All right. Thank you for having me talk about primary fusions for pilon fractures. I've been doing this for a number of years now. And as time goes on, I seem to be treating more and more of these with primary fusions, in part because I think they do fairly well. And I think that the traditional RAFO, it's still pretty good, tends to fail in some scenarios. I don't have any disclosures with this talk. I think we all know that the treating pilon fractures is very challenging. And this is due to the fact that there's significant injury to the bone and the articular surface, but even more so to the soft tissues. And I think that the way I kind of come and look at these injuries is basically it's a bad soft tissue injury with an associated fracture with it. And so I think you really have to treat the soft tissues first. And so these are both intraarticular fractures of the distal tibia and both, in a sense, considered pilon fractures. But I think that we all know that the one on the right can do relatively well, whereas the one on the left, due to the amount of soft tissue and bone injury, is not going to do well and is likely to have some complications and future reconstruction. So I just want to start off with a case of a young guy who's 36 who I just recently saw in clinic. So this is his fracture here. You can see he's got some comminution intraarticularly, but for the most part, a pretty straightforward injury. And this is how he was treated before he was sent to me. And you can see that there's really not a lot of care for the coronal alignment. It's a little bit of valgus. And if you look here carefully on the lateral, you can see that there's kind of a double bubble sign here where there's some articular step off. And so you know this is going to lead to arthritis, which is exactly what happened. And so this is someone who's going to wind up with some sort of arthrodesis just given his age. And this is one of my patients that was treated here. Again, this is a pilon fracture. You can see the CT scan after we fixed the fibula and put him in the external fixator. You can see he's got a lot of central comminution through there. And again, this is one young kid on a treat with open reduction fixation. You can see that I thought we restored the coronal alignment pretty well. If you look at the lateral, we've gotten the articular surface, I think, in a reasonable spot. But here's this gentleman at a little bit over a year, you know, complaining of pain. And he's been having pain relatively since he started walking on it. And you can see looking at the CAT scan at that time that he's got already some bad arthritis and what looks like some AVN with collapse of the anterior portion of his pilon. And so again, you treat him with fusion and he does well. He likes his fusion definitely a lot better than he liked walking around on that arthritic ankle. So the rationale for primary fusion is the cartilage is already damaged and that happens in the time of injury. And these are due to the compression and shear forces that go across the cartilage and the distal tibia. And AVN is something that's not really talked about a whole bunch, but it is actually more common than you think with these pilon fractures. You know, with all pilon fractures, the closed ones included, they get significant stiffness. So the ankle's not going to move like it did before. I think you really see a whole bunch of stiffness with open injuries just due to the bad soft tissue injury. These definitely go on to a rapid rate of arthrosis. And so usually by a year, if you see some joint space there and you know, it's going to kind of collapse even faster and faster. The other thing, the other nice thing about primary fusions is you can give the patient one surgery with one recovery period. So should we be, should we just fuse everyone? Well, I don't think so. Again, another patient of mine that relatively young person with, you know, relatively, you know, straightforward articular injury. And this is something where I think if you can get a reasonable reduction, just like we showed beforehand, and you can try to get it as close to anatomic as you can, you know, they last. And this is here, these are these x-rays here, which I think are a little over eight years out from this patient who still hasn't progressed to arthritic change. And so I think some of these actually can do well, but the vast majority of them are going to wind up like the one I showed before that kind of progressed to arthritis. And so the drawbacks to fusion is that it's functionally limited. I mean, you're giving up the motion at your ankle. You also have to get the fracture and the fusion to heal. And I've had non-unions at the articular surface. I've had non-unions at the metaphyseal area, and I've actually had non-unions of both. So you'll definitely get some non-unions with this fusion. And you have to figure out how to treat them. The other thing is that the patients really miss out on how awful this injury is. You know, they don't go through that time period, like that first guy that I showed where he got rapid arthritis and had terrible pain. They don't realize what the outcome is. The last thing they remember is they had a pretty good working ankle before you did surgery on them. So who should we be fusing? For me, these are the highly accommodated or unreconstructible pylons, ones that I don't think I can piece back together, give a reasonable shot to heal. Open injuries, I think these wind up with a lot of stiffness. They're also get infected and have further surgeries. Delayed presentation, for me, that's anybody over four weeks. I think my ability to get all the fragments back together and the articular surface reconstructed is pretty poor. The elderly limited activity, again, these people aren't going to miss that motion that they get, that they lose at the ankle joint. Neuropathics, I think those people do well with fusions as well. And so this is another gentleman who's in his mid-thirties, a migrant worker who sustained this pylon injury. He was treated in an outside facility with an external fixator. You can see that didn't really do a great job of getting him reduced. So here he is poorly reduced, and they did me the favor of holding on to this guy until his skin was ready, which was somewhere around three weeks before he showed up to my office. So now by the time we're operating on him, it's going to be a little bit after four weeks. And so here's this CAT scan. You can see he's got a lot of impaction anteriorly, as well as a lot of articular involvement. And so how do we approach this? Well, really the first thing is you got to still treat it like a pylon. So you got to reconstruct the pylon. You got to make sure you pay attention to your sagittal and coronal alignment. The articular reconstruction is not as important because you're going to be doing a fusion, but you still want to try to put it back together. And then you stabilize the pylon. Again, same principles as fixing it, build back to front with K-wires, lag screws when and if needed, and you can use plate fixation for the tibia where it's needed. So now once you've got that stabilized joint debrided, it makes it a lot easier because there's not as many moving parts. You still need to do a thorough debridement. Again, these are the same principles as doing an ankle arthrodesis. So you're just combining them. You can use orthobiologics or allograft as needed for the closed injuries. And then now you got to work on getting it fused. So you have to span that joint and that can be done with plates. It can be done with screws. It could be done with nails. And certainly if you get the pylon fixed well enough and stable enough, you can actually use some compressive techniques as well to cross there. So again, get back to our case. We brought him back and he had a lot of deformity posteriorly. So we put him prone, fixed him from the back, trying to restore the posterior anatomy. And then we came back into the front and this is the clinical picture of what you see again. That's a lot of comminution, a lot of different pieces. And by the time you free him up at four weeks, that's something I can't put back together. There may be people out there that can do it, but I can't. So this is one that we did primary fusion on. Again, here he is back to work healed. So another case here. So that kind of highlighted the late presentation. This is one that was treated by one of my partners. You can see it's pretty awful pylon injury, a lot of interlateral comminution and basically comminution everywhere. It's open and it's open in the midline and then extending medially. And what they did was they made incisions to breathe the fracture directly medially and centrally. And you can see that the joint line is somewhere close to that black line right there. So they're kind of blocking you out by the time they put on this plate. Again, they've now reduced the fibula and now you have an extensile lateral approach as well as an extensile intramedial approach. And with the comminution being where it's at, you can see that for me, this is not reconstructible. It's also not easy to access and treat like a standard pylon. And so sometimes you have to think out of the box a little bit. And so what we did when we came back here is I was going to leave the fibula alone and we restored the diaphysial segment with some lag screws, tried to piece it back together when I could, and then debrided the joint from the intramedial spot. Some of it had to do blindly. And then you pass the rod down across the joint and held it distally into the talus. And that way we could salvage the subtalar joint to leave this young lady with some motion. So again, here she is healed, doing okay after a fracture, but again, it's healed and again, we preserved her subtalar joint. So this is another one, bad open injury, also grossly contaminated. So this is someone who had mud and dirt stuck into their bone. So we treated it with irrigation and debridement, placed them into an external fixator. Again, probably not the hardest pylon you're going to come across, but again, grossly contaminated and open. And so he had required multiple debridements, wound up getting osteomyelitis, required IV antibiotics, and we treated him for an extended period of time with the fixator. So at six weeks, you can come back, get your bone samples. Bone samples were negative. You can treat him with a primary fusion and here he is healed. So what about hind foot nails? And I get this question asked to me all the time, why not just shove a nail up there? Well, it is certainly easier. You can do it through limited incisions and there's some question of whether you can start some earlier weight bearing and you probably can. For me, the disadvantages is it eliminates a normal subtalar joint. And so I think from doing foot and ankle, and I think a lot of us know that isolated subtalar joint fusions do really, really well. Isolated ankle fusions do pretty well. TTC fusions are not really all that functional and certainly for this patient population, which is going to be younger, it's not really an ideal treatment. So I tend to stay away from nails whenever possible. I do think it's really good for neuropathics or the elderly with limited function or soft tissue envelope, because again, you can have smaller incisions and really get them to fuse and get them weight bearing a little bit earlier. So this is a mid-sixties gentleman who is an alcoholic with neuropathy and peripheral vascular disease. This is an injury that happened four days before he presented to the emergency room. He was having some soreness, but he came in really because his ankle was turning in. So this is one that again, is not reconstructable for me. He's neuropathic, he's got peripheral vascular disease. And so this is one that I think you can go in there and treat it better with a fusion. And this is a good indication I think for me for a nail. So there's relatively very little literature out there. One of the first studies came out in 2014, this JBGS study that showed pretty good results with primary arthrodesis with accommodated high energy pilon fractures. We also published our paper in foot and ankle clinics on primary arthrodesis for pilon fractures. Aside from that, there's a smattering of some case reports and small series in the literature, but for the most part, these are kind of the kind of the papers that are out there. So in summary for me, I fix any pilon that is fixable. And I certainly will try to give the young people a shot if I think I can get the articular surface reduced and anatomic for the right patient and the right fracture pattern. I think you should definitely consider primary fusion. And I think you really have to spend some time discussing why you're fusing with the patient. I think you have to let them know that this is a terrible injury. It's something that likely will go on to have future reconstruction or future surgery and something that can actually even occur within a year or two. And you have to be ready for complications. Again, non-unions are something that I've come across with these and you just have to be ready for them. Thank you. All right. Thanks, John. That was actually a great talk and kind of answered a few of the questions I'm probably going to pose to you in just a second here. So let me hopefully share my screen, open system preferences. Okay, guys, it looks like I'm going to have to quit and log off. Just one second. I'll be right back. All right. So, first of all, I want to thank John for a great talk. I mean, that was very insightful, and obviously, I don't have a lot of experience with doing acute fusions for pilon fractures. I've done some, but that has opened my eyes to maybe doing a little bit more in the future. So, that's me, I'm the moderator, it's a glam shot. And then, these are my disclosures, none of which are relevant to this presentation. And so, the goals of this, just to remind everyone, is that you should be able to understand modern theories of soft tissue and bony injury patterns in pilon fractures, develop tools for treatment and planning and surgical decision-making, including when to consider an acute fusion, and then learn technical and practical tips in pilon fracture surgery. So, hopefully, we're going to cover at least some of those things in our discussion now. So, John, again, thank you for your talk on primary fusion for pilon fractures, and let's jump into some cases. So, this is number one. So, I thought we'd just maybe ease into things a little bit here. So, this is a 40-year-old, otherwise healthy male, was at work, had a fall from height, and presented this injury. It's a closed injury, no other, I mean, I think he had some rib fractures, but no other associated injuries. All right, any thoughts, John? Yeah, I think, for one, this is, you said closed, right? Closed injury, yeah. Yeah. So, I think, for me, this is one that, if I'm there, I'm going to treat this within a couple of days. I usually get a CT before I start, because this is one that I'm going to probably fix from the back with my external fixator. So, I'm going to put this guy prone initially, and I think you can get that posterior piece locked in, as well as that posterior medial piece you can see up by the shaft. So, you'll be able to get those in and restore it, because those are ones that I think are very difficult to get in the future. Trying to get indirect reduction on those in a couple weeks is really hard. Okay. So, I would put him prone. I would fix the back half, and then I would put an external fixator on, and then wait. All right. And you have a publication on that, actually, on the stage treatment of these with initial fixation in the back. Now, I know a subsequent study came out that there potentially is an increased risk of nonunion doing it that way. Has that been your experience, or just kind of a case-by-case thing? Well, I'll have to say that I was probably more enthusiastic about it. I was doing it for all of them. Now, for these types of patients, for the younger patients, I tend to fix it right away. There is some increased incidence of nonunion. That was actually a follow-up from our study in Tampa. But for me, and I wrote a response to this in the JOT, but for me, I'd rather get the articular surface anatomic, which you can do through that, and you can always treat a metaphyseal nonunion. I mean, that is easy, right? You can treat a metaphyseal nonunion with bone grafting, and as long as you have one shot to get the articular surface correct, and I think for me, that's more important. Okay. Great. So this is, I wasn't there when this happened, and so this was his initial treatment. So any thoughts on this? No, I think this is fine. I think they have it. I think they've done a good job of getting whatever they can reduce. The alignment looks pretty good. The posterior half actually lined up pretty well with the external fixator, so I think that's pretty good. How do you feel about this one external fixator pin? It's clearly not ideal to have it at the level of the fracture, but I definitely would probably have it a little bit higher up, for sure. But I think this actually brings up one of the challenges. My partner did this, and the hard part, I think, especially with these pilon fractures with kind of diaphysial extension, is it's a little bit of a rock and a hard place, because if you do a spanning external fixator where the pins are far away from the fracture, it's just really unstable. And I think that I've struggled with that as well, because whether or not pin plate overlap really matters, I think is debatable, but you certainly don't want a pin right in the fracture site. But if you go a lot higher with this, there's just a long span between the top and the bottom of the fixator. And so I've had some issues with not really being able to control the fracture as well as I'd want to. Yeah. I know the old mantra is to keep your pins out of future hardware, but I've given up on that. I usually try to stay at least a few finger breaths above the extent of the fracture, and then I'll bypass the pin sites with my plates, or sometimes I'll leave my plates between the pin sites, and I usually cure at them, I close them, and put some antibiotics in them as well. So, and I haven't had much of an issue with that. Yeah. I mean, I've had the same thing. And the other thing too, is especially with how long we run our plates, especially for this fracture, there's no way you're not going to overlap your pin sites. I mean, there's one study that says it may matter, there's one study that says it doesn't. I haven't seen that be a major issue. All right. So again, I mean, this is kind of the questions, and you've already hit on some of these things, but the initial treatment, is this, so I guess what you're saying is, is this for a young guy, if you can get to this within the first 48 hours or so, you're considering fixing this all the way, or you do stage treatment, X-fix, and come back, or it kind of just depends? Yeah. I don't know. I've still been a little gun shy about fixing it, because I think that one that you just showed, I think requires back and front operations, and I like to give people a little bit of time in between. So that's when I probably would fix the back, you know, within the first probably five days, and then wait until the skin was ready for another assault on the soft tissues, maybe like another week or a couple of weeks. Okay. And then for these, now this guy doesn't have, these guys has an intact fibula, but for those people that do have a fibular fracture, are you pretty routinely fixing that? And if so, are you doing it at the time of your external fixation, time of definitive treatment, maybe ignoring it? I don't, I don't ignore it. I'm a friend of the fibula. Okay. I don't ignore it. I never do that. But the, I'm definitely a friend of the fibula, but I would say, I would say maybe 50-50 at this point. And I certainly was a lot more fixing the fibula right off the bat. I think if the fibula is easy to fix, I think you should fix it. Okay. When you do your external fixator. If it's really comminuted, I think it's really hard to do that right away. It will save you some time in the end, but I think that it's sometimes if you get a bad reduction of your fibula, it will block your reduction of your tibia. So I'm kind of 50-50. And sometimes if I don't really have a great plan set out or where I'm going to put my incisions, I'll leave the fibula alone. Yeah. Yeah. It's interesting. I mean, actually, there's one, I mean, Tornetta has a study out there that says that it doesn't matter necessarily if you repair the fibula with a pilon fracture. I have a hard time believing that. I mean, I think it has so much association with stability of the talus. I think some of these people absolutely have syndesmotic injuries as well as their pilon fracture. So I just, I mean, I agree with you and I'm kind of in the same boat that if it's simple, I'll fix it right away. If it's complex, I tend to leave it for a later date. Okay. So takes us to our next. So this is, I gave you some select CT sections here and some 3D reconstructions. And so, you know, one of the questions I have is, you know, between kind of the trauma and the foot and ankle world, I think there's some debate at least as to whether, you know, whether we should be using direct anterior approaches to repair pilon fractures. And so, I mean, this guy, I mean, you can see that, you know, to access that articular impaction, right? I mean, you're going to have to go, I don't think anyone can tell you they're going to get that through an anterolateral exposure. So for you, I mean, are you still doing an anteromedial approach for these? Are you doing just, you know, direct anteriors or what's your thought process in that? This one is kind of an in-betweener. I think you could do an anteromedial because I think that you can access it easier through an anteromedial and you can still probably put some sort of medial plate as well. I probably still would do this one through a direct anterior approach because that's what I like the best. And I'd probably use, after I got that fixed, I'd probably use a PERC medial approach, put a long spanning medial plate on. Okay. Another question about this guy. So, you know, this is where we are now. And I can see exactly what you're saying about doing, staging it, fixing that piece in the back. I think that would have probably made your life a lot easier or my life a lot easier. For the metaphyseal region in this guy, do you, I mean, in this particular fracture, you know, I mean, it's kind of an in-between, you know, it's like, it's not terribly comminuted. There's some pieces there. Are you just going for the joint and then spanning that? Do you try to piece that together? What's your thoughts on that? Yeah, I usually try to piece it together as best I can. I still think it needs some support medially because a lot of times, and particularly this one is one that's a classic example, is you get comminution there and impaction medially. And one of the things I've seen commonly where people try to fix it is everybody likes to get all the bone pieces perfectly back together. And a lot of times if you get that medial side all pieced back together and the bone's touching bone, you've put it into varus. So I've seen that. So I tend to span it, but I try to get the pieces back and I try to restore the anatomy as much as possible. Okay. All right. So this is what I did. I mean, and it just is, you know, I'm absolutely open to critiques or thoughts. So if you, I'm going to go back one slide here real quick. So if you look here, there's that, you know, there's this medial piece here that I thought actually, although it's just a cortical fragment, I thought it was going to be a really important read to length because, because otherwise I just didn't have a great idea of, and this is a challenge for me, especially with a ton of metapsyl comminution, kind of where the joint belongs in space. Like what, how long is it supposed to be? Where's the rotation of it? I think that's almost as difficult as putting the joint together itself. And so, so I actually went after that. So I did a limited posterior medial approach, got that cortical piece, and then that kind of allowed me to just start to build back to that. And I did an indirect reduction of that posterolateral joint fragment. This is a little 2-5 shans pin that I'm using to joystick it, and then taking wires from the intact tibia into that piece to hold it. This was still a struggle though. I mean, it took a long time to get to this point, but I did think it was helpful to start to kind of build back to that. And then you kind of sequentially, then you can reduce that big medial malleolar, kind of medial joint shearing fragment, and then the anterolateral piece. For me, you know, I, like most things, I tend to use little mini fragment plates to assist with reduction, hold different pieces in place. And then this is something I found helpful. So I actually, I did an anterior medial approach and then put the plate in through that. In my experience of that, kind of just like sliding a plate through an anterolateral approach, it really wants to skive off the back of the tibia. And so I'll just use this blocking drill bit here to redirect it so that it doesn't kind of keep falling off that same path where it's in the right place distally, but off the back of the tibia approximately. Yeah. So there he is. Yeah. And, you know, I've known, I mean, this guy's, you know, three weeks post-op now, so I'm assuming he's going to do amazing. Yeah. Sure will. Yeah. The thing is, you never know, right? I mean, some of these do really well, because I mean, it's well reduced, the alignment's back. Some of these do really well, and then other ones just don't yet. And I still have yet to figure out or predict it. Right. I've had the same experience where some, so with someone, you've got a great reduction and I don't think the joint is that bad and then they just, they just, they just go south. So all right. Well, I think that that was our, that was our warmup there. A couple of questions. So when, when do you get these guys moving? Two weeks. Two weeks, as long as the incisions are looking good. I sometimes may do it if I, if the, if their incisions are looking bad, I'll do it from a week to two week basis, but usually two weeks they're in a boot moving. Okay. And then when are you letting these guys bear weight? Usually somewhere around eight to 10 weeks. I would have to say the vast majority of my patients just go ahead and select whatever time they want to start walking. Right. If it's, if it's up to me about eight to 10 weeks, depending on the fracture pattern and the fixation. Okay. All right. All right. Number two. Yeah. So this is a guy, he's a 57 year old, but you know, with some, with some asterisks. So his history of IV drug use is currently clean. He is, had a previous stroke that is a hemorrhagic stroke. He's aphasic and he's got right-sided hemiplegia with a foot drop and uses an AFO. He comes in with this, that according to the patient and his sister, who's his caregiver, he just kind of fell out of bed. And this is what he's got. So is, is this a guy where you're thinking fusion might be the right answer? I sure am. Like this is, this is kind of a softball for the fusion. Sorry. Yeah. I think this is, I think for me, this is fusion all the way. Really the only thing I was actually thinking about was whether you would use a nail to fuse it or try to get away with just an A standard ankle fusion. Okay. And I think for 57 hemiplegia and foot drop I probably would do a nail for this one. Okay. And for this one, I mean, you know, even with people that have bad disease, you can do it through a small lateral approach, you know, maybe like three centimeter, four centimeters. You can take off the distal fibula, access your joint, scrape it off through there, take off the lateral process. You can get to your subtalar joint after you take off the lateral process really easily and then nail and fixation. Okay. So I yeah, I mean, this is a CT scan just to kind of drive that point home. I didn't have the full story in this guy when he first got presented to me. And so I did this initially, which in hindsight, I wish I had skipped this step. You know, I mean, he, you know, we got him reduced with a fixator, repeated the CT, which showed that it was still horribly comminuted, low periarticular fracture. And again, that I was then more aware, I guess, of his social and health related issues. So I talked to him about it and yeah, I mean, so these are my questions, but again, you've kind of already hit on those is, you know, so whether or not to include the subtalar joint, I think you've talked about it in your talk as well. So I guess for, especially for younger patients, where they're, you know, some of those cases you show where they're high energy open injuries, you're trying to avoid including a subtalar joint if possible, correct? Yep. Okay. And then the weight bearing status for these people. So again, young patient, I get it, they can wait that eight to 10 weeks, but for someone like this guy, are you letting him wait there sooner on a nail? I think, yeah, probably, I think as soon as like, as soon as his heel incision is looking good, I probably let him bear weight for transfers. So maybe two to four weeks for weight bearing for transfers and then probably at six weeks full weight bearing. Okay. And especially for this one, cause this one has a lot of stability to it. Yeah. You know, I think the ones that you do for when there's a lot of metaphyseal comminution and you really, you're using a long nail and extending it. Those ones, sometimes I may wait a little bit longer, treat it more as more of a standard Pilon, but for this one, you know, that one's got some inherent stability with the rod. So probably about six weeks for full weight bearing, two to four weeks for weight bearing for transfers. Actually. And so one of the guests brings a question. One of the cases you showed, you actually use an integrated nail to do an ankle fusion. I mean, how, how often have you, that's kind of an exception for you. I did it once you saw it. There it is. Okay. Got it. So even for folks with the kind of profound metaphyseal comminution, you're still trying to, you know, plate that, or, you know, plate it and then come back and graft it later if needed. Yeah. But, you know, I'd have to say for just Pilon's, I treat a lot of Pilon's with, that have that metaphyseal diaphyseal extension. I treat a lot of them with rods for that portion. And then I'll plate around the rods for the standard Pilon. So I do use rods a lot for Pilon fractures, just not for fusions. Got it. Okay. Great. All right. So this is, yeah, this was exactly what you described. We did a limited approach, prepared the joints. You know, I do think one of the points you touched on, especially for younger patients, is that one of the challenges I've felt with this when I've done it, not for this patient population, is that it's difficult because you still have to rebuild the fracture, right? So, I mean, I think that there's, I mean, I definitely have people who have come to me after an acute arthrodesis, where it's just like, they just put a nail in and like, there's no, there's no, there's pieces everywhere, right? Metathesis, articular surface. There's just, it's like a bridging nail. And so I guess that's one of my things is, I mean, do you find it necessarily easier to do a fusion? Or, I mean, it seems like it's just as hard, if not harder than fixing a pylon, correct? Well, I think it's almost just as hard. I mean, you're spending time, you know, the time that you're, I think you're gaining from not trying to fix the articular surface anatomically, you're spending on joint prep and everything else. So I would say they're pretty, you know, it's a toss up really. Maybe a little bit faster when you're doing a primary fusion because you still have to do all the steps to fix it. You just don't have to fiddle with the articular surface as much. Right. I mean, I just think that's potentially one of the misconceptions about it is that like, it's somehow an easier thing to do. I think it's almost like primary fusion for a calcaneal fracture, right? I mean, you still got to get the tuberosity reduced. You still got to get the pieces together, and then you got to do a good joint prep and figure out a way to hold it. So this is how I did. I mean, and I think, I mean, at least this has been my experience in this patient population. I feel like I get kind of a partial union. You know, I mean, he's doing great. I mean, he's back to himself. He's walking with a brace. I mean, he's doing everything he needs to do. But, you know, maybe it's an issue with my own joint prep. I feel like I have challenges sometimes with getting a complete union, especially at the tibia-tailor joint when I'm doing these. So, okay, our last case. So now we're going to, I think, amp it up a little bit here. So this is a 50-year-old guy who was involved in a motor vehicle collision. Past medical history, he's morbidly obese, has some hypertension, and he's type 2 diabetic, well-controlled on oral medications. And so he comes in with this injury you see here, okay? And then, so I guess your initial thoughts or impressions here. That's a big leg for sure. So this is closed? Not necessarily. Oh, okay. Yeah, yeah. That's what I was expecting, okay. Yeah, yeah, so that's his soft tissue injury right there. So his vascular, he's got intact blood flow, doesn't have a vascular injury. Surprisingly, you know, he's got some paresthesias, but neurologically intact. So, you know, this is what you're dealing with. Okay. So obviously, you know, just like you're in the operating room, you have to get it cleaned out really well. The goal would be to try to see if you get some primary skin closure on that. You know, the other thing that you're gonna be really hurting for is that the, you know, your pins are gonna have to go through some element of that soft tissue just based on how high it extends. Yeah. So I think external fix it. I try to wash it out. You have to remove any devitalized bone that's there. He's probably gonna need a couple of washouts based on that level of contamination and soft tissue stripping. And I just probably put him into a fixator for now and see what happens after it gets cleaned out. Mm-hmm. So that's the initial stage there. So, and again, I think this just highlights the challenges of kind of managing some of these injuries, especially with extension proximally. So this was my, one of my partners did this initially, obviously beautiful closure. And they tried to keep the pins, you know, kind of out of the zone of the injury. The problem is they've got, you know, basically pins in the foot and pins at the knee. And, and so this is what his, you know, post, you know, in floor shots look okay, but then you get a plain film post-op and you can just see how unstable this injury is. There's just not a lot of control of diaphysis. So, so I took this guy back, you know, tried to get it more stable. I have to put a pin closer to the zone of injury. I fixed his fibula. There was a big joint piece that still had some tissue, excuse me, not joint piece, cortical piece that still had some tissue attachment. So again, I thought maybe you would give us some read to length. And so I put a couple of mini frag screws in that. So, you know, we're at this point right here, right? So, I mean, this is what things are looking like. His soft tissue is still pretty marginal. I mean, that anterior wound is closed, but it's not looking quite as good as it did that first time you closed it. So what, you know, where are you kind of thinking about going with this guy from here? Well, I think you have a whole bunch of different options. I guess it depends on what kind of person you are. I definitely think this guy's gonna get a fusion because that for me is not reconstructable. And like you said, soft tissue wise, by the time you're able to kind of reconstruct that, it's not gonna do all that great. So I'm already thinking fusion and the key is to how to set up that success. So I think you have a couple of things. One is you could convert this guy to like a thin wire fixator. You could, you know, you could also, like I said, put some sort of temporary stabilizing piece down so you could exchange out the X-Fix. And this is one that you could actually probably nail across the tibia, either integrate, or you could put in a hind foot nail. And then you could probably put some cement around and maybe do a masculine technique to fill that in. Cause he's obviously gonna need some element of bone grafting to get up to the shaft. Okay. So this is where, this is a CT scan. So I mean, joint, you know, at least on these cuts that I gave you isn't horrible, but you can see the, I mean, this is a cortical piece that's like, you know, over the tail navicular joint. I mean, so it's just the amount of soft tissue damage here is pretty impressive. So, you know, things took a turn at this point. So I, this is later on, this is like three debridements later, you know, cause his, some of his skin died. He had, he developed an infection and this is a big antibiotic spacer that you can see in there now. So, and I obviously open to thoughts on this. My thought process was I just wanted to create some distal block that I could bring something down to. So I did a limited reduction of that articular surface just through small incisions. And, you know, and again, in hindsight, I'm wondering why I didn't just include his talus cause that would have given me even more to work with there. But yeah, I mean, this, so basically we, this is where we kind of stopped things. We paused here. So he has a spacer in place. He got antibiotics. His skin actually got better. Shockingly, he didn't end up needing a flap for this. And so for me, I mean, this is obviously, this is a conversation about a bunch of things, right? And I'm talking to this guy about whether or not amputation is the right answer for him, which is pretty reasonable. He's really opposed to that idea. He's, I mean, and to, you know, he's still sensate. He's still got some motor function. He's still well perfused. And he's got some functional aspects that are salvageable. Yeah, and so it's just like you touched on. I mean, so for me, you know, this guy's now got a seven and a half to eight centimeter bone defect kind of from that articular block up to the healthy portion of his diaphysis. And so for a defect that big, are you still thinking that, are you still gonna try or attempt to mask away for that? I think I would just because that's what I do the most and I've had okay success with it. The, and the other nice thing is you're introducing your own bone. You know, the problem is, you know, I saw that you put the custom cage in there, which is not necessarily a terrible idea, but I always get nervous with a history infection and the diabetes of putting something in there because those tend to kind of bone grows into them and through them. And if you have some problems down the road, and I've, even though that's a pretty big defect, I've had some pretty good success with mask away. And I usually tend to use, when I come back for defects that big, I usually use both, both crest autographs and I'll do a Rhea and sometimes maybe a couple Rheas of both femurs. Bone transport, I think is also another option. You can, in theory, shorten them and lengthen them over time. I'm not that patient of a person and I don't do it that often. So, but I think that that's also another option. I probably wouldn't do the cage thing. It's just not, I just worry about that wouldn't be an even more of a problem down the road. Yeah. I mean, I basically, I agree. I, the only thing for me is that the, you know, defects and I don't have a hard cutoff on it, but I have had less success with larger defects of the tibia. I think femur, it just heals. I mean, I've had femurs heal around an antibiotic spacer, but the tibia, I've had, I would say mixed success with trying to do a bone grafting of a larger defect with a masculine technique. So I've actually started to do kind of creeping, I would say, kind of into more of the bone transport world. And so that's what I chose for this guy. And so we just did, you know, I just flat cut basically that proximal piece and the distal piece. And then this is basically what we did. So we set him up for a transport and, you know, this is still in progress. And I would say again, in hindsight for this, I wish I had done something to include his foot into this outside of just the wires, right? I mean, and I guess that's one of the questions is, you know, what would you do, you know, if you were fusing this, right? One of the challenges for me is like, how am I going to simultaneously compress this tibia-tailor joint and do this bone transport? And I'm certainly, I'm sure there's guys that are, you know, classically trained in this that could do that and, you know, not bat an eye at it. For me, that's just one step too many. Yeah, no, I think that's gotta be a staged thing. Okay. So I think the bone transport's a good idea. You know, the key is with these is always buy-in from the patient. The good news is he doesn't want an amputation. Right. And I think the nice thing is where you, when you're going to do this type of thing, if you're going to do it, is you did it right where even if this thing all falls apart, you've cut that tibia at a nice level where you can have a really decent amputation. I think that's really one of the things too. I mean, ideally you try to get into the metaphysis, you know, because that will grow a little bit further, but then if this thing falls apart or doesn't heal, then you're in real big trouble for salvaging a below-knee amputation. And I've had that happen. And that's why. Yeah, so I think that that's really, I think that's a good place to make your cut on that bone. But yeah, I agree. I think that it would have been easier to do the fusion first and you would have gotten yourself a little bit bigger bone block distally. But I think it's fine. And this is a guy who obviously realizes it's long haul. So, you know, having an ankle fusion down the road when it all heals to him will be fine. And this guy also is, you know, he has had, he's made some mistakes, but he's a very compliant guy and he's got social support. He's got people who can help him because that's a huge deal with these fixers. I mean, you can't turn the struts in the back yourself. You have to have someone who can actually help you, who can understand. And he actually does have that. So this is basically where we are now. I mean, he's not, he's halfway basically at this point. So this is definitely to be determined. I mean, his regenerate isn't, I would say, the most robust I've ever seen. It's definitely there. And the hard part is, I mean, for me, is being patient with these. I mean, and my typical experience is I will get delayed healing at some level, you know, whether it's at the docking site or of the regenerate or both. So at some point, this guy probably will be converted to a nail of some kind, assuming he doesn't get infected or have some horrible complication in the process. So, yeah, thanks. I appreciate it. So I will thank you. That's all the cases that I have. So I appreciate your help. And that was a great talk. Yeah, thanks.

primary fusions

pilon fractures

soft tissues

case examples

rationale for primary fusion

functional limitations

surgical techniques

individualized treatment methods