Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation commonly used for acute management of pilon and unstable ankle fractures or in presence of compromised soft tissues CT performed after fixator to better delineate fracture pattern setup OR with radiolucent table and C-arm perpendicular from contralateral side Positioning supine on radiolucent OR table with feet at end of bed, bump under ipsilateral hip non-sterile tourniquet Tibial Pins tibial pins placed proximal to fracture and just medial to anterior tibial crest ensure placement does not interfere with definitive fixation Calcaneal Pin transcalcaneal pin inserted from medial to lateral starting point 2cm inferior to medial malleolus and 2cm anterior to posterior border of calcaenus Bar Placement and Fracture Reduction span tibial pins with bar, creating stable base connect bars from stable base to calcaneal transfixtion pin medially and laterally check AP/Lat fluoro of fracture site and pull traction while applying varus/valgus and anterior/posterior force Postoperative non-weight bearing in splint, CT of ankle afterwards 1-2 wks: serial soft tissue checks, pin site cleanings and dressings Planning & Preparation Surgical Planning fixator provides fracture stabilization and soft tissue ligamentotaxis to allow for decreased articular impaction and soft tissue swelling CT performed after fixator placement to better delineate fracture pattern and articular injury fixator to be left on until swelling resolves and return of skin wrinkles (10-14 days), can be used for definitive management if significant comorbidities decreased incidence of wound complications and deep infections with fixator treatment compared to ORIF, can combine with limited percutaneous fixation using lag screws Table and Imaging setup OR with radiolucent table c-arm from contralateral side perpendicular to table, monitor at foot of bed in surgeon direct line of site Equipment & Positioning Equipment spanning external fixator system (ie. Stryker Hoffman 3, Zimmer, Synthes, Jet-X) compact or small external fixator system if foot pins needed c-arm Patient Position supine with feet at the end of the bed, bump under ipsilateral hip to get limb into neutral rotation patella pointed towards ceiling, often foot will be externally rotated through fracture site distally thigh tourniquet optional Surgical Technique Approach mark out proximal extent of fracture in distal tibia using fluoro want pins to be at least 3cm proximal to fracture anticipate what will be used for definitive fixation and ensure pins do not imede determine what forces (varus/valgus) on AP fluoro are needed for reduction under traction palpate and mark out tibial crest anteriorly tibial pins need to be placed just medial to tibial crest, never lateral to avoid injury to anterior tibial artery, vein, deep peroneal nerve with bicortical drilling and pin placement on back table prepare trochars, drill guides, and sleeves x2 into horizontal bar connector holes 1 and 4/5 place trochars firmly on skin to mark distance and location between skin incisions typically want one hand with at least between tibial pins Tibial Pins 15blade through skin down to bone, hemostat to spread soft tissue place trochars firmly on bone in vertical orientation along medial aspect of tibial crest, hold firmly and do not slide off of tibial crest alternatively can initially aim drill laterally until starting hole is made, then bring hand vertical to complete drilling remove innermost trochar and drill hole for proximal pin feel penetration of 1st cortex, tap 2nd cortex, then carefully go through 2nd cortex, do not plunge remove 2nd inner sleeve and insert pin with T-handle by hand, feel pin engage both cortices repeat same steps above for 2nd pin check that pins are centered on tibia on AP fluoro, move horizontal bar connectors or rod 2-3cm from skin and tighten down the closer the bars are to skin the stronger the construct, do not get too close otherwise can abrade skin check lateral fluoro image of pins to make sure bicortical pin placement, do not want too long Calcaneal Pins move distal to calcaneus, mark out proposed pin site on medial calcaneus and check with fluoro transcalcaneal pin 2cm distal to medial mallelous, 2cm anterior to posterior border of calcaneus need adequate bone bridge to avoid pin breakout inferiorly 15blade through skin on, hemostat spread to bone insert pin on power with center threads into calcaneus pin needs to be parallel to ground and perpendicular to bone with assistant holding lower leg straight up and down (look at tibial crest and foot) can check start point and parallel trajectory on fluoro, make pin parrallel to tibial plafond drill through opposite side of calcaneus, when pin poking through opposite side use 15blade for skin and hemostat for soft tissue check that center threads are fully seated in calcaneus if increased hindfoot control needed can add 2nd calcaneal pin anterior to first pin with bar connector to join together (rare) if dorsiflexion needed can add 1st metatarsal pin +/- 5th metatarsal pins with connector bar and rod to maintain dorsiflexion (can alternatively use splint) need to be careful since metatarsal pins are small and easily slide off of sides of bone bolt cutter to remove pointed end of calcaneal pin, place endcaps on both sides of pin Bar Placement and Fracture Reduction place pin-bar connectors to tibial horizontal bars and calcaneal pins 2-3cm from skin size 11 bar connector bolt for tightening needs to be pointed towards ceiling for later tightening estimate bar length needed (i.e. 6’, 70kg male,~450-500mm) bar length needs to accommodate fracture reduction and increased limb length add 2 carbon fiber bars in triangle (delta) formation into system and gently tighten bar connectors for provisional fixation check AP fluoro of fracture site and pull traction while applying varus/valgus force to get in line, tighten connectors with T-handle check lateral fluoro of fracture site, gently loosen connectors and adjust anterior/posterior force as needed for reduction, retighten connectors with T-handle retighten all connectors with T-handle Confirm Reduction and Pin Placement take final AP/Lat of pin sites and fracture site reduction Closure Irrigation & Hemostasis irrigate pin sites and deflate tourniquet if inflated Dressing and Splint xerform around pin site bases then cover with gauze and kerlix wrapped tightly short leg postmold splint with extra padding under heel for immobilization, dorsiflex ankle to prevent equinus if needed Postoperative Care Immediate Post-op non-weight bearing in splint CT of ankle to delineate fracture pattern and articular comminution 1-2 Weeks non-weight bearing in splint serial soft tissue checks, await return of skin wrinkles serial pin site cleanings and dressings surgical planning for definitive fixator management vs. ORIF / tibiotalar arthrodesis depending on fracture characteristics and patient comorbidities Complications Document Complications pin tract infections loss of reduction in external fixator ankle stiffness nonanatomic restoration of articular surface iatrogenic injury to anterior tibial artery, vein, deep peroneal nerve during tibial pin placement (if placed lateral to medial)