I use a posterior approach when I'm doing an anti-glide plate but I've never gone that far posterior. I've generally fixed posterior mall fractures with a few A to P screws percutaneously. It works real well and a lot of docs are doing it including a lot of guys at the AO course this past week. Is it hard to do a lag screw and lateral plate with such a posterior approach?
We just did a posterior approach for a pilon today. The axial on the CT showed the most displaced fragment to be posterior lateral. in order to reduce it an anterior approach would just be difficult, not to mention the soft tissue envelope is usually not as crappy posteriorly.
Eventhough physics dictates the lateral fib plate is for a butress and the posterior is for antiglide it seems to not matter if you put a plate posterior just to use as a butress. If you have a traditional oblique fib fracture you can put your compression screw from posterior to anterior either inf to sup or sup to inf. Then put the plate posterior and on top of the interfrag screw.
If the fibular fracture is not oblique then the miniplates in the minifrag set work really well for temporary fixation, then put your 1/3 tubular or zimmer fibular plate or anyother plate over the minifrag plate. all hardware is left in.
The miniplate thing works well for almost all fractures and may cost more in hardware but saves overall OR time.
I think the posterior approach is easier and better exposure especially if you use cerebellar self retaining retractors - much better than "extern" retractors.
If the posterior mal is almost reduced and just needs a percutaneous clamp for screw fixation then I agree that the med and lat approach are sufficiant w/ perc screws A-P.
There is a good paper that describes the approach...however at the end it does not recommend it, but w/out real basis.
1: J Orthop Trauma. 2006 Feb;20(2):104-7. Links
Complications associated with the posterolateral approach for pilon fractures.Bhattacharyya T, Crichlow R, Gobezie R, Kim E, Vrahas MS.
Partners Orthopaedic Trauma Service, Massachusetts General Hospital, and Brigham and Women's Hospital, Boston, MA 02114, USA.
OBJECTIVE: To review the complication rates of open reduction and internal fixation (ORIF) of tibial pilon fractures using the posterolateral approach. DESIGN: Retrospective review. SETTING: Two level I trauma centers. PATIENTS: Nineteen consecutive pilon fractures at an average of 13 (range, 13-45) months follow-up. Average age 46 (range, 21-72) years. Four of 19 were open fractures. INTERVENTION: Because of the high incidence of wound complications associated with the anterior approach for pilon fractures, patients were treated with initial temporary external fixation followed by delayed ORIF through the posterolateral approach to the distal tibia. The hypothesis was that the abundant soft-tissue coverage of the posterior distal tibia would decrease the rate of wound complications. MAIN OUTCOME MEASUREMENTS: The incidence of wound complications, nonunion, and early posttraumatic arthritis. This was a chart and radiograph retrospective review. RESULTS: The mean time to definitive treatment was 13 (range 2-30) days. Nine of 19 patients (47%) developed complications. There were 6 patients with wound problems, 2 patients with aseptic nonunions, 2 patients with infected nonunions, 3 tibiotalar fusions, and 1 patient with a 3-mm step off. In total, there were 14 major complications in 9 patients. Ten of 19 patients did not have any complication. CONCLUSIONS: The posterolateral approach does not eliminate the complications common to other approaches, but does offer a potential alternative when soft tissue concerns prevent other approaches. We do not recommend the posterolateral approach for the routine treatment of tibial pilon fractures.
PMID: 16462562 [PubMed - indexed for MEDLINE]
ANd this other one that I have not read yet...
1: Injury. 2000 Mar;31(2):71-4. Links
Postero-medio-anterior approach of the ankle for the pilon fracture.Kao KF, Huang PJ, Chen YW, Cheng YM, Lin SY, Ko SH.
Department of Orthopedic Surgery, Kaohsiung Medical University, Taiwan, Republic of China.
A good view of the operative field is important for better reduction and fixation in surgical treatment of fractures. The exposure of the ankle joint for the pilon fracture is commonly through the anterior approach, or combined with the medical approach. But sometimes it is still difficult to have complete viewing of the articular surface and to apply internal fixation by that approach. In recent years, we developed a "postero-medio-anterior" approach of the ankle joint by one incision. This approach provides an excellent exposure of the anterior, medial and posterior aspects of the ankle joint with a clear view of the articular surface. In our 45 cases of pilon fracture during 1991 to 1995, there was no incisional injury to the neurovascular bundle. Superficial wound edge necrosis was noted in two cases which healed later without further procedure. Therefore, we recommend this approach as a simple and reliable incision for open reduction of pilon fractures.
PMID: 10748807 [PubMed - indexed for MEDLINE]
Related ArticlesA staged protocol for soft tissue management in the treatment of complex pilon fractures. [J Orthop Trauma. 2004] Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques. [J Orthop Trauma. 2001] Surgical treatment for pilon fracture of the ankle-open reduction and internal fixation. [Kaohsiung J Med Sci. 1998] ReviewPosterolateral approach for open reduction and internal fixation of trimalleolar ankle fractures. [Can J Surg. 2005] ReviewMarginal plafond impaction in association with supination-adduction ankle fractures: a report of eight cases. [J Orthop Trauma. 2001] » See Reviews... | » See All...
Are you coming to ACFAS?
