Finally, we evaluated patients by their injury type (pilon versus unstable ankle fractures) and segregated them further by where they had their ex-fix placed (ED versus OR) (Table 5). In both the injury groups, polytrauma patients were found to have their ex-fix placed more commonly in the OR (P < 0.05). Given that the unstable ankle fracture group had a statistically significantly higher rate of ex-fix revision, we looked to see whether the location of the original ex-fix placement had an effect on the revision—no statistically significant difference was found in the rate of ex-fix revision in the unstable ankle fracture group between the patients who had ex-fix placed in the ED and those who had ex-fix placed in the OR (P = 0.86).
Pilon and unstable ankle fractures are challenging injuries to manage, even in the most experienced hands. The soft-tissue injury and thin soft-tissue envelope, in addition to the complex, comminuted fracture patterns of the distal tibia and fibula, make these injuries difficult to reduce, stabilize, and manage in the long term.
Strategies to treat these injuries have evolved over the past several decades. The classic article by Rüedi and Allgöwer13 advocated for immediate open reduction and fixation for these injuries, with good results in greater than 70% of their patients. However, those favorable results were not reproducible by authors who subsequently advised against immediate definitive management of these fractures.14-16 In the late 1990s and early 2000s, a staged approach to these injuries was introduced with initial ex-fix, with or without internal fixation of the fibula, for restoration of length and alignment of the extremity.3,4 When the soft tissues were amenable, this was followed by definitive open reduction, internal fixation of the tibia and/or the fibula. Patterson and Cole3 reported that this approach to treating these injuries resulted in good subjective and objective outcomes in 77% of their cohort and an anatomic reduction was achieved in 73% of their population.
Our study demonstrated that postsurgical complication and revision ex-fix rates were similar between the ED ex-fix group (12.7% and 15.9%, respectively) and the OR ex-fix group (18.3% and 12.1%, respectively) (P = 0.53 and P = 0.62, respectively). The theoretical argument to avoid placing an ex-fix in the ED is the infection risk, unsatisfactory reduction necessitating a trip to the OR, and other surgical complications. Although this study is not a prospective, randomized trial and has the biases inherent to retrospective studies, we were able to demonstrate that the ED ex-fix is as safe, reliable, and equally effective as the OR ex-fix. Additionally, we were able to demonstrate that it can effectively be performed under local anesthesia (for the Steinmann pin placement) and procedural sedation by the ED provider (for the reduction portion).
Patients receiving an ex-fix for unstable ankle fractures (AO classification 44A, 44B, or 44C) were more likely to require a revision ex-fix than those receiving an ex-fix for pilon fractures (7 of 14, 50% versus 7 of 81, 8.6%; P < 0.001). This likely demonstrates the difficulty in controlling unstable ankle fractures with an ex-fix, because these fractures are often unstable in multiple planes. Conversely, pilon fractures and their axial loading mechanisms benefit from an ex-fix to maintain length and alignment before definitive fixation rather than maintain a reduced tibiotalar joint. Of note, the patients with unstable ankle fractures all had a fairly large posterior malleolus piece (average size, 31.4%). The gastrocnemius-soleus complex is a powerful muscle group, which absent a notable, intact posterior malleolus can subluxate the ankle joint posteriorly. On comparing the patients who needed a revision performed on their ex-fix for inadequate reduction or loss of reduction with those who did not needed a revision ex-fix, we did not find a statistically significant difference in the size of posterior malleolus piece in the two groups. Although the need for a revision ex-fix did not differ between the ED and OR ex-fix groups among those with unstable ankle fractures, these data may suggest that additional pins placed in the metatarsals or other strategies to limit posterior displacement of the talus may be of benefit.
Additionally, the cohort of patients receiving an ex-fix for unstable ankle fractures were markedly older than those receiving an ex-fix for pilon fractures (60.6 versus 44.9; P = 0.0003). The higher rate of revision ex-fix in the unstable ankle fracture group may have also been a result of the poorer bone quality in older patients undergoing ex-fix for these fractures. Given that our study involved multiple surgeons, the guidelines for acceptable reduction were subjective, with varying degrees of subluxation deemed acceptable or unacceptable.
Barbieri et al17 described their results of treating 37 patients with hybrid limited internal fixation and ex-fix for tibial plafond fracture.4 They described their overall complication rate to be 35%, with 9% of the patients losing the surgical reduction, necessitating revision surgery. Our study was able to report a lower overall complication rate of 14.6%, although we did stage the surgeries (ex-fix first, ORIF second) as opposed to performing hybrid surgery like the authors of that study. The revision surgery for loss of reduction after ex-fix placement was similar to that in our study (15% of all patients).
In our study, we found that patients who sustained a polytrauma (defined as patients who required surgical intervention for an injury other than their ankle fracture) were more likely to undergo OR ex-fix (18 of 33) than ED ex-fix (14 of 63) (P = 0.001). This likely was due to patients being more likely to receive an OR ex-fix because they were already undergoing general anesthesia, they were more likely to receive ex-fix in that setting as they were already in the OR. We found that discharge before final surgical fixation was higher in the OR ex-fix group (13 of 33) than in the ED ex-fix group (9 of 63) (P = 0.005); however, this did not result in a shorter hospital stay as the OR ex-fix group had an average hospital stay of 14 days and the ED ex-fix group had a total hospital stay of 13 days (P = 0.39). To evaluate this further, we isolated patients who were not considered polytrauma to eliminate the confounding need to stay in the hospital. The average length of stay for the non-polytrauma patients in the OR ex-fix group was 9 days compared with 12 days for the ED ex-fix group. Although a trend to lower length of stay in the OR group was observed, we could not identify statistical significance between the two groups, which may have been limited by the relatively small numbers in these groups (P = 0.09).
Perhaps most markedly, our study demonstrated that no difference exists in the complication rate, revision rate, or deep infection rate between the OR and the ED ex-fix groups. Though not directly related to the ex-fix, other postsurgical complications are included in Table 3 (prominent hardware, nonunion, and DVT) to show that the place (ED versus OR) where ex-fix was placed had no effect on the rate of complications and they were similar in both the groups.
A limitation of our study was the relatively small number of unstable ankle fractures. This small number is likely because of the fact that ankle fractures are rarely so unstable that they require an ex-fix. Because of these numbers, drawing meaningful conclusions about the infection risk, revision ex-fix rate, and other postsurgical complications based on a small cohort is difficult. Additionally, this study is retrospective in nature, and treatment decisions were made based on the clinical situation, patient factors, and individual surgeon’s preference, rather than a standardized protocol. Patients with closed injuries who did not have threatened soft tissues or another reason for being in the OR (ie, polytrauma patients) had an ex-fix placed in the ED. However, there were occasions where the surgeon chose to place the ex-fix in the OR for unknown reasons.
Our study is the first that we are aware of in the literature to demonstrate that no difference exists in the ex-fix revision rate associated with the use of an ED or OR ex-fix when treating unstable ankle and pilon fractures. Additionally, we demonstrate that the rate of deep infection after definitive fixation is similar in both the groups. The length of hospital stay was also not markedly different between the ED and the OR groups. Our study shows that for these injuries, an ED ex-fix is a safe and effective alternative to OR ex-fix. While previously described as useful in austere environments, we suggest that this method can and should be used more commonly. Though not the focus of this study, an ED ex-fix requires fewer resources, such as the OR and general anesthesia, and thus may potentially decrease the cost of treating these injuries.
References printed in bold type are those published within the past 5 years.
1. Lareau CR, Daniels AH, Vopat BG, Kane PM: Emergency department external fixation for provisional treatment of pilon and unstable ankle fractures. J Emerg Trauma Shock 2015;8:61–64.
2. Banerjee R, Bradley MP, DiGiovanni CW: Use of emergency room external fixator in provisional reduction of posterior malleolar fractures. Am J Orthop (Belle Mead NJ) 2004;33:581–584.
3. Patterson MJ, Cole JD: Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma 1999;13:85–91.
4. Sirkin M, Sanders R, DiPasquale T, Herscovici D: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 2004;18:S32–S38.
5. Liporace FA, Yoon RS: Decisions and staging leading to definitive open management of pilon fractures: Where have we come from and where are we now? J Orthop Trauma 2012;26:488–498.
6. Crist BD, Khazzam M, Murtha YM, Della Rocca GJ: Pilon fractures: Advances in surgical management. J Am Acad Orthop Surg 2011;19:612–622.
7. Liporace FA, Mehta S, Rhorer AS, Yoon RS, Reilly MC: Staged treatment and associated complications of pilon fractures. Instr Course Lect 2012;61:53–70.
8. Koulouvaris P, Stafylas K, Mitsionis G, Vekris M, Mavrodontidis A, Xenakis T: Long-term results of various therapy concepts in severe pilon fractures. Arch Orthop Trauma Surg 2007;127:313–320.
9. Pugh KJ, Wolinsky PR, McAndrew MP, Johnson KD: Tibial pilon fractures: A comparison of treatment methods. J Trauma 1999;47:937–941.
10. Wang C, Li Y, Huang L, Wang M: Comparison of two-staged ORIF and limited internal fixation with external fixator for closed tibial plafond fractures. Arch Orthop Trauma Surg 2010;130:1289–1297.
11. Haidukewych GJ: Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma 2002;16:678–685.
12. Behrens F, Searls K: External fixation of the tibia: Basic concepts and prospective evaluation. J Bone Joint Surg Br 1986;68:246–254.
13. Rüedi TP, Allgöwer M: The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res 1979;105–110.
14. Ovadia DN, Beals RK: Fractures of the tibial plafond. J Bone Joint Surg Am 1986;68:543–551.
15. Bourne RB, Rorabeck CH, Macnab J: Intra-articular fractures of the distal tibia: The pilon fracture. J Trauma 1983;23:591–596.
16. Helfet DL, Koval K, Pappas J, Sanders RW, DiPasquale T: Intraarticular “pilon” fracture of the tibia. Clin Orthop Relat Res 1994:221–228.
© 2019 by American Academy of Orthopaedic Surgeons
17. Barbieri R, Schenk R, Koval K, Aurori K, Aurori B: Hybrid external fixation in the treatment of tibial plafond fractures. Clin Orthop Relat Res 1996;332:16–22.