Temporary Transarticular K-wire Fixation of Critical Ankle Injuries at Risk: A Neglected “Damage Control” Strategy?
Abstract
High-energy ankle fracture-dislocations are at significant risk for postoperative complications. Closed reduction and temporary percutaneous transarticular K-wire fixation was first described more than 50 years ago. This simple and effective “damage control” strategy is widely practiced in Europe, yet appears largely forgotten and abandoned in the United States. Anecdotal opposing arguments include the notion that drilling K-wires through articular cartilage may damage the joint and contribute to postinjury arthritis. This article describes the experience in a US academic level I trauma center with transarticular pinning of selected critical ankle fracture-dislocations followed by delayed definitive fracture fixation once the soft tissues are healed. Median patient follow-up of 2 years showed that the transarticular pinning technique was performed safely, not associated with increased postoperative complication rates, and characterized by good subjective outcomes using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcome Score questionnaire. [Orthopedics. 2015; 38(2):122–127.]
The authors are from the Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado.
Dr Friedman and Ms Ly have no relevant financial relationships to disclose. Dr Mauffrey is a paid consultant for DePuy Synthes and Abbott Medical. Dr Stahel has received speaker’s honoraria from DePuy Synthes and Stryker Spine.
Correspondence should be addressed to: Philip F. Stahel, MD, Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, Denver, CO 80204 ( philip.stahel@dhha.org).
Most ankle fractures are managed as an out-patient procedure by early definitive internal fixation, with a low risk of wound complications and surgical site infections.1–5 A recent large case-control study in the United Kingdom revealed an incidence of 4% for superficial and 1.1% for deep surgical site infections after ankle fracture fixation,2 rates in line with those previously published.6 A subset of patients with acute ankle injuries is considered at particular risk for postoperative wound complications and infections. These patients include smokers and those with diabetes mellitus, osteoporosis, bimalleolar ankle fractures, open ankle fractures, malreduced ankle fractures requiring revision surgery, and intraoperative placement of a surgical drain.3,6–11 High-energy ankle fracture-dislocations represent a particularly challenging entity susceptible to postoperative wound complications and unplanned surgical revisions, including the potential downstream need for transtibial amputations in cases of unsalvageable infections.12–16
The ideal management strategy for unstable ankle-fracture dislocations with critical soft tissues remains a topic of debate.17,18 The widely used concept of closed reduction and temporary splint immobilization until definitive fracture fixation bears the risk of prolonged soft tissue swelling and ongoing skin tension due to the unstable ankle joint.19,20 This modality also precludes adequate monitoring of the soft tissue envelope related to recurrent ankle joint dislocation or subluxation whenever the splint is removed. Alternative options include immediate definitive surgical management with open reduction and internal fixation (ORIF)21–25 and the more conservative “damage control” approach of temporizing external fixation.26–28
The concept of percutaneous vertical transarticular pin fixation as a “salvage” option for unstable fracture-dislocations of the ankle dates back to descriptions in the Italian literature in 195829 and in the British literature in 1963.30 The first landmark article in the US literature appeared in 1965.31 The technique described by Childress31 involves placement of one 7/64-inch (2.8 mm) diameter or 2 parallel 3/32-inch (2.4 mm) diameter Steinmann pins. Multiple current publications from Europe emphasize the validity and safety of this staged concept with initial closed reduction and transarticular pin fixation followed by delayed definitive ankle fracture fixation once the soft tissue swelling has subsided.32–35 However, this “historic” technique has been largely abandoned in the US orthopedic community.
The current study was designed to analyze the experience in a US academic level I trauma center with the damage control approach of temporary transarticular pin fixation followed by delayed definitive ORIF for selected ankle-fracture dislocations at risk for significant soft tissue complications.
Materials and Methods
