A staged protocol for soft tissue management in the treatment of complex pilon fractures

Can Laser-Assisted Indocyanine Green Angiography Be Used to Quantify Perfusion Changes During Staged Fixation of Pilon Fractures? A Pilot Study

OBJECTIVE

To quantify soft tissue perfusion changes in pilon fractures during staged treatment using laser-assisted indocyanine green angiography (LA-ICGA).

SETTING

Level 1 trauma center.

DESIGN

Prospective cohort study.

PATIENTS/PARTICIPANTS

Twelve patients with 12 pilon fractures participated in the study. Seven patients had OTA/AO classification of 43-C3, 3 had 43-C2, and 2 had 43-B2.

MAIN OUTCOME MEASURES

LA-ICGA was performed with the SPY fluorescence imaging platform. Analysis via ImageJ was used to generate a fractional area of perfusion (FAP) based on fluorescent intensity to objectively quantify soft tissue perfusion. Anterior, medial, and lateral measurements were performed at the time of initial external fixation (EF) application and then at the time of definitive fixation.

RESULTS

FAP within the region of interest was on average 64% medially, 61% laterally, and 62% anteriorly immediately before EF placement. Immediately before definitive open reduction internal fixation, fractional region of interest perfusion was on average 86% medially, 87% laterally, and 86% anteriorly. FAP increased on average 24% medially ( P = 0.0004), 26% laterally ( P = 0.001), and 19% anteriorly ( P = 0.002) from the time of initial EF to the time of definitive open reduction and internal fixation.

CONCLUSIONS

Quantitative improvement in soft tissue perfusion was identified through the course of staged surgical management in pilon fractures. LA-ICGA potentially may be used to determine appropriate timing for definitive surgical intervention based on the readiness of the soft tissue envelope. Ultimately, these findings may influence clinical outcomes with respect to choice of surgical approach, soft tissue management, surgical timing, and wound healing.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Temporary circular external fixation for spanning the traumatised ankle joint: A cohort comparison study

BACKGROUND

Temporary spanning fixation aims to provide bony stability whilst allowing access and resuscitation of the traumatised soft-tissue envelope. Conventional monolateral fixators are prone to half-pin morbidity in feet, variation in construct stability and limited weight-bearing potential. This study compares traditional delta-frame monolateral external fixators to ankle spanning circular fixators.

METHODS

Two cohorts were matched for demographics and fracture patterns. The quality of initial reduction and the maintenance of reduction until definitive surgery was assessed by two authors and categorised into four domains. Secondary measures included fixator costs, time to definitive surgery and complications.

RESULTS

Fifty-five delta-frames and 51 circular fixators were statistically matched for demographics and fracture pattern. "Excellent" and "Good" initial reduction was achieved in 50 (91%) delta-frames and 51 (100%) circular fixators (p = 0.027). Deterioration of initial reduction quality was seen in 12 (22%) delta-frames and two (4%) circular fixators (p < 0.001). Post-fixator dislocation occurred in five (9%) delta-frames and one (2%) circular fixator (p = 0.147). Median duration in spanned fixation was 11 days in both groups (p = 0.114). Three (5%) delta-frames and 13 (25%) circular fixators were used as definitive fixation. The mean implant cost was 4,307 USD for delta-frames and 3747 USD for circular fixators.

CONCLUSION

Temporary spanning circular fixation offers superior intra-operative reduction and maintenance of reduction and provides more opportunity to be used as definitive fixation. Circular fixation implants also proved to be less expensive and protected against further scheduled or unscheduled returns to theatre.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes

Few is investigated about the management of acute fore- and midfoot injuries in diabetics. With well controlled diabetes, indications and techniques are similar to non-diabetics. With poorly controlled diabetes, medical optimization should be exercised. Stable internal fixation in case of surgical treatment and prolonged offloading independent of the choice of treatment are advised. With manifest Charcot neuroarthropathy, the goal is to achieve a plantigrade, stable foot that is infection- and ulcer-free and ambulant with orthopaedic shoes. If operative treatment is chosen, the concept of superconstructs in combination with prolonged protection in a well-padded total contact cast is applied.

Incisional and Surrounding Periarticular Soft Tissue Management With Negative Pressure Therapy

Periarticular injuries of the lower extremity are known for wound healing and infection complications. The role for incisional negative pressure wound therapy for lower extremity periarticular fractures has expanded over the last 10 years in hopes of minimizing complications. To date, there is no standardized published protocol of how negative pressure wound therapy is best used in lower extremity periarticular fractures. A review of strategies to decrease complications associated with the operative management of lower extremity periarticular fractures to include the use of incisional negative pressure wound therapy is presented.

Risk Factors for Infection and Subsequent Adverse Clinical Results in the Setting of Operatively Treated Pilon Fractures

OBJECTIVE

To determine patient-specific and injury-specific factors that may predict infection and other adverse clinical results in the setting of tibial pilon fractures.

DESIGN

Retrospective chart review.

SETTING

Level 1 academic trauma center.

PATIENTS

Two hundred forty-eight patients who underwent operative treatment for tibial pilon fractures between 2010 and 2020.

INTERVENTION

External fixation and/or open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

Fracture-related infection rates and specific bacteriology, risk factors associated with development of a fracture-related infection, and predictors of adverse clinical results.

RESULTS

Two hundred forty-eight patients were enrolled. There was an infection rate of 21%. The 3 most common pathogens cultured were methicillin-resistant Staphylococcus aureus (20.3%), Enterobacter cloacae (16.7%), and methicillin-resistant Staphylococcus aureus (15.5%). There was no significant difference in age, sex, race, body mass index, or smoking status between those who developed an infection and those who did not. Patients with diabetes mellitus ( P = 0.0001), open fractures ( P = 0.0043), and comminuted fractures (OTA/AO 43C2 and 43C3) ( P = 0.0065) were more likely to develop a fracture-related infection. The presence of a polymicrobial infection was positively associated with adverse clinical results ( P = 0.006). History of diabetes was also positively associated with adverse results ( P = 0.019).

CONCLUSIONS

History of diabetes and severe fractures, such as those that were open or comminuted fractures, were positively associated with developing a fracture-related infection after the operative fixation of tibial pilon fractures. History of diabetes and presence of a polymicrobial infection were independently associated with adverse clinical results.

LEVEL OF EVIDENCE

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

Is It Safe to Prep the External Fixator In Situ During Staged ORIF of Bicondylar Tibial Plateau Fractures? A Retrospective Comparative Cohort Study

OBJECTIVES

To compare the risk of deep infection and unplanned reoperation after staged open reduction internal fixation (ORIF) of bicondylar tibial plateau (BTP) fractures whether elements of the temporizing external fixator were prepped into the surgical field or completely removed before definitive fixation.

DESIGN

Retrospective comparative cohort study.

SETTING

Two academic Level 1 trauma centers.

PATIENTS/PARTICIPANTS

One hundred forty-seven OTA/AO 41-C (Schatzker 6) BTP fractures treated with a 2-stage protocol of acute spanning ex-fix followed by definitive ORIF between 2001 and 2018.

INTERVENTION

Seventy-eight fractures had retained elements of the original ex-fix prepped in situ during surgery for definitive internal fixation, and 69 had the ex-fix construct completely removed before prepping and draping.

MAIN OUTCOME MEASURES

Deep infection and unplanned reoperation.

RESULTS

Among 147 patients treated with staged ORIF, the overall deep infection rate was 26.5% and the reoperation rate was 33.3%. There were high rates of deep infection (26.9% vs. 26.1%, P = 0.909) and unplanned reoperation (30.8% vs. 36.2%, P = 0.483) in both groups, but no difference whether the ex-fix was prepped in or completely removed. Within the retained ex-fix group, there was no difference in infection with retention of the entire ex-fix compared with only the ex-fix pins (28.1% vs. 26.1%, P = 0.842).

CONCLUSIONS

We observed high complication rates in this cohort of OTA/AO 41C BTP fractures treated with staged ORIF, but prepping in the ex-fix did not lead to a significant increase in rates of infection or reoperation. This study provides the treating surgeon with clinical data about a common practice used to facilitate definitive fixation of unstable BTP fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Impact of Early Limited Surgical Intervention to Treat Pilon Fractures

BACKGROUND

The operative treatment of pilon fractures is classically treated with a staged protocol with ankle spanning external fixator, followed by definitive open reduction and internal fixation in order to decrease risk of soft tissue complications and infection. However, treatment of pilon fractures with patrial tibial fixation in addition to ankle spanning external fixation at the time of index procedure may facilitate final fixation while avoiding complications that were associated with acute definitive fixation.

METHODS

Retrospective cohort series of 113 patients treated for pilon fractures from September 2012 to November 2018 at a single level 1 trauma center. Charts were reviewed to compare patients who underwent traditional management with a staged protocol and those who had a limited tibial reduction and fixation (LTRF) during the index procedure. The main outcome measurement was time to definitive fixation.

RESULTS

Twenty-six percent of patients (29 of 113) had limited tibial reduction and fixation (LTRF) during index surgery. Mean time between index procedure and definitive ORIF was 4.75 days less for LTRF cohort compared to standard stage cohort (10.86 ± 7.44 vs. 15.61 ± 8.59 days, P = .009). The index procedure took on average 51 minutes longer in the LTRF cohort (P < .001), yet definitive procedure operative time was decreased by an average of 98 minutes (P < .001), and overall (index plus definitive) operative duration was shortened by an average of 50 minutes (P = .044). There was no difference in rate of infection between LTRF (3.1%) and traditional treatment (2.5%) (P = .86) or reduction quality (P = .270). There were no nonunions in either treatment group.

CONCLUSION

Patients who had LTRF had quicker time to definitive ORIF and decreased operative time for definitive ORIF. There was no difference in infection rate, reduction quality, or nonunion rate between groups.

LEVEL OF EVIDENCE

Level IV, Retrospective Cohort Study.

Open Reduction and Internal Fixation of a Partial Articular (OTA-43B) Pilon Fracture Through a Direct Anterior Approach

We present the management of an OTA-43B Pilon fracture with a depressed plafond fragment, medial comminution, and displacement of the Chaput fragment. The patient was initially managed with external fixation to gain initial reduction of the pilon fracture and to allow the soft tissues to heal. As demonstrated, the extensile anterior approach can be modified and used to see the anteromedial and anterolateral tibial plafond so an anatomic reduction could be obtained. Also detailed is the reduction and fixation strategy and soft tissue closure, all of which plays a critical role in the outcome.

Searching for a New Parameter in the Healing of Tibia Pilon Fractures: Fracture Area Measurement

BACKGROUND

Tibia pilon fractures are associated with high complication rates, decreased quality of life, and low patient satisfaction. Although many factors such as reduction quality and soft-tissue coverage have been identified, researchers continue to investigate the factors that affect healing in tibia pilon fractures. Our objective was to investigate the effect of initial fracture crack width and displacement degree on clinical functional results in tibia pilon fractures.

METHODS

In this retrospective cohort study, 40 patients with Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association type 43B and 43C tibia pilon fractures and operated on through the extensile anteromedial approach were analyzed. The demographic data of the patients, injury mechanisms, fracture type, reduction quality, clinical results, and postoperative complications were recorded. To evaluate the objective quantity of initial fracture crack width and displacement, a new parameter was defined: "fracture area." All measurements were conducted using a feature from the picture archiving and communication system on anteroposterior and lateral radiographs taken separately in standard fashion.

RESULTS

With an average follow-up period of 29.2 months (range, 24-40 months), 34 patients (85%) had excellent or good results, whereas only two patients (5%) had poor clinical results. Age, injury mechanism, and reduction quality have a significant relationship with Maryland Foot Score (P < .001, P < .037, and P < .001, respectively). Preoperative fracture area, measured on both the anteroposterior and the lateral views, are significantly related to both Ovadia-Beals Score and Maryland Foot Score (P < .001 for each).

CONCLUSIONS

Preoperative fracture area measurement has a major effect on healing of tibia pilon fractures. Increased initial fracture area is correlated with poor clinical functional results. High-energy injuries, older age, and poor reduction quality are also related to worse clinical outcomes.

Retrospective Analysis of Infection Factors in Secondary Internal Fixation after External Fixation for Open Fracture of a Long Bone: A Cohort of 117 Patients in a Two-Center Clinical Study

Purpose

To investigate infection risk factors after secondary internal fixation (IF) of open fracture of a long bone with removed fixation frame and explore the safe range of feasible operation for abnormal inflammatory indicators.

Methods

Clinical data of 117 cases of open fracture of a long bone that underwent temporary external fixation (EF) in one stage and IF in two stages were retrospectively analyzed. Collected data included age, sex, Gustilo type, multiple injuries, debridement time, duration of EF, needle infection, interval of conversion to IF after external fixator, preoperative white blood cell (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin (ALB), blood glucose, and prognosis. We selected these factors for univariate analysis of postoperative surgical site infection (SSI) and multivariate logistic regression analysis of statistically significant risk factors and created receiver operating characteristic (ROC) curves to compare the diagnostic efficiency of each index and determine the optimal screening point.

Results

We followed up 117 patients, with 130 limbs affected. Univariate analysis showed that ESR, CRP, ALB, WBC, EF time, and Gustilo fracture type were significantly associated with SSI. Multivariate logistic regression analysis showed that CRP, duration of EF, and Gustilo fracture type were independently associated with postoperative infection. Area under ROC curves for WBC, ESR, and CRP were 69.7%, 73.2%, and 81.2%.

Conclusions

We demonstrated the role of Gustilo classification of open fractures in predicting postoperative infection, especially for open fractures above type III. If the inflammatory indexes return to normal or show a downward trend, and the second-stage IF operation is performed within the cutoff values, postoperative recurrent infection was reduced.

Management of a Rare Case of Closed Pilon Fracture With Fibula Displaced in the Foot

Pilon fractures are intra-articular injuries involving the tibial plafond and have a wide range of complexity. The timing and type of fixation in these injuries is dictated by soft tissue status and energy imparted to the distal tibial plafond. We had a unique clinical situation in which axial loading of the talus caused severe comminution of the tibial plafond and fracture of the distal third of the fibula. Further action of these forces caused displacement of the fibular segment into dorsum of the foot along with part of the articular surface of the tibial plafond without causing any external wound. This case was challenging because displacement of the distal fibula resulted in disruption of important syndesmotic and lateral ankle ligaments. Fibular segment was without any soft tissue attachment and was reimplanted in the ankle mortise like a free fibula graft. Near normal ankle biomechanics were achieved in this case through anatomic reduction of the articular surface, reimplantation of the fibula in the ankle mortise, and repair of syndesmotic and lateral ankle ligaments. There was satisfactory clinical and radiological outcome on follow-up of more than 4 years. To our knowledge, this is the only case in Standard English literature where in the case of pilon fracture, the fibula had displaced in the foot without external wound.

Long-Term Trajectory of Recovery Following Pilon Fracture Fixation

OBJECTIVES

To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5-year follow-up.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation.

INTERVENTION

None.

MAIN OUTCOMES MEASURES

Patient-reported outcome measures were measured at baseline, 6 months, 1 year, and 5 years using the Short-Form 36 Health Survey (SF-36) Physical Component Score and Mental Component Score, Short Musculoskeletal Functional Assessment, and the Foot and Ankle Outcome Score.

RESULTS

One hundred two patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score of 9; 74 patients (73%) completed 1-year follow-up; 40 patients (39%) completed 5-year follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year and then ongoing but slower improvement between 1 year and 5 years. Sixty-four patients returned to baseline SF-36 Physical Component Score at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared with baseline. Psychological well-being (SF-36 Mental Component Score) did not significantly change from baseline at 5 years.

CONCLUSION

Functional recovery following open reduction and internal fixation for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental well-being showed no change from baseline at 5 years. This information may be useful when counselling patients.

LEVEL OF EVIDENCE

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

The local soft tissue status and the prediction of local complications following fractures of the ankle region

INTRODUCTION

Well-known risk factors (RF) for soft tissue complications following surgical treatment of fracture of the ankle region include diabetes, smoking, and the local soft tissue status. A weighted analysis might provide a risk profile that guides the surgical treatment strategy. The aim of this meta-analysis was to provide a risk profile for soft tissue complications following closed fractures of the ankle region.

METHODS

This review provides a meta-analysis of studies that investigate potential risk factors for complications in fractures of the ankle region.

INCLUSION CRITERIA

Original articles that were published between 2000 and 2020 in English or German language that calculated odds ratios (OR) of RF for soft tissue complications. Further, this study only includes articles that investigated fractures of the ankle region including pilon fracture, calcaneal fractures, and fractures of the malleoli. This study excluded articles that provide exploratory analyses, narrative reviews, and case reports. RF were stratified as patient specific systemic RF (PSS), patient specific local RF (PSL), and non-patient specific RF (NPS). PSS RF includes comorbidities, American society of anaesthesiology (ASA), requirement of medication, additional injuries, and smoking or substance abuse. PSL RF includes soft tissue status, wounds, and associated complications. NPS RF includes duration of surgery, staged procedure, or time to definitive surgery. Random effect (RE) models were utilized to summarize the effect measure (OR) for each group or specific RF.

RESULTS

Out of 1352 unique articles, 34 were included for quantitative analyses. Out of 370 complications, the most commonly assessed RF were comorbidities (34.6%). Local soft tissue status accounted for 7.5% of all complications. The overall rate for complication was 10.9% (standard deviation, SD 8.7%). PSS RF had an OR of 1.04 (95%CI 1.01 to 1.06, p = 0.006), PSL an OR of 1.79 (95% 1.28 to 2.49, p = 0.0006), and NPS RF an OR of 1.01 (95%CI 0.97 to 1.05, p = 0.595). Additional injuries did not predict complications (OR 1.23, 95%CI 0.44 to 3.45, p = 0.516). The most predictive RF were open fracture (OR 3.47, 95%CI 1.64 to 7.34, p < 0.001), followed by local tissue damage (OR 3.05, 95%CI 1.23 to 40.92, p = 0.04), and diabetes (OR 2.3, 95%CI 1.1 to 4.79, p = 0.26).

CONCLUSION

Among all RFs for regional soft tissue complications, the most predictive is the local soft tissue status, while additional injuries or NPS RF were less predictive. The soft tissue damage can be quantified and outweighs the cofactors described in previous publications. The soft tissue status appears to have a more important role in the decision making of the treatment strategy when compared with comorbidities such as diabetes.

Open versus closed pilon fractures: Comparison of management, outcomes, and complications

BACKGROUND

Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups.

METHODS

This retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807).

RESULTS

Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p = 0.017, respectively), ORIF-treated 43C closed fractures had shorter time to union (p = 0.005). Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (24%), superficial infection (21%). All occurred more frequently in FWF-treated patients.

CONCLUSION

Most ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups, yet few were statistically significant. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.

Assessment of alternative techniques to quantify the effect of injury on soft tissue in closed ankle and pilon fractures

INTRODUCTION

Local soft tissue status (STS) guides the timing for definitive surgical treatment strategies of fracture fixation around the ankle joint. The aim of this study was to assess different types of new technical devices in relation to the surgical treatment in closed ankle and pilon fractures.

METHODS

This study was designed as a cohort study. Adult patients admitted between February 1, 2019 and December 31, 2020 presenting with closed ankle fracture requiring surgical treatment were eligible. The exclusion criteria were previous injuries to the lower extremity, acute deep venous thrombosis, skin diseases, and delayed presentation (admission >24 hours after injury). Moderate-energy trauma includes injuries sustained during team sports, biking, and running. The primary outcome was the assessment of the degree of soft tissue involvement following closed fractures by comparing different techniques focusing on the ankle region and including ankle and pilon fractures. The variables of interest included the circumference of soft tissue swelling around the ankle, determined within a 5-mm range in the area of the medial and lateral malleolus and the bone-skin distance on a plain radiograph, determined by the largest distance from the malleolus to the border of the soft-tissue shadow. STS assessment included optical measures of local perfusion (O2C, Lea Inc. Germany) and tactile measures of mechanical characteristics (Myoton® tensiometer AS, Estonia). Measurements of Group Temp (temporary stabilization) and Group Def (definitive surgery) were taken on admission and prior to the treatment strategy decision. The contralateral non-injured ankle served as a control. The quality of assessment tools was quantified by calculating the smallest detectable change (SDC).

RESULTS

In total, 38 patients with a mean age of 40.4 (SD 17.8) years were included. The SDC was 3.2% (95%CI 2.5 to 3.8) for local blood flow and 1.1% (95%CI 0.4 to 1.7) for soft tissue stiffness. The circumference of the injured area at admission was significantly higher than that of the healthy site (28.2 [SD 3.4] cm versus 23.9 [SD 2.4] cm, p < 0.001). The local perfusion (blood flow 107.5 (SD 40.79 A.U. vs. 80.1 [SD 13.8] A.U., p = 0.009), and local dynamic stiffness of the skin (668.1 (SD 148.0) N/m vs 449.5 (SD 87.7) N/m, p < 0.001) were significantly higher at the injured site. In Group Temp, the local blood flow was significantly higher when compared with Group Def (109.6 [SD 39.8] vs. 94.5 [SD 13.0], p = 0.023). The dynamic stiffness of the soft tissue was significantly higher in Group Temp (679.4 N/m [SD 147.0] N/m vs. 573.0 N/m (SD 93.8) N/m, p < 0.001). The physical properties of STS were comparable among the fracture types. None of the included patients had local soft tissue complications.

CONCLUSION

Closed fractures of the ankle and the pilon are associated with an increase in local circulation and local soft tissue stiffness and tension. These changes of the STS following injury can be quantified in a standardized and reproducible manner.

Minimally Invasive Reduction and Fixation Techniques of Pilon Fractures Based on the Preoperative CT Findings

Tibial plafond fractures are often associated with significant articular cartilage and soft tissue damage. The presence of co-morbidities has been associated with an increased risk of surgical site complications. With improved in surgical techniques and implants, complication rates have declined; however, the overall prognosis often remains poor. The aims of this study were to evaluate the results of innovative minimally invasive reduction and fixation techniques in tibial plafond fractures based on a CT classification and to compare the difference between short and long-term outcomes. Based on preoperative CT findings, fractures were classified into varus, valgus, anterior, posterior, and neutral types. The minimally invasive reduction and fixation techniques depend on type of fracture, size and location of the intraarticular fragments, and degree of comminution of the extra-articular component. Ninety-one pilon fractures (90 patients) underwent minimally invasive reduction and fixation, of which 7 fractures (7.69%), required open reduction because of intraoperative failure to achieve anatomic reduction. Of the 84 fractures that underwent successful minimally invasive reduction and fixation reported, 35 fractures (41.7%) with excellent outcomes, 40 fractures (47.6%) with good outcomes, 6 fractures (7,1%) with fair outcomes, and 3 fractures (3.6%) had poor outcomes for the long-term American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score (follow-up ≥ 60 months). These results prove that minimally invasive treatment is an effective and durable treatment option for intra-articular pilon fractures. We encourage future clinical studies to further refine minimally invasive techniques for pilon fractures to improve outcomes.

Morbidities and prognostic factors after tibial pilon fracture: impact on patients

INTRODUCTION

This study aims primarily to characterize the sequelae and morbidity associated with tibial pilon injuries from the patients' perspectives in terms of multiple surgical interventions, duration of hospital stay, downtime from work, loss of productivity and impact on patients' lives. The secondary aim is to review the associated risk factors for these morbidities.

MATERIALS AND METHODS

All patients with surgically treated tibial pilon fractures from 1st July 2007 to 30th June 2017 were included. The morbidities reviewed focused on delay to surgery, numbers of surgeries, limb amputation, length of stay (LOS), readmissions, duration of medical leave (ML), follow-up and number of outpatient visits.

RESULTS

There were 102 patients included in the review and up to 70% of them had an average 7 days delay to definitive surgery. They also required an average hospital LOS of at least 2 weeks extending up to 3 more weeks if soft tissue reconstruction was necessitated. Up to a third of patients were readmitted with 15% of them needing further treatment. These patients required a notable period of downtime from work as shown in the long ML (mean 152.6 days [S.D. = 110.7]). Multiple conditional regression models showed AO/OTA classification (B and C) and open fracture as independent predictors of delay to surgery. Predictors for increased LOS were high velocity mechanism of injury at 4 days longer and patients who needed soft tissue reconstruction at 21 days longer. In terms of downtime from work, only work injury has been identified as an independent predictor of ML at 88.5 days longer.

CONCLUSION

Tibial pilon fractures leads to significant morbidities with profound negative impact on patients' lives in terms of multiple surgical interventions required, prolonged hospital stay, need for readmissions and prolonged downtime from work. These morbidities from patients' perspective should be emphasized to patients and employers to manage their expectations and potential limitations.

Adaptation of the Centers for Disease Control Surgical Wound Classification System for Orthopaedic Trauma Surgery

OBJECTIVES

To evaluate a proposed orthopaedic-specific surgical wound classification system (SWCS) and the current Centers for Disease Control (CDC) system in a series of detailed clinical vignettes and to identify the degree of satisfaction with CDC SWCS and desire for institution of an orthopaedic-specific SWCS.

METHODS

Forty-five clinical vignettes and a 5-question survey were distributed to current and past members of the Orthopaedic Trauma Association's Classification Committee. Respondents were asked to provide wound class for each vignette using the CDC system and orthopaedic-specific SWCS.

RESULTS

The orthopaedic-specific and CDC SWCS had interclass correlations of 0.95 and 0.91, respectively. When the systems were compared, in 34% of cases, there was no grade change; in 63% of cases, the wound was graded higher using the orthopaedic-specific SWCS. When only the procedure was changed between vignettes, wound classification was infrequently affected. There was near universal dissatisfaction with the CDC SWCS and desire for an orthopaedic-specific system.

CONCLUSIONS

Both the CDC SWCS and orthopaedic-specific SWCS have excellent interobserver reliability. Incorporation of orthopaedic-specific language affects wound classification. There is low satisfaction with the current CDC SWCS and a desire exists for further development and validation of an orthopaedic-specific SWCS.

The injury characteristics of open pilon fractures predictive of complications

OBJECTIVE

Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C).

DESIGN

Retrospective Case Series.

SETTING

Level I Trauma Center.

PATIENTS/PARTICIPANTS

A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria.

INTERVENTION

The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required.

MAIN OUTCOME MEASUREMENTS

Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications.

RESULTS

Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from > 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication.

CONCLUSIONS

Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment.

LEVEL OF EVIDENCE

Level III.

Visualization of the distal tibial plafond articular surface using four established approaches and the efficacy of instrumented distraction: a cadaveric study

Purpose

Direct visualization is a very effective method in accomplishing adequate articular surface reconstruction in fracture repair. This study investigates distal tibial plafond articular surface visibility using the anteromedial, anterolateral, posteromedial, and posterolateral approaches, the effect of instrumented distraction on visibility, and which zones of the articular surface are visible for each approach.

Methods

The anteromedial, anterolateral, posteromedial, and posterolateral approaches to the distal tibial plafond were performed on 16 cadaveric ankle specimens. The articular surface visualization for each approach was marked using an electrocautery device with manual and instrumented distraction. Articular surface visualization was photographically documented. Digital axial segmentation and quantitative analysis of the visualized distal tibial plafond articular surface were performed.

Results

With manual distraction, distal tibial plafond articular surface visualization, expressed in percent of overall articular surface, was limited to 9% (SD ± 9) for the anteromedial, 24% (SD ± 18) for the anterolateral, 26% (SD ± 10) for the posteromedial, and 30% (SD ± 18) for the posterolateral approaches. Using instrumented distraction significantly improved articular surface visualization in all instances (p < 0.001). The anteromedial approach visible articular surface increased to 63% (SD ± 13), the anterolateral to 72% (SD ± 22), the posteromedial to 62% (SD ± 11), and the posterolateral to 50% (± 17).

Conclusion

This study demonstrates the efficacy of instrumented distraction when attempting surgical visualization of the distal tibial plafond articular surface. Knowledge of approach specific articular surface visibility may assist the surgeon in choosing the appropriate approach(es) based on case-specific distal tibial plafond fracture patterns.

Level of evidence

IV, cadaver study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01927-w.

A nomogram for predicting skin necrosis risk after open reduction and internal fixation for tibia fractures

The purpose of our study was to determine the risk factors for skin necrosis after open reduction and internal fixation (ORIF) for tibia fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from tibia fractures and had been surgically treated by ORIF in our institution between August 2015 and October 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of skin necrosis, and a nomogram model was constructed to predict the risk of skin necrosis. The predictive performance and consistency of the model were evaluated by the Hosmer‐Lemeshow (H‐L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.906 (95% confidence interval 0.88~0.94). The H‐L test revealed that the nomogram prediction model had good calibration ability (P = .467). Finally, we found a correlation between skin necrosis and limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) after ORIF for tibia fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high‐risk patients, as interventions could be taken early to reduce the incidence of skin necrosis.

Management of Pilon Fractures-Current Concepts

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.

Tips and Tricks in surgical reduction of the posterior column of AO/OTA C3 pilon fractures

BACKGROUND

Accurate posterior column reduction remains a challenging and controversial topic in the management of complex pilon fractures (AO/OTA C3). We aim to report the outcomes of surgical treatment for 22 AO/OTA C3 pilon fracture cases between January 2015 and May 2017 and highlight some traps and tips.

METHODS

Three patients underwent two-stage early plating on the posterior column through a posterolateral approach. The remaining 19 patients were treated with two-stage delayed plating on the posterior column: 11 patients were treated with a posterolateral approach, five patients with a modified posteromedial approach, and three patients with a single anterior approach. The reduction of the posterior column was evaluated according to the Burwell-Charnley's radiographic criteria, and functional outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scores.

RESULTS

Posterior column malreduction occurred in five cases, including in one case that was re-adjusted immediately and in another case that was re-adjusted during a two-staged delayed operation. According to Burwell-Charnley's criteria, the satisfactory rate of fracture reduction was 81.8%. After 1 year, the mean AOFAS score was 81.9 (81.9 ± 9.9); the outcome was excellent in three (20.0%), good in nine (60.0%), and fair in three (20.0%). Excellent or good outcomes were noted in 12 patients (80.0%).

CONCLUSIONS

The combined anterior and posterior approach is suggested in the second stage of plating so that the posterior column fragments can be re-adjusted intraoperatively, if necessary. Following these procedures, satisfactory reduction and recovery of good ankle function can be anticipated.

Temporizing Care of Acute Traumatic Foot and Ankle Injuries

Temporizing care has become a critical part of the treatment armamentarium for select foot and ankle injuries. Indications for performing temporizing care are based on the specific injury pattern, the host, associated injuries, as well as surgeon resources. Foot and ankle injuries are often associated with severe adjacent injury to the soft tissue sleeve. An acute procedure performed through a traumatized soft tissue envelope will often lead to the failure of wound healing and/or infectious complications. Thus, delayed reconstruction of acute foot and ankle injuries is often advisable in these cases.

Complications and Soft-Tissue Coverage After Complete Articular, Open Tibial Plafond Fractures

OBJECTIVES

To evaluate the incidence of nonunion and wound complications after open, complete articular pilon fractures. Second, to study the effect that both timing of fixation and timing of flap coverage have on deep infection rates.

DESIGN

Retrospective case series.

SETTING

Three Academic Level 1 Trauma Centers.

PATIENTS

One hundred sixty-one patients with open OTA/AO type 43C distal tibia fractures treated with open reduction internal fixation (ORIF) between 2002 and 2018. The mean (SD) age was 46 (14) years, 70% male, with median (interquartile range) follow-up of 2.1 (1.3-5.0) years (minimum 1 year). There were 133 (83%) type 3A and 28 (17%) type 3B open fractures.

INTERVENTION

Fracture fixation: acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours). Soft-tissue coverage: rotational or free flap.

MAIN OUTCOME MEASUREMENT

Primary outcomes included deep infection and nonunion. Secondary outcomes included rates of soft-tissue coverage and reoperation.

RESULTS

Acute fixation (<24 hours) was performed in 36 (22%) patients; 125 (78%) underwent delayed, staged fixation. Deep infection occurred in 27% patients and was associated with men (33% vs. 16%, P = 0.029), smoking (38% vs. 23%, P = 0.047), and type 3B fractures (39% vs. 25%, P = 0.046). Acute fixation of type 3A fractures demonstrated a higher rate of infection (38% vs. 20% P = 0.036) than delayed, staged fixation. In type 3B fractures, early flap coverage (<1 week) demonstrated a lower rate of infection (18% vs. 53%, P = 0.066) and 20% (vs. 43%) with a single-staged "fix and flap" procedure (P = 0.408). Nonunion occurred in 36 (22%) and was associated with deep infection (43% vs. 15%, P < 0.001). Fifteen (42%) were septic nonunions. Twenty-nine of the 36 (81%) nonunions achieved radiographic union after median (interquartile range) 27 (20-41) weeks and median (range) 1 (1-3) revision ORIF procedures. There was no difference in the rate of secondary union between septic and aseptic nonunions (85% vs. 86%, P = 1.00). There was a high rate of secondary procedures (47%): revision ORIF (17%), irrigation and debridement (15%), and removal of implants (11%).

CONCLUSIONS

Complete articular, open pilon fractures are associated with a high rate of complications after ORIF. Early fixation carries a high risk of deep infection; however, early flap coverage for 3B fractures seems to play a protective role. We advocate for aggressive management including urgent surgical debridement and very early soft-tissue cover combined with definitive fixation during single procedure if possible.

LEVEL OF EVIDENCE

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

Dorsal minimally invasive plate osteosynthesis of the distal tibia with regard to adjacent anatomical characteristics

INTRODUCTION

The aim of this study was to perform MIPO of the distal tibia from a dorsomedial and dorsolateral approach and to evaluate their feasibility and risk of injury to adjacent anatomical structures.

MATERIAL & METHODS

A total of 18 extremities from 9 adult human cadavers was included in the study. In each cadaver, one lower leg underwent application of a 12-hole 3.5 LCP metaphyseal plate from the medial and the further one from the lateral approach. For the medial approach, a 4 cm skin incision was performed at the tibial border of the Achilles tendon, starting from 1 cm proximal to its insertion point at the calcaneal tuberosity. Entrance was gained between the medial border of the flexor hallucis longus tendon and the medial neurovascular bundle. Regarding the lateral approach, the skin was incised over a length of about 4 cm at the lateral border of the Achilles tendon, approximately 1 cm proximal to its insertion point. Entrance was gained between the Achilles tendon and the peroneus brevis muscle. The plates were inserted in direct bone contact in a proximal direction and the proximal and distal ends were fixed. During dissection, the proximal and distal holes beneath the crossing points of the neurovascular bundle and the plate were noted. The distal and proximal intersection points of the neurovascular bundle and the plate were measured with reference to the distal border of the plate.

RESULTS

Concerning the medial approach, the neurovascular bundle was on median located between the 6th and 11th plate holes starting from distal. The bundle intersected the plate distally at a mean height of 65.8 mm and proximally at 156.8 mm on average. For the lateral approach, the neurovascular bundle was situated between the 6th and the 12th plate hole from distal. It crossed the plate distally at a mean of 61.0 mm and proximal at a mean height of 153.9 mm. In none of the cases, lacerations of the neurovascular bundle were observed.

CONCLUSION

In conclusion, MIPO from the dorsomedial and dorsolateral approach are both safe procedures as indicated by our study.

Comparison Between the Modified External Fixation and Calcaneal Traction in Ruedi-Allgower Type II/III Pilon Fractures

Background

To compare the effect of modified external fixation and calcaneal traction in a staged management of Ruedi-Allgower type II/III tibial pilon fractures.

Material/Methods

The data of 62 patients with Ruedi-Allgower type II/III tibial pilon fractures who were treated in Liuzhou People’s hospital from January 2017 to December 2018 were extracted in this retrospective analysis. There were 32 patients in the temporary external fixation (TEF) group and 30 patients in calcaneal traction (CT) group. Outcomes, including the duration of the surgical procedure, pin track infection, degree of limb swelling, time to second-stage operation, postoperative comfort score, and visual analog scale (VAS) score, were compared.

Results

The effective rate of swelling reduction after treatment was 85% in the TEF group and 60% in the CT group; the average time to the second-stage operation was 8.34±1.29 days in the TEF group and 10.60±2.27 days in the CT group; the postoperative comfort scores were 70.1±3.2 and 61.3±3.5 in the TEF group and CT group, respectively; the postoperative VAS scores at 24 h, 48 h, and 7 days were 7.90±1.06, 4.88±0.83, 2.72±1.14 in TEF group, and 8.50±0.86, 6.27±1.36, 3.57±1.19 in CT group, respectively. There were 1 case of pin tract infection identified in the TEF group and 4 in the CT group. All differences were statistically significant (P<0.05).

Conclusions

The modified external fixation is more effective than calcaneal traction in treatment of Ruedi-Allgower type II/III tibial pilon fractures in the first-stage of combined management.

A Pilon Fracture With Fibular Head Dislocation Treated With the Use of 3D Preoperative Planning: A Case Report and Literature Review

Pilon fractures with intact fibula have been associated with low-energy trauma. However, the compression force onto the ankle joint can damage the tibiofibular linkage as in a Maisonneuve fracture. Herein, we describe a case of a patient who had a pilon fracture (AO type 43 C3.2) without a fibular fracture. Three-dimensional preoperative simulation by reduction with the surface registration technique was performed as the fibular length was intact and there was no reference for the tibial length. The preoperative simulation revealed superior fibular head dislocation and shortening of the distal tibia. After emergency external fixation on the day of arrival, a 2-staged surgery was performed. During the first operation, the fibular head was reduced and the tibial posterolateral fragment was fixed to restore the tibia length. During the second operation, medial and anterolateral fragments were fixed in order to reduce joint surface of the distal tibia. In general, proximal fibular head fractures are easily overlooked. In the case of pilon fractures with severe length shortening of the tibia without a fibular fracture, a proximal tibiofibular injury should be suspected.

Stress Distributions and Micromovement of Fragment Bone of Pilon Fracture Treated With External Fixator: A Finite Element Analysis

Osteoporosis and osteoarthritis are common pathological problems of the human bone tissue. There are some cases of pilon fractures associated with these 2 pathological conditions. In terms of treatment, for a normal and healthy bone with pilon fracture, the use of the Delta external fixator is a favorable option because it can allow early mobilization for patients and provide stability for the healing process. However, the stability of the external fixator differs when there is low bone stiffness, which has not been previously investigated. Therefore, this study was conducted to determine the stability of the external fixator to treat pilon fracture associated with osteoporosis and osteoarthritis, particularly to differentiate the stress distribution and micromovement of fracture fragment. Three-dimensional finite element models of the ankle and foot bones were reconstructed based on the computed tomography datasets. The bones consisted of 5 metatarsal, 3 cuneiform, and 1 each of cuboid, navicular, calcaneus, talus, fibula, and tibia bones. They were assigned with linear isotropic behavior. The ankle joint consisted of ligament and cartilage, and they were assigned with the use of linear links and the Mooney-Rivlin model, respectively. During simulation of the gait cycle, 70 N and 350 N were applied axially to the tibia bone to represent the swing and stance phases, respectively. The metatarsal and calcaneus bones were fixed to prevent any movement of the rigid body. The study found that the greatest von Mises stress value was observed at the pin-bone interface for the osteoporosis (108 MPa) model, followed by the osteoarthritis (87 MPa) and normal (44 MPa) models, during the stance phase. For micromovement, the osteoporosis model had the largest value at 0.26 mm, followed by the osteoarthritis (0.09 mm) and normal (0.03 mm) models. In conclusion, the greatest magnitudes of stress and micromovement were observed for the osteoporosis bone and extra care should be taken to treat pilon fracture associated with this pathological condition.

Modern Principles in the Acute Surgical Management of Open Distal Tibial Fractures

Over the past two decades, management of open distal tibial fractures has evolved such that a staged approach, with external fixation and débridement during the index procedure, followed by definitive fixation and wound closure at a later date, is often considered the standard of care. Although definitive treatment of these complex injuries is often done by a multidisciplinary team of surgeons well versed in periarticular fracture repair and soft-tissue coverage in the distal extremity, the on-call orthopaedic surgeon doing the index procedure must understand the principles and rationale of the staged treatment algorithm to avoid compromising definitive treatment options and ensure the best possible patient outcome. The mechanism of injury, neurovascular status, size and location of soft-tissue injury, fracture pattern, and concomitant injuries in the polytraumatized patient should direct the treatment plan and anticipated outcomes. This review focuses on evaluation and management of these complex injuries with an emphasis on early aggressive débridement, principles of initial fracture fixation, and modern options for soft-tissue coverage, including local and free tissue transfer.

Outcomes and Complications With Treatment of Open Tibial Plafond Fractures With Circular External Fixator

BACKGROUND

Open tibial plafond fractures (Orthopaedic Trauma Association and AO Foundation [OTA/AO] 43) are associated with severe complications, including deep infection (closed fractures, 20%; open fractures, 30%), amputation (3%-14%), and nonunion (up to 25%). Circular external fixators (CEFs) can minimize soft tissue injury. This study aimed to report the rate of union and occurrence of severe complications in patients with open tibial plafond fractures treated with CEFs.

METHODS

A retrospective review of case series was conducted at 3 level I trauma centers. The study included patients older than 18 years with open tibial plafond fractures treated with CEFs. The reported outcomes included union rate, deep infection, operative complications, and limb alignment. The radiographic measurements of anatomic alignment were obtained. Fifty-two patients were included in the study.

RESULTS

The primary union rate was 79%. No deep infection occurred in the majority (92%) of patients. No patient required amputation of the affected limb or free flap coverage.

CONCLUSION

Definitive fixation of open tibial plafond fractures with CEFs avoided severe soft tissue complications but resulted in variation in final radiographic alignment.

LEVEL OF EVIDENCE

Level IV, case series.

A Systematic Review Of Primary Ankle Arthrodesis In The Treatment Of Pilon Fractures

BACKGROUND

Pilon fractures are severe, intra-articular and comminuted fractures to the distal tibia. They are uncommon injuries and are often associated with fibular fractures. The optimal management of these fractures is widely debated. Open reduction and internal fixation (ORIF) and external fixation have been used to treat these fractures. Ankle arthrodesis is often used in the latter stages of management for end-stage ankle arthritis. The aim of this systematic review was to identify the outcomes associated with using primary ankle arthrodesis in pilon fractures.

METHODS

Ovid Medline and PubMed were searched from the inception of their databases until October 2018. Eligible literature for use in our review included patient cohorts that had been operated in the form of primary ankle arthrodesis. All relevant data was included that met the inclusion criteria. The demographic of the patients with pilon fractures and this operative management were identified. The outcomes of interest were fusion rate, infection rate, length of follow-up and patient reported outcomes. 8 papers were deemed eligible for review.

RESULTS

Of the 8 papers that were eligible, 6 were retrospective studies, 1 was a case report and 1 was an abstract. There were a total of 109 patients included. Fusion rate was 100% in 5 of the studies. 6 of the 7 studies that reported on infection rate had no post-operative infections. Outcome assessment scores were used in 5 of the studies. The SF-36 score, the FOAS and the AOFAS were used.

CONCLUSIONS

This review shows that primary ankle arthrodesis yields reasonable results in the management of pilon fractures. However, the quantity and quality of current literature is not sufficient and further studies with larger cohorts and longer follow-up times are warranted.

Open Pilon Fracture Postoperative Outcomes with Definitive Surgical Management Options: A Systematic Review and Meta-analysis

BACKGROUND

Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Different techniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole, very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgical management options can influence postoperative complications, and if this can influence future management protocols.

METHODS

We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications and functional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD42020184213). The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation, osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was also measured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions.

RESULTS

The search yielded 309 results and a total of 18 studies consisting of 484 patients were included. All fractures included were open, and consisted of 64 Gustilo-Anderson Type I, 148 Type II, 103 Type IIIa, 90 Type IIIb and 9 Type IIIc. 60 Type III fractures could not be further separated and 12 were ungraded. Both ORIF and Ex-Fix were found to have statistically similar AOFAS scores (P=0.682). For all included studies, the Ex-Fix group had significantly higher rates of superficial infections (P=0.001), non-unions (P=0.001), osteoarthritis (P=0.001) and bone grafting (P=0.001). The meta-analysis found no significant difference in non-union (pooled OR=0.25, 95% CI: 0.03 to 2.24, P=0.44) or deep infection rates (pooled OR=1.35, 95% CI: 0.11 to 16.69, P=0.12) between the ORIF and Ex-fix groups.

CONCLUSION

Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to have a significantly higher risk of postoperative complications which must be considered by surgeons when choosing surgical management options. Further research, ideally in a randomised control trial format, is required to definitively demonstrate ORIF superiority in the management of open pilon fractures.

Surgical Management of Distal Tibia Fracture: Towards An Outcome-based Treatment Algorithm

Introduction:

Distal tibia fractures are frequently associated with an extensive soft tissue injury which then leads to a higher risk of complications such as infection, non-union and eventually poor overall outcome. The purpose of this study is to measure the outcome of distal tibia fractures treated with internal fixation, external fixator or Ilizarov external fixator(IEF). We aim to propose an algorithm for management of distal tibia fractures by evaluating the treatment options, outcomes and risk factors present.

Material and Methods:

This study is a cross-sectional study of all distal tibia fractures treated surgically in Tengku Ampuan Rahimah Hospital, Klang from 1st January 2016 till 30th June 2018. Patient records were reviewed to analyse the outcomes of surgical treatment and risk factors associated with it.

Results:

Ninety-one patients were included with a mean age of 41.5 years (SD = 16.4). Thirty-nine cases (42.9%) were open fractures. Thirty-eight patients (41.8%) were treated with internal fixation, 27 patients (29.7%) were treated with IEF and 26 patients (28.6%) were treated with an external fixator. Among open fractures cases, no significant finding can be concluded when comparing each surgical option and its outcome, although one option was seen better than the other in a particular outcome. Initial skeletal traction or temporary spanning external fixator in close fractures reduced the risk of mal-alignment (p value=0.001). Internal fixation is seen superior to IEF and external fixator in close fractures in term of articular surface reduction (p value = 0.043) and risk of mal-alignment (p value = 0.007).

Conclusion:

There is no single method of fixation that is ideal for all pilon fractures and suitable for all patients. This proposed algorithm can help surgeons in deciding treatment strategies in the challenging management of distal tibia fractures to reduce associated complications.

Is Definitive Plate Fixation Overlap With External Fixator Pin Sites a Risk Factor for Infection in Pilon Fractures?

OBJECTIVES

To determine if overlap of definitive plate fixation with external fixator pin sites is a risk factor for infection in pilon fractures.

DESIGN

Retrospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

One hundred forty-six patients with pilon fractures treated between 2012 and 2018.

INTERVENTION

Staged treatment with ankle-spanning external fixation, followed by delayed open reduction and internal fixation.

MAIN OUTCOME MEASURES

Demographic, radiographic, and operative data were reviewed, and the distance between the temporary external fixator pin sites and the definitive plate was measured. The primary outcome measure was the development of a deep postoperative infection.

RESULTS

Overall, 22 (15%) patients developed deep wound infections. Overlap of definitive plate and external fixation pin site occurred in 58 (40%) of ankles. Of these, 7 (12%) developed deep wound infection compared with 15 (17%) patients without overlap (P = 0.484). There was no significant difference in amount of overlap (P = 0.636) or distance from plate to pin site (P = 0.607) in patients with and without deep infection. Of the patients with deep infection, 11 (50%) occurred in patients with open fractures.

CONCLUSIONS

Overlap of definitive plate fixation with primary spanning external fixator pin sites is not a risk factor for development of deep infection in a staged treatment of high-energy pilon fractures.

LEVEL OF EVIDENCE

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

New Principles in Pilon Fracture Management: Revisiting Rüedi and Allgöwer Concepts

The tibial pilon fracture is a complex lesion, which requires experienced clinical judgment and adequate planning to achieve good results. Treatment concepts enunciated by Rüedi and Allgöwer remain valid but have undergone modifications. The reconstitution of the fibular length is not always the first step to be performed. In the reconstruction of the articular surface, the prognosis is already sealed by the initial cartilage damage, and it is better to achieve stability and alignment. The stabilization of the medial column is essential, but it must be associated with the stabilization of at least one other column in complex fractures.

High-Energy Pilon Fractures: Role of External Fixation in Acute and Definitive Treatment. What are the Indications and Technique for Primary Ankle Arthrodesis?

External fixation is an essential tool in the management of high-energy pilon fractures. Reduction techniques using the external fixator and fixation constructs for use with external fixation as a part of stage management are reviewed. The concepts of external fixation with limited articular fixation is discussed. The use of circular external fixation in both acute management of high-energy pilon fractures, as well as the indications and technique for acute ankle arthrodesis as part of primary treatment of pilon fractures are outlined.

Fracture blisters: pathophysiology and management

Open fractures are considered an orthopaedic emergency due to the severe soft tissue disruption that might potentially lead to devastating complications. On the other hand, closed fractures, and especially those resulting from high-energy mechanisms, are also often accompanied by severe soft tissue trauma. Soft tissue envelope compromise can have a detrimental effect on the final outcome of the patients. Fracture blisters in particular, develop as a sign of significant local tissue trauma and appear in a time period between 6 to 72 hours post-injury. They can delay the definitive fracture treatment for a considerable amount of time and at the same time they also increase the risk for post-operative wound complications. Awareness of fracture blisters pathophysiology and their management options are crucial for orthopaedic surgeons, in order to achieve a favorable clinical outcome. In the herein study we present a concise synopsis of the pathophysiology pathways and management options of fracture blisters.

Definitive management of open pilon fractures with fine wire fixation

INTRODUCTION

The BOAST (British Orthopaedic Association Standards for Trauma) guidelines advise that open pilon fractures amongst other open lower limb fractures need to be treated at a specialist centre with Orthoplastic care. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures treated as per BOAST guidelines alongside a treatment protocol which consisted of early wound debridement and spanning external fixation, delayed soft tissue coverage with a flap when necessary and delayed definitive fixation with the use of a Fine Wire Fixator.

MATERIAL AND METHODS

We conducted a retrospective analysis of open pilon fractures treated between 2014 and 2019. All patients were included for the assessment of the rate of infection and fracture healing. Functional outcome assessment was performed in all patients according to the American Orthopaedic Foot and Ankle Score (AOFAS) at 12 months post injury.

RESULTS

There were 20 patients including 16 males and 4 females. The mean age was 50.45 years. Initial wound with bone debridement and application of a spanning external fixator was performed within an average of 13.5 hours. The mean time from primary surgery to definitive fixation was 24.5 days. There were 3 patients with Gustilo Type I injuries, 6 with Type II, 4 Type with type IIIa and 7 with Type IIIb injuries. Average time to bone union was 10.4 (Range: 2-18) months. The mean AOFAS score was 74.2 (Range: 28-97). A Taylor Spatial Frame was used on 18 patients, while 2 patients had an Ilizarov frame. A corticotomy was performed on 4 patients with critical bone defect post debridement. There was 1 case of deep infection and 9 cases of superficial infection. There were also 4 cases of delayed union which required bone grafting from their femur using a RIA (Reamer Irrigation Aspirator).

CONCLUSION

Our study suggests that the use of staged wound debridement including relatively aggressive bone debridement in conjunction with systemic and local antibiotics, external fixators and patient tailored conversion from spanning external fixator to fine wire frame achieves low rates of wound infection and complications for patients with open pilon fractures.

Biomechanical evaluation of three different configurations of external fixators for treating distal third tibia fracture: Finite element analysis in axial, bending and torsion load

External fixators have been widely used in treating open fractures and have produced excellent outcomes, as they could successfully heal bones. The stability of external fixators lies greatly in their construction. Factors that associated with the stability of the external fixators includes stress, displacement, and relative micromotion. Three-dimensional (3D) models of bone and external fixators were constructed by using 3D modelling software, namely Materialise and SolidWorks, respectively. Three different configurations of external fixators namely Model 1, Model 2, and Model 3 were analysed. Three load cases were simulated to assess the abovementioned factors at the bone, specifically at the fracture site and at the external fixator. Findings showed that the double-cross configuration (Model 3) was the most promising in axial, bending, and torsion load cases as compared to the other two configurations. The no-cross configuration (Model 1) had the highest risk of complication due to high stress, relative micromotion, and displacement in the bending and torsion load cases. On the other hand, the single-cross configuration (Model 2) had the highest risk of complication when applied with axial load. In conclusion, the double-cross locking construct (Model 3) showed the biggest potential to be a new option for medical surgeons in treating patients associated with bone fracture. This new double-cross locking construct showed superior biomechanical stability as compared to single-cross and no-cross configurations in the axial, bending, and torsion load cases.

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery

SIGNIFICANCE

Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues.

AIM

The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery.

APPROACH

The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative.

RESULTS

Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management.

CONCLUSION

While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.

Posterolateral plating is a safe alternative for the treatment of distal tibial fractures

INTRODUCTION

We assessed the outcome and safety of posterior plating of distal tibial fractures.

METHODS

We conducted a retrospective case series at a Level I trauma center. Seventy-four consecutive patients with distal tibial fractures treated with anatomically contoured 3.5-mm T-shaped locking compression plate using a posterolateral approach from January 2008 through April 2018 were included in the study. The mean patient age was 48 years (range, 18-87 years). Fifty-nine percent of the patients were male patients, 47% of the fractures were open fractures; and 27% of the patients had multiple traumatic injuries. Eleven fractures were AO/OTA type 42, 22 were type 43A, and 41 were type 43C. Sixty-two (84%) patients were treated with initial spanning external fixation (median time, 23 days) and staged open reduction and internal fixation. The main outcome measure was unplanned reoperation to address implant failure, nonunion, deep surgical site infection, or symptomatic implant.

RESULTS

Overall risk of unplanned reoperation was 15% (11 of 74 patients, 95% confidence interval, 9%-25%). Four (5%) reoperations were for nonunion, three (4%) were for surgical site infection, two (3%) were for infected nonunion, and two (3%) were for implant prominence. Loss of alignment >10 degrees occurred in one patient who underwent unplanned reoperation for nonunion. No plate breakage occurred. Median time to reoperation was 221 days (range, 22-436 days). Only one other complication was noted: wound dehiscence associated with the posterolateral approach, which was treated with irrigation and débridement and a 6-week regimen of oral antibiotics.

CONCLUSIONS

Use of a posterolateral approach with a pre-contoured locking compression T-plate for the treatment of distal tibial fractures led to reasonable outcomes with an acceptable risk of unplanned reoperation, even with a high proportion of open fractures commonly staged with external fixation.

What are the Risk Factors for Deep Infection in OTA/AO 43C Pilon Fractures?

OBJECTIVES

To determine the risk factors for deep infection in OTA/AO 43C pilon fractures.

DESIGN

Retrospective, case-control study.

SETTING

Single institution, Level 1 trauma center.

PARTICIPANTS

All patients with 43C pilon fractures treated over a 5-year period with follow-up to bony union. One hundred fifty of 169 of identified patients met inclusion criteria.

INTERVENTION

Operative treatment of tibial pilon fracture.

MAIN OUTCOME MEASUREMENTS

Deep infection; patient demographics, Gustilo-Anderson classification, location of open fracture wounds, surgical approaches.

RESULTS

The overall rate of deep infection was 16.7%. Body mass index, tobacco use, and diabetes were not associated with deep infection. The rate of Gustilo-Anderson type 3A and 3B fractures was significantly higher in those with infection, but the overall open fracture rate was not significantly different between the groups. Medial and anterior open fracture wound location was significantly associated with deep infection, whereas lateral open fracture wound location was not. In closed fractures, anteromedial and anterolateral approaches were not significantly associated with infection, but posterolateral approach was associated with deep infection. Segmental bone loss and the need for soft tissue coverage were the only independent risk factors for deep infection.

CONCLUSIONS

High-grade open pilon fractures are at risk of deep infection, and medial/anterior open fracture wounds are particularly vulnerable to developing deep infection. The anteromedial/anterolateral surgical approaches should be selected based on a complete understanding of the fracture pattern and soft tissue injury; however, the posterolateral approach to the tibia should be used with some caution. Ultimately injury factors (segmental bone loss and need for soft tissue coverage) seem to be the most important variables in driving deep infection, and a complete understanding of the bone and soft tissue injury is needed to manage these injuries effectively.

LEVEL OF EVIDENCE

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

Pressure reducing skin pie-crusting in extremity trauma: An in-vitro biomechanical study and human case series

BACKGROUND

Multiple small relaxing skin incisions oriented parallel to the longitudinal axis (so-called "pie-crusting") near traumatic lacerations or surgical incisions in edematous tissue beds have been utilized to achieve primary closure when edema or skin loss would otherwise have made this difficult. Our study hopes to demonstrate (1) biomechanical evidence that pie-crusting decreases wound closure tension and (2) provide a case series with data showing clinical results.

MATERIALS AND METHODS

This study is a biomechanical cadaveric study and retrospective small series cohort using 16 porcine limbs and 7 patients with 8 wounds in which pie-crusting was performed. An elliptical incision was made on the porcine limbs and the wound closure tension was measured with a hydraulic test machine before and after pie-crusting. The retrospective patient cohort had pie-crusting performed on traumatic wounds that were difficult to primarily close. The patient cohort was assessed by retrospective chart review examining wound dimensions before and after pie-crusting, and wound healing at final follow-up.

RESULTS

The biomechanical data showed that pie-crusting the wound with both a single and double row of incisions significantly decreased the closing tension. A single row decreased wound tension by an average of 34%. Using an average of 3.5 parallel layers of pie-crusting at the time of definitive closure all wounds in the patient cohort closed and healed well with no complications at average follow-up (average 18 months).

CONCLUSION

Pie-crusting may allow for easier wound closure and decrease the need for skin-grafting in edematous extremity wounds, with minimal patient morbidity.

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures

BACKGROUND

Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs.

METHODS

The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded.

RESULTS AND CONCLUSION

Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6 days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.

Pilon Fractures in Patients Older Than 60 Years of Age: Should We Be Fixing These?

OBJECTIVES

To compare complications after operatively treated pilon fracture between elderly patients (≥60 years) and younger patients (<60 years).

DESIGN

Retrospective comparative study.

SETTING

Two Level-1 academic trauma.

PATIENTS/PARTICIPANTS

Of the 740 tibial plafond fractures (OTA/AO 43-B & 43-C) treated January 2006 through December 2016, 538 patients had a minimum of 1 year follow up.

INTERVENTION

Open reduction-internal fixation (ORIF).

MAIN OUTCOME MEASUREMENT

Treatment failure defined as either nonunion or arthrosis.

RESULTS

A total of 72 patients comprised the elderly group (mean age 66 years) and 466 patients comprised the younger group (mean age 44 years) (P < 0.001). Besides significantly more tobacco use in the younger group, patient demographics and fracture characteristics did not differ. Locking plates were used significantly more in elderly patients (47% vs. 32%, P = 0.01). Using chi-square analysis, we were unable to detect a difference in treatment failure (elderly 43% vs. young 37%, P = 0.33), infection (elderly 10% vs. young 13%, P = 0.4), or malunion (elderly 3% vs. young 4%, P = 1.0). Using regression analysis, age >60 was not associated with treatment failure [odds ratio (OR) 1.2 (0.7-2.1), P = 0.52]. Bone loss (OR 2.7 [1.8-4.1], P < 0.001), open fracture (OR 1.6 [1-2.5], P = 0.03), and malreduction (OR 4.2 [2.5-7.3], P < 0.001) were associated with failure.

CONCLUSIONS

Age >60 years is not an independent predictor of surgical treatment failure of pilon fractures as defined by nonunion or arthrosis. This is the largest cohort of pilon fracture in elderly patients and indicates that we should continue to treat elderly patients similar to their younger counterparts using ORIF.

LEVEL OF EVIDENCE

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

Does surgical approach affect sagittal plane alignment and pilon fracture outcomes?

PURPOSE

Sagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement.

PATIENTS AND METHODS

A retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs.

RESULTS

580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02).

CONCLUSIONS

The sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.