 cases were due to segmental tibia fractures ≫ 4 cases were due to multiple injuries that precluded early complex surgery ▷ 95 patients underwent single-stage primary ORIF ▷ Primary ORIF was performed within 24 hours of injury in 67 (71%) cases Tibial Pilon Fractures 43 Primary ORIF was performed within 48 hours of injury in 84 (88%) cases ▷ Median time from injury to ORIF was 18 hours Average age: 44 years (19 to 68 years).

ORIF of tibial pilon was performed when soft-tissue edema resolved, generally at 7 to 14 days after injury. 7 days (4 to 30 days) ▷ 5 cases (17%) developed partial-thickness wound necrosis. All were treated successfully with local wound care ▷ 1 late complication of chronic osteomyelitis that resolved with hardware removal Follow-up available on 17/19 open fractures ▷ Average time from external fixator to ORIF: 14 days (4 to 31 days) 38 Chapter 4 2 cases developed partial-thickness wound necrosis.

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