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

Plating of pilon fractures based on the orientation of the fibular shaft component: A biomechanical study evaluating plate stiffness in a cadaveric fracture model

OBJECTIVES

To evaluate mechanically superior method of pilon fracture fixation by comparing axial stiffness between anterolateral and medial tibial locking plates in a cadaveric fracture model.

METHODS

Eight matched pairs of fresh frozen cadaver specimens (lower limb after through-knee disarticulation) were used to eliminate confounder of bone quality. Simulated pilon fractures were created so that each pair represented either varus or valgus fracture pattern (AO 43-A2) with associated fibular fractures (transverse or comminuted). Specimens were plated with DePuy anterolateral or medial locking plate and axial load applied, measuring displacement at the fracture site. Each lower extremity was tested with a fracture wedge in place and removed to mimic comminution. Average force at which failure occurred was compared between the two fixation methods, for varus and valgus fracture pattern respectively, with the use of a Mann-Whitney U test.

RESULTS

On average, medial plate fixation of varus fractures resulted in 2.27 times (range of 1.6-3.9) greater load prior to failure as compared to anterolateral plate. Similarly, valgus simulated fractures tolerated 1.6 times (range 1.12-2.34) higher force prior to failure if anterolateral plate was applied versus medial plate. Analysis utilizing the Mann-Whitney U test for fracture patterns vs plate configuration approached statistical significance (p = 0.081 varus failure and p = 0.386 valgus failure).

CONCLUSIONS

Lateral plate fixation is biomechanically superior for pilon fractures resulting from valgus force as evident by comminuted fibular fracture. Similarly, medial plate location resulted in improved stiffness in compression for varus type fractures, evident by transverse fibular fracture. We approached statistical significance, however our lack of power regarding adequate sample size is an issue that is consistent with other biomechanical studies in this area.

Patient reported health related quality of life early outcomes at 12 months after surgically managed tibial plafond fracture

INTRODUCTION

Tibial plafond fractures represent a small but complex subset of fractures of the lower limb. The aim of this study was to describe the health related quality of life, pain and return to work outcomes 12 months following surgically managed tibial plafond fracture.

METHODS

The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) database was used to identify patients with tibial plafond fractures. All patients captured by VOTOR with a tibial plafond fracture between September 2003 and July 2009, were identified consecutively and comprised the initial cohort. The radiographs of all identified patients were classified using the AO/OTA fracture classification. A review of the included patient's medical records was performed. Data were collected on the injury event, management and complications. Outcomes at 12 months were prospectively collected by telephone interview and included return to work, a numerical rating scale for assessment of pain and the Short Form 12 (SF-12).

RESULTS

There were 98 unilateral tibial plafond fractures; 91 fractures were managed operatively, 4 non-operatively and 3 underwent amputation. The 91 operatively managed patients were the focus of this study. A two-stage management approach, involving temporary external fixation, followed by definitive open reduction and internal fixation, was the most common operative treatment. The follow-up rate at 12 months was 70%. 57% had returned to work by 12 months post-injury, the median (IQR) pain score was 2 (0-5) and 27% reported moderate to severe persistent pain. Mean PCS-12 scores were significantly lower than Australian norms (p=0.99), 38.2 for males and 37.5 for females.

CONCLUSIONS

The presence of persistent pain, loss of physical health and a low return to work rate highlights the profound impact of tibial plafond fractures on patients' lives. Although this study looked at the early 12 month results, it is expected these outcomes will continue to improve over time. Further studies, with larger patient numbers, must focus on how to improve not only the operative management of these fractures, but also patient's mental and overall physical health in the long term. Improved management techniques and early identification of injury patterns known to perform poorly may help long-term outcomes.

High-energy pilon fractures management: State of the art

High-energy pilon fractures are challenging injuries. Multiple options are described for the definitive surgical management of these fractures, but there is no level I evidence for optimal management. The current management and recommendations for treatment will be reviewed in this article.

Anatomical reduction of the fracture, restoration of joint congruence and reconstruction of the posterior column with a correct limb axis minimising the soft-tissue insult are the key points to a good outcome when treating pilon fractures.

Even when these goals are achieved, there is no guarantee that results will be acceptable in the mid-term due to the frequent progression to post-traumatic arthritis.

In high-energy fractures with soft-tissue compromise, a staged treatment is generally accepted as the best way to take care of these devastating fractures and is considered a local ‘damage control’ strategy.

The axial cuts from the CT scan images are essential in order to define the location of the main fracture line, the fracture pattern (sagittal or coronal) and the number of fragments. All of this information is crucial for pre-operative planning, incision placement and articular surface reduction.

No single method of fixation is ideal for all pilon fractures, or suitable for all patients. Definitive decision making is mostly dependent on the fracture pattern, condition of the soft-tissues, the patient’s profile and surgical expertise.

Cite this article: Tomás-Hernández J. High-energy pilon fractures management: state of the art. EFORT Open Rev 2016;1:354-361. DOI: 10.1302/2058-5241.1.000016.

Does a Staged Posterior Approach Have a Negative Effect on OTA 43C Fracture Outcomes?

OBJECTIVE

To determine whether multiple approaches pose an increased risk to fracture healing when compared with a standard single approach in the treatment of pilon (OTA 43C) fractures.

DESIGN

Retrospective review of a prospective database.

SETTING

Level I academic trauma center and level II community trauma center.

METHODS

From January 1, 2005 to December 31, 2011, all records of patients treated for OTA 43C fractures of the distal tibia were reviewed. Patients were grouped according to multiple (posterior-anterior) and single (anterior-alone) approaches. Medical charts and surgical documentation were reviewed and postoperative computed tomography (CT) scans were examined for residual articular displacement and quantified. Ultimate union rate was correlated with approach strategy. Articular reduction was subdivided into 3 groups (<1, 1-2, and >2 mm).

RESULTS

A total of 116 patients were identified as having had 43C fractures treated surgically with postoperative CT scans completed. Twenty-six fractures presented as an open injury. Of these 116 patients, 35 underwent staged fixation of the posterior malleolar component at an average of 2 days postinjury, followed by delayed anterior fixation at an average of 14 days postinjury. The remaining 81 patients underwent anterior fixation alone, on average 17 days postinjury. Twenty-one patients were lost to follow-up before 12 months. Of the 95 patients with sufficient follow-up (≥12 months), there were 24 nonunions. There was a statistically significant association of nonunion with staged posterior approach (40% vs. 19%, P = 0.015). CT reduction for staged posterior versus anterior-alone approach was not significantly different for any of the 3 categories (63% vs. 57% <1 mm, 31% vs. 26% 1-2 mm, and 6% vs. 17% >2 mm).

CONCLUSIONS

In this series, there was no statistically proven benefit to combined surgical approaches to tibial pilon fractures with regard to the quality of articular reduction. It appears from this investigation that there may be a significantly higher risk of nonunion associated with the addition of the staged posterior approach. Although articular reduction is of paramount importance, multiple approaches for direct reduction and fixation of all fragments may lead to further complications.

LEVEL OF EVIDENCE

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

Impact of Intraoperative Cone Beam Computed Tomography on Reduction Quality and Implant Position in Treatment of Tibial Plafond Fractures

BACKGROUND

The intraoperative assessment of the articular surface in displaced intra-articular distal tibia fractures can be challenging using conventional fluoroscopy. The aim of the study was to determine the frequency and the method of intraoperative corrections of fracture reductions or implant placements during open reduction, internal fixation by using cone beam computed tomography (CT) after conventional fluoroscopy.

METHODS

Displaced intra-articular distal tibia fractures were retrospectively analyzed from August 2001 until December 2011. The fractures were classified according to the standards of the AO/OTA as type B or C and treated with open reduction and internal plate fixation. After primary reduction using conventional fluoroscopy, an additional cone beam CT scan was used to determine the alignment of the joint line and the implant position. The number of intraoperative revisions of the primary reduction due to the use of cone beam CT was analyzed.

RESULTS

A total of 143 patients with an intra-articular tibial plafond fracture were included in the analysis. In 43 patients (30%), an intraoperative correction was performed after the cone beam CT scan. In 34 (24%) of these cases, intraoperative correction was required because of inadequate joint line reduction. Nine (6%) corrections were required as a result of a malposition of the implant. The revision rate did not differ by fracture classification.

CONCLUSION

Despite its acceptance as the standard method of imaging, intraoperative conventional fluoroscopy for the assessment of implant positioning and fracture reduction of tibial plafond fractures is limited. The intraoperative utilization of cone beam CT provided additional information for the surgeon to detect insufficient reduction or implant malposition.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Negative pressure wound therapy for Gustilo Anderson grade IIIb open tibial fractures

BACKGROUND

Traditionally, Gustilo Anderson grade IIIb open tibial fractures have been treated by initial wide wound debridement, stabilization of fracture with external fixation, and delayed wound closure. The purpose of this study is to evaluate the clinical and radiological results of staged treatment using negative pressure wound therapy (NPWT) for Gustilo Anderson grade IIIb open tibial fractures.

MATERIALS AND METHODS

15 patients with Gustilo Anderson grade IIIb open tibial fractures, treated using staged protocol by a single surgeon between January 2007 and December 2011 were reviewed in this retrospective study. The clinical results were assessed using a Puno scoring system for severe open fractures of the tibia at the last followup. The range of motion (ROM) of the knee and ankle joints and postoperative complication were evaluated at the last followup. The radiographic results were assessed using time to bone union, coronal and sagittal angulations and a shortening at the last followup.

RESULTS

The mean score of Puno scoring system was 87.4 (range 67-94). The mean ROM of the knee and ankle joints was 121.3° (range 90°-130°) and 37.7° (range 15°-50°), respectively. Bone union developed in all patients and the mean time to union was 25.3 weeks (range 16-42 weeks). The mean coronal angulation was 2.1° (range 0-4°) and sagittal was 2.7° (range 1-4°). The mean shortening was 4.1 mm (range 0-8 mm). Three patients had partial flap necrosis and 1 patient had total flap necrosis. There was no superficial and deep wound infection.

CONCLUSION

Staged treatment using NPWT decreased the risks of infection and requirement of flap surgeries in Gustilo Anderson grade IIIb open tibial fractures. Therefore, staged treatment using NPWT could be a useful treatment option for Gustilo Anderson grade IIIb open tibial fractures.

Functional outcome and general health status after treatment of AO type 43 distal tibial fractures

INTRODUCTION

Distal tibial fractures are uncommon, but they result in poor overall outcome. The objective of this study was to assess functional outcome and general health status after the treatment of distal tibial fractures and identify factors that affect these outcome measures.

PATIENTS AND METHODS

A retrospective cohort study including 118 AO type 43 distal tibial fractures in 116 patients was conducted. With regard to articular involvement, fractures were classified as either simple (A1-B2, n=70) or complex (B3-C3, n=48). Twenty relevant demographic and operative variables were studied. Functional outcome, quality of life and pain were assessed using the Foot Function Index (FFI) and AOFAS ankle score, physical and mental SF-36, and Visual Analog Scale (VAS) questionnaires, respectively.

RESULTS

Over 75% of patients experienced noteworthy loss of ankle function. The general health status assessment showed markedly affected quality of life with more than two-third of all responding patients suffering from pain every day. In fact, complex fractures and increased complication rate were associated with worse functional outcome, whereas prolonged time to definite surgery affected both functional outcome and general health status significantly.

CONCLUSIONS

Complex distal tibial fractures were associated with poor functional outcome scores and delayed (-staged) surgery has been shown to prevent postoperative soft tissue problems. However, soft tissue injury associated with distal tibial fractures itself affected both the postoperative functional outcome and general health status as well. This should contribute to the understanding of treatment and outcome of distal tibial fractures.

LEVEL OF EVIDENCE

3.

Complications and functional outcome after fixation of distal tibia fractures with locking plate - A multicentre study

INTRODUCTION

The aim of this study was to evaluate the proportion of complications and the functional outcome following ORIF with low-profile locking plates in patients with distal tibia fractures.

METHOD

Retrospective data was retrieved using county databases, operation books, health record and X-ray images for 6 hospitals (1 level 1, 5 level 2) in the Region of Southern Denmark. Between January 2007 and April 2011 70 consecutive patients with 71 distal tibia fractures were treated with low-profile locking plate were included. The proportion of post-operative complications, classified as minor and major complications, was retrieved from electronic health records and patient interviews. Long-term functional outcome assessed by EuroQol EQ-5D-5L questionnaire, AOFAS Ankle-Hindfoot scale, and return to pre-injury job function through patient interview and examination.

RESULTS

There were 32 43A, 5 43B and 34 43C-fractures, 12 open and 10 high-energy fractures. Forty-nine cases (69%) experienced complications during the follow-up time, of which 34 were minor complications and 15 were major complications. Median EQ-5D-5L index value was 0.76, median EQ VAS-score was 80, and median AOFAS score was 73. Thirty-three percent of working patients had not returned to work as a result of the fracture.

CONCLUSIONS

Our study suggest that treatment of distal tibia fractures with low-profile locking plates might have a higher proportion of complications and worse functional outcome than previously reported.

LEVEL OF EVIDENCE

Therapeutic level IV Case Serie.

A Systematic Review of the Role of Surgical Approaches on the Outcomes of the Tibia Pilon Fracture

BACKGROUND

The role of each surgical approach on the outcomes of pilon fractures has not been investigated in a systematic review.

METHODS

This systematic review was conducted with a thorough literature search on PubMed using the keywords ("pilon" OR "plafond") "fracture." Only articles written in the English language that have been published within the past 15 years and discussed the surgical approach were considered.

RESULTS

A total of 733 patients were included in this review. All the fractures were either OTA Type B or C fractures: 157 were Type B and 576 were Type C. Anterior and medial approaches have some of the best results in the literature with respect to complication rate. The posterolateral and anteromedial approaches have markedly higher complication rates.

CONCLUSIONS

The anterolateral group had the largest number of patients-comprising one third of the entire study population. The anterior approach had one of the lowest complication rates with a patient base that had a high proportion of OTA Type C fractures. The medial approach produced a low complication rate over a larger patient base that had a higher proportion of OTA Type B fractures.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Systematic review.

Impact of Infection on Fracture Fixation

Surgical site infection can be a devastating complication that results in significant morbidity in patients who undergo operative fixation of fractures. Reducing the rate of infection and wound complications in high-risk trauma patients by giving early effective antibiotics, improving soft tissue management, and using antiseptic techniques is a common topic of discussion. Despite heightened awareness, there has not been a significant reduction in surgical site infection over the past 40 years. Patients should be treated aggressively to eliminate or suppress the infection, heal the fracture if there is a nonunion, and maintain the function of the patient.

A Two-Stage Protocol With Vacuum Sealing Drainage for the Treatment of Type C Pilon Fractures

Management of type C pilon fractures remains controversial and challenging. The aim of the present study was to provide a 2-stage protocol with vacuum sealing drainage for the treatment of type C pilon fractures. From March 2009 to March 2012, 16 patients (mean age 42.3 years) were admitted to our department with type C pilon fractures and treated with single-stage external fixation and second-stage internal fixation (anteromedial incision) combined with vacuum sealing drainage. The American Orthopaedic Foot and Ankle Society scale score averaged 86.5 for this group of patients. The range of motion was 30° ± 8.9°. An excellent or good American Orthopaedic Foot and Ankle Society scale score was obtained for all patients. None of the 16 patients developed skin necrosis, nonunion, or fixation failure during the follow-up period. Moreover, the visual analog scale pain scores were 0.7 ± 0.8, 0.9 ± 0.7, and 1.4 ± 1.0 during rest, active movement, and weightbearing, respectively. The postoperative radiographs showed excellent treatment effects. A 2-stage protocol, combined with vacuum sealing drainage, for the treatment of type C pilon fractures can eliminate deep infection and complex surgery and is a simple and effective treatment method. In addition, full exposure of the anteromedial incision, the avoidance of the anterior tibial muscle tendon sheath, and the avoidance of soft tissue injuries are generally recommended in this operation.

Minimally invasive osteosynthesis of distal tibial fractures using anterolateral locking plate: Evaluation of results and complications

PURPOSE

Soft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on ante- rolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures.

METHODS

This is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive anterolateral tibial plating. This study evaluates the bone and soft tissue healing along with emphasis on complications related to bone and soft tissue healing.

RESULTS

Full weight bearing was allowed in mean time period of 4.95 months (3-12 months). A major local complication of a wound which required revision surgery was seen in one case. Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Mean distance between the posterolateral and anterolateral incision was 5.7 cm (4.5-8 cm).

CONCLUSION

The minimally invasive distal tibial fixation with anterolateral plating is a safe method of stabilization. Distance between anterolateral and posterolateral incision can be placed less than 7 cm apart depending on fracture pattern with proper surgical timing and technique.

Incidence of Intracapsular Placement When Inserting Medial Talar Body Schanz Pins: An Anatomic Study

OBJECTIVES

Medial talar body pins may be inserted to provide points of fixation in the hindfoot when applying external fixators. Because of the proximity to the ankle joint, there is a risk of intracapsular pin placement. We hypothesized that intracapsular placement is common when inserting medial talar body pins.

METHODS

Medial talar body pins were inserted in 12 fresh frozen cadaver ankles. Arthrography of each ankle was then performed to determine whether the pin was intracapsular. Each pin was then removed, and fluoroscopy was repeated to evaluate for contrast extravasation from the pin insertion site. The distance from the apex of the talar head to the anterior extent of the ankle capsule was measured to determine a safe area for extracapsular pin placement.

RESULTS

Arthrograms of all 12 ankles demonstrated that the pins were intracapsular. After pin removal, there was contrast extravasation from the pin insertion site in all specimens. Contrast was present in the pin tract in all specimens. Mean distance from the talar head to the anterior ankle capsule was 20.95 ± 4.8 mm (range, 12.2-27.3 mm) on the lateral view and 15.5 ± 1.8 mm (range, 12.4-20.0 mm) on the anteroposterior view of the foot.

CONCLUSIONS

There is a high rate of intracapsular pin placement when inserting medial talar body pins. Pin placement within the joint capsule risks seeding a sterile joint with bacteria and fistula formation when the pin remains in place for prolonged periods. For this reason, talar body pins should be avoided in temporizing external fixation frames.

External Fixation: Principles and Applications

The modularity and ease of application of modern external fixation has expanded its potential use in the management of fractures and other musculoskeletal conditions. In fracture care, it can be used for provisional and definitive fixation. Short-term provisional applications include "damage control" and periarticular fracture fixation. The risk:benefit ratio of added stability needs to be assessed with each fixator. Soft-tissue management is critical during pin insertion to lessen the risk of loosening and infection. Although provisional fixation is safe for early conversion to definitive fixation, several factors affect the timing of definitive surgery, including the initial injury, external fixator stability, infection, and the physiologic state of the patient.

Risk factors of deep infection in operatively treated pilon fractures (AO/OTA: 43)

BACKGROUND/AIMS

The purpose of this study is to evaluate risk factors of deep infection following pilon fractures.

METHODS

This investigation was performed after gathering a six-year retrospective database from a single academic trauma center.

RESULTS

These include an overall incidence of deep infection of 16.1% (57/355). Deep infection was diagnosed at an average of 88 days (±64 days) from initial injury with a range of 10-281 days. Development of deep infection occurred in 23.2% (33/142) of open fractures, vs 11.3% (24/213) of closed fractures.

CONCLUSION

Open fractures, hypertension and male gender were associated with an increased risk of developing deep infection. In addition, even optimal surgical management may not significantly modify rates of deep surgical site infection.

Management of high-energy tibial pilon fractures

Tibial pilon fractures result from high-energy trauma unlike usual ankle fractures. Their management provides numerous challenges to the orthopaedic surgeon including obtaining anatomic reduction of articular surface and the management of associated soft tissue injuries. This article aims to review major advances and principles that guide our practice today. We also discuss a treatment algorithm based on a staged approach to the fracture: initial spanning external fixation followed by definitive fixation.

Does the Fibula Need to be Fixed in Complex Pilon Fractures?

OBJECTIVES

To review a series of patients with complex plafond injuries with a metadiaphyseal dissociation who did not have the fibula fixed and compare with patients who had their fibula fixed using patients without a fibula fracture as a control group.

DESIGN

Retrospective case-control study.

SETTING

Level 1 Trauma center at a university hospital.

PATIENTS/PARTICIPANTS

Skeletally mature patients with a complete metadiaphyseal plafond fracture, and adequate presentation, postreduction, and healed radiographs to measure varus and valgus alignment.

INTERVENTION

Surgical treatment [external fixator or open reduction internal fixation (ORIF)] of high energy pilon fractures.

MAIN OUTCOME MEASUREMENTS

Metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications.

METHODS

From 364 patients with plafond fractures, 111 had high energy injuries with metadiaphyseal dissociation and form the basis of the study. Radiographs and charts were reviewed for fracture characteristics, metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications.

RESULTS

Of the 111 study patients, 93 patients were treated definitively with ORIF of the tibia and 18 patients were treated definitively in an external fixator. Within the 93 patients treated definitively with ORIF of the tibia, we identified 3 groups of patients those with a fibula fracture that was fixed (26 patients), those with a fibula fracture that was not fixed (37 patients), and those without a fibula fracture acting as the control group (30 patients). Between the 2 groups having a fibula fracture treated with ORIF of the tibia, there was no difference in fibula fracture pattern or location. For the 26 patients who had fibular fixation, it was performed in 11 patients at an average of 17 days for inability to hold length and alignment and in 15 patients to augment fixation in poor bone stock or to aid in the reduction. Patients with initial valgus deformity were more likely to have their fibula fixed. There was no difference in the postoperative or final alignment between the patients with fibula fractures (with or without fixation) and those without fibula fractures (P = 0.92). When comparing the 3 groups, the only statistical finding between the 2 groups was that those with fibula fixation required plate removal (P < 0.0001).

CONCLUSIONS

Fibular fixation is not a necessary step in the reconstruction of pilon fractures, although it may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation. We found a higher rate of plate removal if the fibula was fixed.

LEVEL OF EVIDENCE

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

Open surgical management of high energy ipsilateral fractures of the fibula and calcaneus

BACKGROUND

Simultaneous ipsilateral fractures of the calcaneus and fibula are the result of high-energy injuries. Open surgical treatment of both fractures can be performed with incisions based on the described blood supply of the lower extremity.

METHODS

A retrospective review for all patients with ipsilateral fractures of the calcaneus and fibula was performed over an eight-year period. Thirty-eight patients were identified. Eleven patients (28.9%) were treated with open reduction and internal fixation through two separate incisions. Average follow-up was 48.8 weeks.

RESULTS

Two patients (18.1%) required a secondary procedure. Three patients (27.2%) developed incisional cellulitis that resolved with oral antibiotics and one patient required local wound care. All fractures united.

CONCLUSIONS

Ipsilateral fractures of the calcaneus and fibula require open reduction and internal fixation when closed or percutaneous treatment is not appropriate. We describe an operative approach based on the angiosomes of the lower extremity that allows for treatment of these complex injuries and report the associated complications.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures

OBJECTIVES

To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails.

DESIGN

Retrospective analysis.

SETTING

Level I trauma center with follow-up in a private orthopaedic practice.

MAIN OUTCOME MEASUREMENTS

Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation.

PATIENTS

A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing.

RESULTS

Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal.

CONCLUSIONS

Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases.

LEVEL OF EVIDENCE

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

Optimal Management of High-Energy Pilon Fractures

The ideal treatment method for fibular fractures associated with high-energy pilon injuries remains unknown. In this investigation, the authors reviewed a consecutive series of 137 patients who sustained high-energy pilon injuries and assessed the effect of fibular fixation and timing on radiographic and clinical outcomes. At a mean follow-up of 18.7 months, the authors found that the presence or lack of fibular fixation did not have an effect on the timing or rate of union of the pilon fractures; similarly, there was no significant difference between these groups regarding the presence or development of coronal or sagittal malalignment intraoperatively or at final follow-up. Fibular union rates were also not significantly different between groups, but fibular fixation increased operative time in a statistically significant manner. Interestingly, when comparing fibular fixation during the temporization stage vs the definitive fixation stage, the authors found that early fixation of the fibular fracture also had no effect on alignment, healing, or complication rates. Fixation of the fibula during external fixation placement statistically increased operative time during temporization but did not significantly decrease operative time during definitive stabilization. The authors cannot recommend fibular fixation with all associated pilon fractures because the presence or timing of fibular fixation does not significantly change the radiographic outcomes, complication rate, or need for future surgical interventions. Future clinical analysis is needed to further delineate the indication for fibular fixation in this scenario.

Definitive fixation of tibial plateau fractures

Tibial plateau fractures present in a wide spectrum of injury severity and pattern, each requiring a different approach and strategy to achieve good clinical outcomes. Achieving those outcomes starts with a thorough evaluation and preoperative planning period, which leads to choosing the most appropriate surgical approach and fixation strategy. Through a case-based approach, this article presents the necessary pearls, techniques, and strategies to maximize outcomes and minimize complications for some of the more commonly presenting plateau fracture patterns.

Arthrofibrosis of the knee following a fracture of the tibial plateau

The aim of this study was to report the incidence of arthrofibrosis of the knee and identify risk factors for its development following a fracture of the tibial plateau. We carried out a retrospective review of 186 patients (114 male, 72 female) with a fracture of the tibial plateau who underwent open reduction and internal fixation. Their mean age was 46.4 years (19 to 83) and the mean follow-up was16.0 months (6 to 80). A total of 27 patients (14.5%) developed arthrofibrosis requiring a further intervention. Using multivariate regression analysis, the use of a provisional external fixator (odds ratio (OR) 4.63, 95% confidence interval (CI) 1.26 to 17.7, p = 0.021) was significantly associated with the development of arthrofibrosis. Similarly, the use of a continuous passive movement (CPM) machine was associated with significantly less development of arthrofibrosis (OR = 0.32, 95% CI 0.11 to 0.83, p = 0.024). The effect of time in an external fixator was found to be significant, with each extra day of external fixation increasing the odds of requiring manipulation under anaesthesia (MUA) or quadricepsplasty by 10% (OR = 1.10, p = 0.030). High-energy fracture, surgical approach, infection and use of tobacco were not associated with the development of arthrofibrosis. Patients with a successful MUA had significantly less time to MUA (mean 2.9 months; sd 1.25) than those with an unsuccessful MUA (mean 4.86 months; sd 2.61, p = 0.014). For those with limited movement, therefore, performing an MUA within three months of the injury may result in a better range of movement. Based our results, CPM following operative fixation for a fracture of the tibial plateau may reduce the risk of the development of arthrofibrosis, particularly in patients who also undergo prolonged provisional external fixation.

Strategies for surgical approaches in open reduction internal fixation of pilon fractures

Pilon or tibial plafond fractures usually result from high-energy injuries with rotation and/or axial compression. They occur in an area of relatively poor soft tissue coverage and frequently present a surgical challenge in deciding which incisions will be best for performing open reduction internal fixation. A variety of anterior and posterior approaches have been described based on the ease of fracture reduction and internal fixation with plates. Some of the incisions are fracture specific, that is, planned for a limited approach to the pilon. But in more complex cases, a wider exposure is indicated and thus more extensile approaches, both anterior and posterior, can be valuable. This review article will describe the different surgical approaches, focusing on their indication and technique.

External fixation of tibial fractures

External fixation for definitive or initial management of tibial fractures has a long history, with pin-to-bar external fixation being the standard of care for definitive management of tibial fractures. However, the use of this method lessened because of the increased popularity of intramedullary nailing and drawbacks associated with external fixation. This method is still commonly in use in the military environment and can be used for temporary stabilization of tibial fractures, especially in the setting of periarticular injuries. These fixators also may be useful for salvage of open and/or infected fractures that are unsuitable for internal fixation.

Complications and early results after operative fixation of 68 pilon fractures of the distal tibia

Background and aims

In this cohort study, we present comprehensive injury specific and surgical outcome data from one of the largest reported series of pilon fractures of the distal tibia treated in a UK tertiary referral centre.

Methods and results

A series of 68 closed pilon fractures were retrospectively reviewed from case notes, plain radiographs and computed tomography imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow-up period of 7.7 months (1.5–30). Overall, deep infection occurred in 1.6% with superficial infection and wound breakdown occurring in 6.3% of cases. Rates of nonunion and malunion were 7.8%. Radiological posttraumatic arthritis was present in 26.6%, which was symptomatic and requiring orthopaedic management in 9.4%. Further surgery for all causes occurred in 26.6% of cases.

Conclusion

Fixation of these complex fractures in subspecialist units can achieve overall low rates of wound complications, with definitive fixation of selected fractures within 48 h of initial presentation achieving comparable results to those fixed in a delayed fashion. However, this injury continues to have a significant overall complication rate with a high chance of developing early posttraumatic arthritis and of requiring further surgery.

Plate on plate technique of minimally invasive percutaneous plate osteosynthesis in distal tibial fractures, an easy and inexpensive method of fracture fixation

Background:

Plate on plate technique can lessen operative time and patient morbidity.

Objectives:

This study aimed to evaluate the outcomes of minimally invasive percutaneous plate osteosynthesis (MIPPO) using plate on plate technique of locking plate fixation for closed fractures of distal tibia in a prospective study.

Patients and Methods:

Twenty-five patients with distal tibial fractures were treated by MIPPO using locking plate by plate on plate technique. Preoperative variables including age of patient, mode of trauma, type of fracture and soft tissue status were recorded for each patient. Perioperative variables included surgical time and radiation exposure. Postoperative variables included wound status, time to union, return to activity and the American orthopaedic foot and ankle score (AOFAS).

Results:

All the fractures had united at one year. The average time to union was 16.8 weeks. There were two cases of superficial infection and two cases of deep infection, which required removal of hardware after the fracture was united. The average AO foot and ankle score was 83.6 in our study population.

Conclusions:

MIPPO using locking plate by plate on plate technique was a safe, effective, inexpensive and easily reproducible method for the treatment of distal tibial fractures in properly selected patients, which minimized operative time and soft tissue morbidity.

Fracture reduction and primary ankle arthrodesis: a reliable approach for severely comminuted tibial pilon fracture

BACKGROUND

Posttraumatic arthritis and prolonged recovery are typical after a severely comminuted tibial pilon fracture, and ankle arthrodesis is a common salvage procedure. However, few reports discuss the option of immediate arthrodesis, which may be a potentially viable approach to accelerate overall recovery in patients with severe fracture patterns.

QUESTIONS/PURPOSES

(1) How long does it take the fracture to heal and the arthrodesis to fuse when primary ankle arthrodesis is a component of initial fracture management? (2) How do these patients fare clinically in terms of modified American Orthopaedic Foot and Ankle Society (AOFAS) scores and activity levels after this treatment? (3) Does primary ankle arthrodesis heal in an acceptable position when anterior ankle arthrodesis plates are used?

METHODS

During a 2-year period, we performed open fracture reduction and internal fixation in 63 patients. Eleven patients (12 ankles) with severely comminuted high-energy tibial pilon fractures were retrospectively reviewed after surgical treatment with primary ankle arthrodesis and fracture reduction. Average patient age was 58 years, and minimum followup was 6 months (average, 14 months; range, 6-22 months). Anatomically designed anterior ankle arthrodesis plates were used in 10 ankles. Ring external fixation was used in nine ankles with concomitant tibia fracture or in instances requiring additional fixation. Clinical evaluation included chart review, interview, the AOFAS ankle-hindfoot score, and radiographic evaluation.

RESULTS

All of the ankle arthrodeses healed at an average of 4.4 months (range, 3-5 months). One patient had a nonunion at the metaphyseal fracture, which healed with revision surgery. The average AOFAS ankle-hindfoot score was 83 with 88% having an excellent or good result. Radiographic and clinical analysis confirmed a plantigrade foot without malalignment. No patients required revision surgery for malunion.

CONCLUSIONS

Primary ankle arthrodesis combined with fracture reduction for the severely comminuted tibial pilon fracture reliably healed and restored acceptable function in this highly selective patient group. Ring external fixation may be a useful adjunct to internal fixation, and this concept should be further studied.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Staged treatment of high energy midfoot fracture dislocations

BACKGROUND

Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious.

METHODS

One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed.

RESULTS

The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred.

CONCLUSION

Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

An Unusual Ankle Injury: The Bosworth-Pilon Fracture

The Bosworth injury occurs when the distal fibula becomes entrapped posterior to the posterior tibial tubercle, usually as a result of a supination external rotation injury. This uncommon occurrence is a recognized cause of an irreducible ankle dislocation. A pilon fracture is usually a high-energy injury caused by the talus being driven upward into the tibial plafond. The resulting bone and soft tissue injuries often require a staged approach to management. The present report is the first in the medical data to describe a Bosworth injury complicating a pilon fracture. We also discuss a management approach for this rare fracture.

Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes

Background

Ankle fractures are extremely common and represent nearly one quarter of all lower-limb fractures. In the majority of patients, fractures involve the distal fibula. The current standard in treating unstable fractures is through open reduction and internal fixation (ORIF) with plates and screws. Due to concerns with potentially devastating wound complications, minimally invasive strategies such as intramedullary fixation have been introduced. This systematic review was performed to evaluate the clinical and functional outcomes of intramedullary fixation of distal fibular fractures using either compression screws or nails.

Materials and methods

Numerous databases (MEDLINE, PubMed, Embase, Google Scholar) were searched, 17 studies consisting of 1,008 patients with distal fibular fractures treated with intramedullary fixation were found.

Results

Mean rate of union was 98.5 %, with functional outcome reported as being good or excellent in up to 91.3 % of patients. Regarding unlocked intramedullary nailing, the mean rate of union was 100 %, with up to 92 % of patients reporting good or excellent functional outcomes. Considering locked intramedullary nailing, the mean rate of union was 98 %, with the majority of patients reporting good or excellent functional outcomes. The mean complication rate across studies was 10.3 %, with issues such as implant-related problems requiring metalwork removal, fibular shortening and metalwork failure predominating.

Conclusion

Overall, intramedullary fixation of unstable distal fibular fractures can give excellent results that are comparable with modern plating techniques. However, as yet, there is unconvincing evidence that it is superior to standard techniques with regards to clinical and functional outcome.

Level of evidence

Level IV evidence.

Analysis of usage and associated cost of external fixators at an urban level 1 trauma centre

OBJECTIVE

To determine the usage, indication, duration, and cost associated with external fixation usage. Additionally, to show the significant cost associated with external fixator use and reinvigorate discussions on external fixator reuse.

DESIGN, SETTING, AND PATIENTS

A retrospective review of a prospectively gathered trauma database was undertaken to identify all patients treated with external fixation frames for pelvic and lower extremity injuries between September 2007 and July 2010.

MAIN OUTCOME AND MEASURES

We noted the indications for frame use, and we determined the average duration of external fixation for each indication. The cost of each frame was calculated from implant records.

RESULTS

341 lower extremity and pelvic fractures were treated with external fixation frames during the study period. Of these, 92% were used as temporary external fixation. The average duration of temporary external fixation was 10.5 days. The cost of external fixation frame components was $670,805 per year. The average cost per external fixation frame was $5900.

CONCLUSIONS

The majority of external fixators are intended as temporary frames, in place for a limited period of time prior to definitive fixation of skeletal injuries. As such, most frames are not intended to withstand physiologic loads, nor are they expected provide a precise maintenance of reduction. Given the considerable expense associated with external fixation frame components, the practice of purchasing external fixation frame components as disposable "single-use" items appears to be somewhat wasteful.

LEVEL OF EVIDENCE

Level II.

Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification

OBJECTIVE

The primary purpose of this study was to determine whether the Sanders computed tomography (CT) scan classification was still prognostic for outcome when long-term (10-20 years) radiographic and functional data of patients after open reduction and internal fixation for Sanders type II versus type III displaced intra-articular calcaneal fractures (DIACFs) were compared. The secondary purpose was to assess whether a bone graft or a locked plate was needed to maintain a reduction over time.

DESIGN

Prognostic case-control study.

SETTING

Level I trauma hospital.

PATIENTS

Patients with operatively treated Sanders type II/III DIACF managed between January 1, 1990, and December 31, 2000, by a single surgeon were identified from a prospectively gathered database. Skeletally mature patients with a closed isolated DIACF and a minimum of 10-year follow-up were included in this analysis. All fractures were classified according to Essex-Lopresti and Sanders. Of 638 fractures, 208 met the inclusion criteria.

INTERVENTION

Surgery consisted of a lateral extensile approach, posterior facet reduction, and lag screw fixation, followed by reduction of the anterior process and tuberosity with the application of a nonlocked lateral plate. Neither bone graft nor locking plates were used.

MAIN OUTCOME MEASURES

Articular congruity and overall reduction were assessed by CT scan and plain radiography (Böhler and Gissane angle) immediately postoperatively and at the final follow-up examination in all patients. Functional assessment and outcome scores were obtained [AOFAS-AHS, the Maryland Foot Score, Short Form-36 (SF-36), Ankle Osteoarthritis Score (AOS), and Visual Analog Scale (VAS)], and all complications and/or subsequent surgeries were noted. A subtalar (ST) arthrodesis was considered a treatment failure and was used as the determining outcome variable for comparing the 2 groups (II vs.

III) RESULTS

One hundred eight fractures in 93 patients were available for follow-up at a minimum of 10 years (52%). Average follow-up was 15.22 years (range, 10.5-21.2 years). Eighty were joint depression (J) and 28 were tongue-type (T) fractures. There were 70 Sanders type II and 38 Sanders type III fractures. On immediate postoperative CT scan, posterior facet reduction was anatomic in 103 fractures (95%), near anatomic in 3 fractures (1-3 mm), and approximate in 2 fractures (3-5 mm step). There were no failed reductions (>5 mm step). Long-term results indicated that only 3 fractures settled, but no plates failed. There was 1 missed peroneal tendon dislocation. Seven patients had sural neuritis. Twelve fractures (11%) required local wound care for apical necrosis. One patient had a dehiscence resulting in osteomyelitis, requiring a ST fusion. Thirty-one fractures (29 patients) developed ST arthritis, requiring an arthrodesis (30 ST, 1 triple) for unrelenting pain (VAS, 8-10) during the follow-up period, resulting in an overall long-term failure rate of 29%. Further breakdown by fracture type revealed that an ST fusion was performed in 47% of type III fractures (18/38) versus only 19% of type II (13/70) fractures (P = 0.002). Type III fractures were 4 times more likely to need a fusion compared with type II fractures (relative risk = 3.94; 95% confidence interval, 1.64-9.48). The remaining 66 patients (77 fractures) who did not require a fusion were evaluated for long-term functional outcome. Of these, only 1 patient used a cane and had a limp. Seventy-seven percent of the nonfused group (51/66) were within the US norm for the SF-36 PCS, with 46% (30/66) above the norm. The average AOFAS-AHS was 75. The average VAS was 1.75, with scores of 0-1 (very little or no pain) seen in 56% of this subset of patients (37/66).

CONCLUSIONS

Based on the results of this comparative analysis, the Sanders classification remains prognostic; after a minimum of 10 years, type III fractures were 4 times more likely to need a fusion than type II fractures. Secondarily, it seems that neither a locked plate nor a bone graft is required to maintain a reduction over time, as virtually no loss of reduction was seen in this series (3/108, 0.9%). The "joint first" surgical treatment did not adversely affect calcaneocuboid joint outcome. Based on these results, if severe posttraumatic ST arthritis does not occur, long-term (10-20 years) functional results with mild pain, minimal alterations in activities of daily living or work, and essentially normal shoe wear can be expected from a properly performed open reduction and internal fixation. Patients must be counseled regarding difficulty with uneven ground and an inability to return to vigorous sports activities.

LEVEL OF EVIDENCE

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

Outcome of 28 open pilon fractures with injury severity-based fixation

INTRODUCTION

Open pilon fracture management and treatment poses a significant challenge to orthopedic surgeons. The purpose of this study was to determine patient outcomes for open pilon fractures based on wound complication and infection rates, as well as subjective outcome instruments.

MATERIALS AND METHODS

This was a retrospective consecutive case series of 28 fractures with Orthopaedic Trauma Association (OTA)-type 43-B and 43-C open pilon fractures. Mean length of follow-up was 36 months and minimum of 1 year. Ten fractures were Gustilo and Anderson grade IIIB, and the remaining fractures were grades I-IIIA. Patients were initially treated with spanning external fixation and staged wound debridement followed by osteosynthesis of the articular surface. Metaphyseal fixation was by either plate fixation or Ilizarov frame. The primary outcome was the incidence of deep tissue infection requiring surgery. Secondary outcomes included the incidence of other complications (nonunion, malunion, amputation) and functional outcomes (Short Musculoskeletal Functional Assessment Questionnaire and AAOS Foot and Ankle Questionnaire).

RESULTS

Four patients developed deep tissue infections, three in the internal fixation group and one in the Ilizarov group, and all were treated successfully with staged debridement. There were two delayed unions required bone grafting, and infection-free union was ultimately achieved in all fractures. Two patients underwent arthrodesis secondary to post-traumatic arthritis, while no patients experienced malunions or amputations.

CONCLUSIONS

The use of staged wound debridement in conjunction with either plate fixation or Ilizarov frame achieves low rates of wound infection and stable fixation after anatomic joint reconstruction for OTA-type 43-B and 43-C open pilon fractures.

Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits

PURPOSE AND METHODS

External fixation is a safe option for stabilisation of extremity lesions in the polytraumatised patient as well as in fractures with severe soft tissue damage. Nevertheless, long-term-complications are to be expected when external fixation is chosen as a definitive treatment. The purpose of this review article is twofold: primarily, to define the rationale of a procedural change from an external fixator to an intramedullary nail; secondarily, to assess the possible advantages and pitfalls of a single- or two-staged procedure.

RESULTS AND CONCLUSIONS

External fixation of the femur is recommended in multiply injured patients who are critically ill to avoid an additional inflammatory response caused by the surgical trauma of primary nailing. The conversion towards nailing must be done as soon as the clinical condition of the patient has been stabilised. Stable polytraumatised patients do not benefit from initial stabilisation with an external fixator and should immediately be treated with a definitive osteosynthesis. In tibial fractures, external fixation followed by intramedullary nailing is recommendable in fractures with severe soft tissue injuries. Conversion should be done as soon as the soft tissues allow before pin-tract infections occur and performed in a one-staged procedure.

Definitive plates overlapping provisional external fixator pin sites: is the infection risk increased?

OBJECTIVES

The purpose of this study was to compare the infection risk when internal fixation plates either overlap or did not overlap previous external fixator pin sites in patients with bicondylar tibial plateau fractures and pilon fractures treated with a 2-staged protocol of acute spanning external fixation and later definitive internal fixation.

DESIGN

Retrospective comparison study.

SETTING

Two level I trauma centers.

PATIENTS/PARTICIPANTS

A total of 85 OTA 41C bicondylar tibial plateau fractures and 97 OTA 43C pilon fractures treated between 2005 and 2010. Radiographs were evaluated to determine the positions of definitive plates in relation to external fixator pin sites and patients were grouped into an "overlapping" group and a "nonoverlapping" group.

INTERVENTION

Fifty patients had overlapping pin sites and 132 did not.

MAIN OUTCOME MEASURE

Presence of a deep wound infection.

RESULTS

Overall, 25 patients developed a deep wound infection. Of the 50 patients in the "overlapping" group, 12 (24%) developed a deep infection compared with 13 (10%) of the 132 patients in the "nonoverlapping" group (P = 0.033).

CONCLUSIONS

Placement of definitive plate fixation overlapping previous external fixator pin sites significantly increases the risk of deep infection in the 2-staged treatment of bicondylar tibial plateau and pilon fractures. Surgeons must make a conscious effort to place external fixator pins outside of future definitive fixation sites to reduce the overall incidence of deep wound infections. Additionally, consideration must be given to the relative benefit of a spanning external fixator in light of the potential for infection associated with their use.

LEVEL OF EVIDENCE

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

Entrapped posteromedial structures in pilon fractures

OBJECTIVES

To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures.

DESIGN

Retrospective cohort review.

SETTING

Regional Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

About 394 patients with 420 pilon fractures treated between January 2005 and November 2011.

INTERVENTION

Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture.

MAIN OUTCOME MEASUREMENTS

Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure.

RESULTS

40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%).

CONCLUSIONS

In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery.

LEVEL OF EVIDENCE

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

Finite element analysis of three commonly used external fixation devices for treating Type III pilon fractures

Pilon fractures are commonly caused by high energy trauma and can result in long-term immobilization of patients. The use of an external fixator i.e. the (1) Delta, (2) Mitkovic or (3) Unilateral frame for treating type III pilon fractures is generally recommended by many experts owing to the stability provided by these constructs. This allows this type of fracture to heal quickly whilst permitting early mobilization. However, the stability of one fixator over the other has not been previously demonstrated. This study was conducted to determine the biomechanical stability of these external fixators in type III pilon fractures using finite element modelling. Three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones were reconstructed from previously obtained CT datasets. Bones were assigned with isotropic material properties, while the cartilage was assigned as hyperelastic springs with Mooney-Rivlin properties. Axial loads of 350 N and 70 N were applied at the tibia to simulate the stance and the swing phase of a gait cycle. To prevent rigid body motion, the calcaneus and metatarsals were fixed distally in all degrees of freedom. The results indicate that the model with the Delta frame produced the lowest relative micromovement (0.03 mm) compared to the Mitkovic (0.05 mm) and Unilateral (0.42 mm) fixators during the stance phase. The highest stress concentrations were found at the pin of the Unilateral external fixator (509.2 MPa) compared to the Mitkovic (286.0 MPa) and the Delta (266.7 MPa) frames. In conclusion, the Delta external fixator was found to be the most stable external fixator for treating type III pilon fractures.

[Percutaneous osteosynthesis in tibial pilon fractures. Does the surgical technique determine the final result?]

OBJECTIVE

To analyze the outcomes of distal tibia fractures with or without extension into the ankle joint, treated by percutaneous cannulated screws or locking plates.

MATERIAL AND METHOD

A retrospective study was conducted on 107 patients treated between 2001 and 2012.

INCLUSION CRITERIA

fractures 43-A and 43-C1 and C2 according to the AO/OTA system, treated with percutaneous osteosynthesis by locking plate or two cannulated screws in X -letter setting. A total of 33 patients were evaluated: 16 tibial fractures were performed with locking plate (G1) and 17 with cannulated screws (G2). Mean time to surgery was 8.31 days (0-14) in G1, and 2 days (0-7) in G2. The mean follow-up was 72 months (12-132). Mean time to healing: 17.08 weeks (8-48) in G1, and 14.56 weeks (8-24) in G2. The results were evaluated according to the AOFAS scale, with plain X-rays, and complications during follow-up.

RESULTS

The mean evaluation according to the AOFAS score was 78.62 in G1 (22-93), and 90.63 in G2 (70-100), and this was statistically significant. In G1, 61.4% (8) of the results were excellent or good, while in G2 it was 76% (13). There were no axial deformity cases or shortenings. There were 4 superficial infections and one broken device recorded in G1.

DISCUSSION

The percutaneous cannulated screw fixation is a suitable alternative for the management of fractures without significant joint involvement, and seems to offer better functional results than plates. The shortest time from injury to intervention in this group improves the progress of the soft tissues, and can improve the final result.

Bar diameter is an important component of knee-spanning external fixator stiffness and cost

The authors' objective was to determine the effects of bar diameter on the stiffness and cost of a knee-spanning external fixator. The authors studied 2 versions of an external fixator with a difference in bar diameter (small bars, 8-mm diameter; large bars, 11-mm diameter). Fixators were tested using frame dimensions and a synthetic fracture model appropriate for a tibial plateau fracture. Five configurations of each fixator were tested: standard, cross-link, oblique pin, double stack, and super construct. The construct stiffness of each configuration (n=60) was measured in anterior-posterior bending, medial-lateral bending, axial torsion, and axial compression. Cost analysis allowed for calculation of the stiffness per unit cost. In the large bar group, an increase in construct stiffness was noted for all constructs and testing modes. Magnitude of stiffness increase ranged from 24% to 224% (P<.05 in all cases), depending on the configuration and loading mode. Increase in stiffness was so large that double-stack small bars performed similarly to standard construct large bars. Considering that the frame components have similar costs, the double-stack small bar fixator results in a 66% increase in cost for the same stiffness provided by the standard large bar. Bar diameter seems to have a large effect on knee-spanning external fixators. The authors observed an increase in stiffness of up to 191% under anterior-posterior bending despite an increase in bar size of only 37.5%. This finding might allow clinicians to use less expensive frames constructed of larger bars without sacrificing construct stiffness.