Date: Sun, 7 Oct 2001 20:45:50 +0100

From: chris wilson

Subject: pilon and talus fractures

Please see images (shrunk as much as practical) below of a 22 year old man sent on to me 2 weeks after a climbing accident. Initial treatment in a plaster.

Treated by us with "minimal" internal fixation and application of a hybrid frame with 2 rings and wires around the metaphysis and 3 half pins in the diaphysis. Stable construct achieved. Tibial articular surface is well reconstructed-the lateral views are not included but show no articular steps or irregularity and the talus is well centred in the sagital plane.

Question is regarding the talus which had a lateral corner fracture as can be seen. This was a crush and was ungraftable. Now we can see some talar tilt and presumably this constitutes a risk factor for early OA. Are there any measures we could take? Ankle distraction? Limited weight-bearing for how long ? Other measures?

Chris Wilson
Consultant Trauma and Orthopaedic Surgeon
University Hospital Cardiff


Reply at: Orthopaedic Trauma Association forum

Date: Mon, 8 Oct 2001 18:22:54 +0600

From: Alexander Chelnokov

Hello chris,

cw> Now we can see some talar tilt and presumably this constitutes a risk factor for early OA.

Looks like the fibula is relatively shortened (the tibia was over-distracted?). This can cause the tilt also.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia


Date: Mon, 8 Oct 2001 21:32:15 +0100

From: chris wilson

Thank you all for your interest. A lot of list members are telling me to fix the fibula and raise and graft the tibial plafond. I enclose 2 other small images to convince you that the fibula is intact and the tibial metaphsis has been well reduced, and in these circumstances is there any thing we can do about the talar tilt and to improve the prospects of avoiding post-traumatic OA?

Chris Wilson
Consultant Trauma and Orthopaedic Surgeon
University Hospital Cardiff


Date: Tue, 09 Oct 2001 13:33:46 -0600

From: Thomas A. DeCoster

Regarding case of distal tibia fracture treated with reduction and multiple screw fixation supplemented by a small wire external fixator. The talus is tilted in the mortice and the question is what, if anything, to do.

I suggest trying to determine why the talus is tilted. Does it reduce with inversion stress? (appears less tilted on the last xray in second message). If it does not, what is blocking it? Could the posterior tibialis tendon or something else be interposed. If so, can it be removed? Is the distal tibia medial fragment malrotated causing the appearance of talus tile? This looks like it might be true on the first CT and plain xray where the talus seems more normally positioned relative to the fibula. If so, could the medial side of the ring be lengthened or could this fragment be manipulated and re-fixed? What is the talus fracture? Is it the lateral edge of the dome or something else? I would try to get the talus better positioned in the mortice, although I do not think it is crucial to determining outcome. Perhaps a splint in inversion or add hindfoot pins to the fixator and make this a spanning XF or perhaps one of the etiologies mentioned above could be identified and corrected.

TDeCoster

Date: Wed, 10 Oct 2001 09:21:47 +0600

From: Alexander Chelnokov

Hello chris,

Tuesday, October 09, 2001, 2:32:15 AM, you wrote:

cw> these circumstances is there any thing we can do about the talar tilt and to improve the prospects of avoiding post-traumatic OA?

You may apply a foot frame connected to the distal ring with hinges. It allows 1) to eliminate the tilt and 2) start early motions in slight ankle distraction.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia