Entrapped Posteromedial Structures in Pilon Fractures : Journal of Orthopaedic Trauma (original) (raw)

Original Article

Eastman, Jonathan G. MD*; Firoozabadi, Reza MD†; Benirschke, Stephen K. MD†; Barei, David P. MD†; Dunbar, Robert P. MD†

*Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA; and

†Department of Orthopaedic Surgery and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, WA.

Reprints: Jonathan G. Eastman, MD, Department of Orthopaedic Surgery, Davis Medical Center, University of California, 4860 Y St, Suite 3800, Sacramento, CA 95817 (e-mail: [email protected]).

R. P. Dunbar is part of the speakers bureau/gives paid presentations for AO, receives research support as a PI from Smith & Nephew, receives other financial or material support from Innovision, Synthes, and Zimmer, is on the editorial board/governing board of Journal of Orthopaedics and Traumatology and OrthoInfo, and is a board member/committee appointment for the Orthopaedic Trauma Association. The remaining authors report no conflict of interest.

Institutional Review Board (IRB) approval was obtained for this study.

Presented in part at the Annual Meeting of the Orthopaedic Trauma Association, October 3–6, 2012, Minneapolis, MN, and as a podium presentation at the Annual Meeting of the American Academy of Orthopaedic Surgeons, March 19–23, 2013, Chicago, IL.

Accepted November 21, 2013

Abstract

Objectives:

To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures.

Design:

Retrospective cohort review.

Setting:

Regional Level 1 Trauma Center.

Patients/Participants:

About 394 patients with 420 pilon fractures treated between January 2005 and November 2011.

Intervention:

Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture.

Main Outcome Measurements:

Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure.

Results:

40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%).

Conclusions:

In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery.

Level of Evidence:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.