104. REVISION OF PROVISIONAL STABILIZATION IN PILON FRACTURES REFERRED FROM OUTSIDE INSTITUTIONS

Abstract

Purpose: Pilon fractures demonstrate complex osseous and soft tissue injury. Protocols involving immediate tibial reduction and external fixation, with or without fibular fixation, then delayed definitive fixation result in decreased complications. Our purpose was to evaluate the treatment course of pilon fractures provisionally stabilised at outside institutions and subsequently transferred, focusing on the incidence and reasons for revision procedures, and subsequent complication rates.

Method: An institutional trauma database was retrospectively reviewed, demonstrating 668 pilon fractures treated at our institution between 2000–2007. Of these, 39 patients with 42 fractures had a temporising surgical procedure prior to referral. Demographics, injury characteristics, reason for revision, and subsequent complications were determined. Clinical follow-up averaged 60 weeks (range, 1 to 281).

Results: Mean age was 41 years (range, 18–78). Twenty-two fractures (52%) were open; 38 (90%) demonstrated a fractured fibula. Referral occurred an average of 5.8 days (range, 1–20) after initial stabilization. Pre-transfer fixation was revised in 40 fractures (95%). Reasons for revision included tibial malreduction (33 fractures, 83%), fibular malreduction (4 fractures, 10%), pins in the proposed incision (5 fractures, 13%), or loose pins (3 fractures, 8%). Of the 34 fractures with distal pins, 24 (71%) required revision for pin malposition, loosening, drainage, talar placement, or extraosseous placement. Late complications occurred in 14 fractures (33%), including deep infection in 10 (24%), and non-union in 3 (7%). Twenty-three patients (55%) required additional procedures following definitive fixation, including 9 soft tissue coverage procedures and 3 amputations.

Conclusion: The majority of patients with pilon fractures treated with provisional stabilisation followed by referral to our institution required revision prior to definitive fixation. This resulted in many avoidable additional procedures, and a higher complication rate than recent contemporary controls. The authors recommend that, when possible, the initial and definitive management of these injuries be performed at the accepting institution.