Secondary Logo

Journal Logo

External Fixation in the Emergency Department for Pilon and Unstable Ankle Fractures

Shah, Kalpit N., MD; Johnson, Joey P., MD; O'Donnell, Seth W., MD; Gil, Joseph A., MD; Born, Christopher T., MD; Hayda, Roman A., MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: June 15, 2019 - Volume 27 - Issue 12 - p e577–e584
doi: 10.5435/JAAOS-D-18-00080
Research Article
Free

Introduction: Pilon and unstable ankle fractures are often treated initially with an external fixator (ex-fix). Ex-fix application in the emergency department (ED) has been described but not compared with that placed in the operating room (OR).

Methods: Retrospective, case-cohort study was performed at a level-1 trauma center. Using CPT codes, we identified patients who had surgical fixation of pilon or ankle fractures with an initial ex-fix application (in the ED or the OR). Postoperative outcomes and hospital logistical data were compared between the two groups.

Results: Ninety-six patients met the inclusion criteria. The average age of patients was 47 years, and 54 (56%) of the patients were men. Thirty-three patients had the ex-fix placed in the OR, whereas 63 patients had the ex-fix placed in the ED. Postsurgical complications (prominent implant, nonunion, deep infection, deep vein thrombosis, loss of reduction) were seen in 6 of 33 patients in the ED ex-fix group and in 8 of 63 patients in the OR ex-fix group (P = 0.51). Deep infections occurred in 2 of 33 patients in the OR ex-fix group and in 5 of 63 patients in the ED ex-fix group (P = 0.71). Revision ex-fix for loss of reduction was performed in 4 of 33 patients in the OR ex-fix group and in 10 of 63 patients in the ED ex-fix group (P = 0.59). Mean length of stay was 14 days for the OR ex-fix group and 13 days for the ED ex-fix group (P = 0.35).

Conclusion: No statistically significant differences were found in postsurgical complications (surgical or infectious) or ex-fix revision rates for the ED ex-fix group and the OR ex-fix group. Results indicate that uniplanar ex-fix may be safely applied in the ED.

Level of Evidence: Level III, therapeutic

From the Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.

Correspondence to Dr. Shah: kalpit210@gmail.com

Dr. Johnson or an immediate family member serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association. Dr. Born or an immediate family member serves as a paid consultant to Illuminoss, Stryker; serves as an unpaid consultant to BI Medical and BioIntraface; has stock or stock options held in BioIntraface and Illuminoss; has received research or institutional support from Stryker; and serves as a board member, owner, officer, or committee member of AAOS and American College of Surgeons. Dr. Hayda or an immediate family member is a member of a speakers' bureau or has made paid presentations on behalf of AONA and Synthes; serves as an unpaid consultant to BioIntraface; and serves as a board member, owner, officer, or committee member of AAOS, METRC, and Orthopaedic Trauma Association. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Shah, Dr. O'Donnell, and Dr. Gil.

The use of emergency department external fixation (ED ex-fix) has been described for the initial management of both pilon and unstable ankle fractures before definitive fixation.1,2 This method involves transverse proximal tibial and calcaneal traction pins connected in a uniplanar fashion in a “H” configuration1,2 (Figure 1). Application of an ED ex-fix obviates the need for general anesthesia and can be applied if an operating room (OR) is not available, thus facilitating care while potentially decreasing overall hospital costs in patients sustaining pilon and unstable ankle fractures.1,2

Figure 1

Figure 1

Temporary external fixation has been strongly advocated in the management of pilon fractures. In an effort to minimize soft-tissue complications and optimize postoperative outcomes, staged management of these fractures has become a routine.3,4 This protocol involves immediate ex-fix, with or without internal fixation of the fibula; subsequent imaging; and delayed internal fixation.3,4 This delayed approach to fixation allows for the definitive surgical intervention to take place when the soft tissues, and the physiologic status of the patient, are most amenable to definitive fixation while maintaining limb length, alignment, and immobilization with an ex-fix.5-7 This method decreases the rates of postoperative complications, including infection and nonunion, and improves clinical outcomes.3,4 Although several alternative management protocols for the management of high-energy pilon fractures exist, staged management with initial ex-fix is commonly performed.8-10

Ex-fix and staged internal fixation have been used to treat certain ankle fractures.11,12 When soft tissues are not amenable to definitive fixation or if the reduction cannot be held by closed means, a temporary ex-fix may be used until soft tissues are more suitable for definitive internal fixation.11,12

Our study determines whether a difference exists in postsurgical complication rates or revision ex-fix rates for ex-fix placed in the ED compared with ex-fix placed in the OR for pilon and unstable ankle fractures. Additionally, we determine whether any difference exists in the ability to be discharged home before final fixation or hospital length of stay between the groups managed by an ED ex-fix and OR ex-fix. Finally, we also identify any of the above-mentioned differences between patients when grouped by their injury—pilon versus unstable ankle fractures. Our hypothesis is that no difference exists in the complication rates or in the need for revision surgery between these two groups.

Back to Top | Article Outline

Methods

After the institutional review approval, we retrospectively reviewed all patients at our institution from 2013 to 2015 who had surgical fixation of pilon or unstable ankle fractures treated with the application of an ex-fix before definitive fixation. A query of billing and patient databases using CPT codes (Table 1) identified all patients with application, removal, or revision of ex-fix devices and those with management of pilon-type fractures. A preliminary screening identified patients with unstable ankle or pilon factures treated initially with an ex-fix; an additional chart review was conducted on those patients. Although the code for fixation of a bimalleolar or trimalleolar ankle fracture was not searched directly to reduce the number in the initial cohort, a search for patients with CPT codes for the application or removal of the ex-fix should have captured all patients treated with a temporary frame for their unstable ankle injury.

Table 1

Table 1

Patients with ankle and distal tibia articular fractures treated provisionally in an ex-fix were included. Medical records were reviewed for the location of ex-fix placement (ED or OR); total hospital length of stay (from time to admission to discharge following definitive ORIF); the need for ex-fix revision surgery; the total number of surgical procedures; and the postsurgical complications, including deep infection requiring surgical débridement, deep vein thrombosis (DVT), or return to OR for prominent hardware or nonunion. A subgroup analysis was conducted on polytrauma patients defined as having one or more surgical injuries in addition to their surgical ankle injury.

Exclusion criteria included open injuries, an ex-fix placed on other anatomic areas but not the ankle (eg, wrist, knee), an ex-fix placed across additional joints (spanning ex-fix about the knee in addition to the ankle), and an ex-fix placed at outside institutions. The patients otherwise meeting the inclusion criteria were then analyzed.

Fracture patterns were evaluated with the available imaging (radiographs and CT scans). Fractures were classified using AO-OTA criteria—43C1, 43C2, 43C3, and 44C1, 44C2, and 44C3. For the 44-C fractures, the “unstable ankle fractures,” the posterior malleolus size was calculated based on the coronal images of a CT scan of the ankle when available, or on the lateral view of the ankle radiograph. The management was categorized as ex-fix placed in the ED (ED ex-fix) or ex-fix placed in the OR (OR ex-fix). Data were scrubbed of patient identifiers after the collection review.

An ED ex-fix is placed by orthopaedic residents on call who had adequate training and expertise in the procedure. The technique has previously been described.1,2 Local anesthesia was used at the entry and exit site for the proximal tibial and calcaneal pins. A 1 cm longitudinal incision is made on the lateral aspect of the tibia, 3 cm below the tibial tubercle. Care must be taken as the common peroneal nerve splits into the deep and superficial peroneal nerves at the lateral aspect of the knee. A 5 mm centrally threated self-drilling, self-tapping pin is usually used. A 1 cm incision is made on the medial side as the Steinmann pin penetrates the skin. Similarly, a 1 cm incision is made on the medial hindfoot, at the middle of the calcaneal tuber after fluoroscopic confirmation. Another transfixion pin is placed from medial to lateral, posterior and inferior to the neurovascular bundle. An incision is made on the lateral calcaneus as the pin penetrates the skin. Uniplanar ex-fix bars between the transtibial and transcalcaneal pins are then placed to reestablish length and alignment while reducing the tibiotalar joint. The reduction is performed under fluoroscopic guidance in the ED before tightening the ex-fix connectors (Figures 2 and 3).

Figure 2

Figure 2

Figure 3

Figure 3

Typically, the OR ex-fix is placed with two anterior tibial pins; transcalcaneal pins; and, occasionally, metatarsal pins in the first and/or the fifth metatarsal, with ex-fix bars creating a “delta” frame. The differences between the ED and the OR ex-fix constructs are largely because of the ability to safely place ex-fix pins: the proximal tibial and calcaneal pins are used in the ED, whereas the anterior tibial and metatarsal pins are used in the OR.

Postsurgical complications were defined as deep infection requiring surgical débridement, loss of reduction (of final instrumentation, not the ex-fix) necessitating return to the OR, nonunion or prominent hardware requiring further surgical intervention, and DVT. A revision of the ex-fix was noted if performed. The revision was performed in cases of inadequate reduction or loss of reduction after placement of the initial ex-fix.

Statistical analysis was conducted with Microsoft Excel (Microsoft 2014) Stats Pack and included descriptive statistics on patient demographics. Student t-test was used for paired comparisons of quantitative data including revision rate, complications, and hospital length of stay. Significance was set to P < 0.05 a priori.

Back to Top | Article Outline

Results

We identified 1,183 patients based on billing data, of which 96 patients met the inclusion criteria. Of note, the CPT codes for all pilon ankle fracture fixation and all ex-fix placement (regardless of the joint) were used for patient identification, resulting in a comparatively large, initial patient cohort. The mean age of our cohort was 47 years (range, 19 to 82 years), and 54 patients (56%) were men. The average follow-up was 2 years for patients included in this study. Of the 96 patients, 33 (34%) had the ex-fix placed in the OR, whereas 63 (66%) had the ex-fix placed in the ED. Thirty-two patients (33%) were considered polytrauma, defined as having one or more surgical injuries in addition to their surgical ankle injury. Revision of the ex-fix was performed in 14 patients (15%): 10 patients (15.9%) in the ED ex-fix group and 4 patients (12.1%) in the OR ex-fix group (P = 0.62) (Table 2). Twenty-two patients (23%) were discharged home after the initial ex-fix placement, before the final ORIF. The mean hospital length of stay was 13 days (3 to 36 days) for the patients included in our study. Postsurgical complications were seen in 14 patients: 8 patients (12.7%) in the ED ex-fix group and 6 patients (18.3%) in the OR ex-fix group (P = 0.53) (Table 3).

Table 2

Table 2

Table 3

Table 3

No difference was found in the postsurgical complications, revision of the ex-fix, age or sex of the patients, or hospital length of stay between the ED ex-fix group and the OR ex-fix group. Markedly, more of the OR ex-fix patients were polytrauma in both the pilon and unstable ankle fracture groups. The number of days spent in an ex-fix was also evaluated between the two groups, and no notable difference was found (10 days in the ED ex-fix group versus 11 days in the OR ex-fix group; P = 0.66). The OR ex-fix group also had a higher percentage of patients who were discharged home after the ex-fix placement; however, the total length of hospital stay for both the groups was not markedly different (Table 2). To evaluate this point further, we isolated the patients who were not considered polytrauma and calculated their total length of stay—the OR ex-fix group had a mean stay of 9 days, whereas the ED ex-fix group had a mean stay of 12 days (P = 0.09).

We also compared patients based on injury patterns (pilon versus unstable ankle fractures) requiring an ex-fix regardless of OR or ED ex-fix placement. Patients sustaining pilon fractures were found to be markedly younger, had a longer hospital length of stay, and required an ex-fix revision less often than patients sustaining ankle fractures (Table 4). Given that patients with an unstable ankle fracture required a revision of the ex-fix more frequently than patients with a pilon fracture, we evaluated the effect of the size of the posterior malleolus fragment, as these patients all dislocated posteriorly (Table 5). No notable difference was found in the size of posterior malleolus fragment between the group requiring a revision ex-fix and the group not requiring a revision ex-fix (31.91% versus 32.78%; P = 0.852).

Table 4

Table 4

Table 5

Table 5

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).

Back to Top | Article Outline

Discussion

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.

Back to Top | Article Outline

References

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.
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.
© 2019 by American Academy of Orthopaedic Surgeons