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

Primary Arthrodesis of the Tibiotalar Joint in Severely Comminuted High-Energy Pilon Fractures

BACKGROUND

The treatment of highly comminuted tibial pilon fractures is controversial. The aim of this study was to determine the effectiveness and outcomes of primary arthrodesis following highly comminuted tibial plafond fractures.

METHODS

A database search was performed to identify all patients who underwent blade plate arthrodesis at our institution over a sixteen-year period. Inclusion criteria included patients with an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type-C2 or type-C3 pilon fracture that was deemed to be non-reconstructable by the treating surgeon. Outcomes were measured using the Short-Form 36-Item Health Survey, time to independent walking, time to consolidation of the arthrodesis, and wound-healing complications.

RESULTS

A total of twenty patients were included in this study, and seventeen patients (85%) were available for follow-up at a minimum of two years after their surgery. Wound infections or wound dehiscence did not occur in this series. All patients were walking without crutches or a walker at their latest follow-up. One patient developed an aseptic nonunion and healed successfully after revision surgery.

CONCLUSIONS

Blade plate ankle fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with severely comminuted, non-reconstructable pilon fractures.

LEVEL OF EVIDENCE

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

A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/OTA 43-C)

The anterior approaches that have been described for open reduction internal fixation of multifragmentary pilon fractures are designed to reconstruct the comminuted and impacted anterior articular surface onto a stable posterior column. Thus, reduction of the posterior column, particularly proper length, is critical. There are differing opinions of how best to surgically approach the posterior pilon fracture. There is also no clear indication as to the timing of both anterior and posterior reconstructions. Our objectives were (1) to develop a more midline posterior approach that might provide better visualization of the posterior aspect of the posterior column and juxtametaphyseal/diaphyseal parts of the tibia, first on the cadaver and then with patients, and (2) to use this as part of a combined posterior and anterior approach during the same anesthesia for complex tibial pilon fractures (AO/OTA 43-C) in a preliminary study of 6 patients.

Landing on your own two feet: a case report of bilateral calcaneus and open pilon fractures

High energy fractures of the distal tibial plafond and calcaneus have been associated with high functional morbidity and wound complications. Although both of these fractures result from a similar mechanism, they have rarely been reported to occur on an ipsilateral extremity. The combination of these 2 injuries on the same extremity would increase the likelihood of an adverse surgical or functional outcome. We present the case and management strategy of a 43-year-old male with bilateral open pilon fractures and closed calcaneal fractures after falling from a height. A staged protocol was used for the bilateral pilon fractures, with external fixation until operative fixation on day 9. Nonoperative management of the calcaneal fractures resulted in a successful functional outcome at 10 months of follow-up. Treatment of this fracture pattern must incorporate the condition of the soft tissues, an understanding of the fractures, and minimize patient risk factors to optimize the functional and surgical outcomes.

Safety of immediate open reduction and internal fixation of geriatric open fractures of the distal radius

INTRODUCTION AND AIM

There is a paucity of literature regarding outcomes of open fractures of the distal radius. No study has detailed this injury or treatment strategy in the geriatric population. The purpose of this study was to determine the safety of immediate open reduction and internal fixation of geriatric open fractures of the distal radius.

METHODS

A total of 21 geriatric patients with open fractures of the distal radius treated with a single definitive procedure were identified from a prospectively collected database. We reviewed patient demographics, injury characteristics and treatment specifics. Our primary outcome was surgical-site infection defined by need for antibiotics or repeat surgery. Our secondary outcome was need for other re-operation. Patients were contacted and functional scores obtained.

RESULTS

Patients were followed up for an average of 26 months. One deep infection and one nonunion occurred, and they required repeat surgery. Four minor operative complications occurred, including stiffness requiring manipulation and prominent fixation devices requiring removal. Patients maintained an average wrist flexion-extension arc of 89° and pronation-supination arc of 137°. The average QuickDASH (shortened disabilities of the arm, shoulder and hand questionnaire) score was 17.4, indicating minimal disability of the upper extremity.

CONCLUSIONS

Immediate open reduction and internal fixation of geriatric open fractures of the distal radius yields adequate functional results with low risk of major complications.

The 100 most cited papers in foot and ankle surgery

BACKGROUND

The number of citations of a paper gives an indication of an article's merit and importance within a medical specialty. We identify and analyse the 100 most cited papers in foot and ankle surgery.

METHOD

The Science Citation Index Expanded was searched for citations in 15 respected journals containing foot and ankle articles. Papers were analysed for subject, authorship, institution, country and year of publication. The average yearly citation was compared to total number of citations.

RESULTS

3501 foot and ankle papers were returned. The maximum number of citations was 1084 and the mean was 104. The top 100 papers were published between 1979 and 2007, with the majority published in the last decade. The ankle was the most important anatomical region discussed, and basic science and degenerative disease were popular topics. We found a large discrepancy between the total number of citations with average yearly citation.

CONCLUSION

Foot and ankle surgery is a young and rapidly developing sub-specialty within orthopaedics. Recently there has been a significant increase in influential papers published. Certain topics are popular indicating their importance within the field. This study highlights important papers in foot and ankle surgery giving an insight into readership.

Locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop

INTRODUCTION

Tibial fractures with compromised soft tissue envelop may lead to significant complications. The optimal management of these injuries remains controversial. Recently, locking plate used as a definitive external fixator is attractive because it not only minimizes trauma to the soft tissues, but also overcomes the shortcomings of standard external fixators. The objective of this study was to evaluate the outcome of using locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop.

PATIENTS AND METHODS

A prospective series of 12 consecutive tibial fractures with compromised soft tissue envelop were treated using locking plate as a definitive external fixator. Of these patients, six were Gustilo and Anderson type IIIA, three were type II and three were closed fractures (AO/ASIF soft tissue injury classification IC4: 2, IC5: 1). Time to union, nonunion, malunion, leg shortening, range of motion and function for the knee and ankle, deep infection, pin tract infections were evaluated.

RESULTS

The mean bone healing time was 37.8 weeks (range 20-56 weeks). Eventually, all of the fractures united. Most of the fractures healed in acceptable positions. There were no cases of deep infection. Pin tract infection was seen in 1 (8.3 %) patient, no loosening or failure of the external fixator was seen. At the most recent follow-up, the mean range of motion at the knee was extension 0° to flexion 135°, and the mean ankle range of motion was dorsi flexion 12° to plantar flexion 32°. All patients had excellent or good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

CONCLUSION

The locking plate used as a definitive external fixator provided a high rate of union. The patients experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an acceptable complication rate. However, the stiffness of external locked plating is not clear, therefore, clinical recommendation on its practical use to reduce the risk of implant failure still need to be determined.

Total fractures of the tibial pilon

Complete fractures of the tibial pilon are rare and their treatment difficult. The pathophysiology includes three groups: (A) high-energy trauma (motor vehicle injuries), with severe articular and soft tissue lesions, (B) rotation trauma, (skiing accidents), with modest articular and soft tissue damage, and (C) low-energy trauma in elderly people. These three groups occasion very different problems and complications. In emergency situations, these fractures should be stabilized, most often using external fixation to restore length and prepare definitive fixation. The second stage can be applied once soft tissue healing is achieved. Two methods are discussed: internal plating and definitive external fixation. The first goal of treatment is to restore the articular surface, although this does not always prevent secondary arthritis. The second is to restore correct positioning of the foot as regard to the leg. The complication rate is high. Neither of the two fixation techniques has proven to be more effective. In group B, the two methods are similar, but external fixation seems to be safer in group A.

The Jones dressing cast for safe aftercare of foot and ankle surgery. A modification of the Jones dressing bandage

Aftercare of surgical procedures is not consensual in the community of foot and ankle surgeons. Although the incidence of infections following foot and ankle surgery is rare, soft tissue healing might be jeopardized after extensive and multiple approaches. We define a precise fixation technique of the foot and ankle in the immediate post-operative phase by what we call "the Jones dressing cast". This technique is a modification of the Jones dressing bandage. We compared two groups of patients (20 and 23 patients) who underwent similar operative reconstructive procedures, with and without the application of the described cast, respectively, for one week. At the two-month follow-up, we observed that the group, which was treated with the cast required less analgetics, had a reduced hospitalization time and achieved faster autonomy using crutches. It may be assumed that reduced strain to the soft tissue around the foot due to the cast may reduce the complications in the post-operative period.

Is there a role for intramedullary nails in the treatment of simple pilon fractures? Rationale and preliminary results

INTRODUCTION

Certain patients with pilon fractures present with significant soft-tissue swelling or with a poor soft-tissue envelope typically not amenable to definitive fixation in the early time period. The objective of this study was to review the treatment of simple intra-articular fractures of the tibial plafond (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 43C1-C2) via intramedullary nailing (IMN) with the assessment of clinical and radiographic results and any associated complications.

MATERIALS AND METHODS

Retrospective clinical and radiological reviews of 31 patients sustaining AO/OTA type 43C distal tibial fractures treated with IMN were evaluated. Our main outcome measurement included achievable alignment in the immediate postoperative period and at the time of union along with complications or need for secondary procedures within the first year of follow-up.

RESULTS

Seven patients were lost to follow-up. All the remaining patients achieved bony union at a mean union time of 14.1 ± 4.9 weeks with no evidence of malunion or malrotation. All patients were at full-weight-bearing status at 1-year follow-up. Complications were notable for one delayed union, one non-union, one patient with superficial wound drainage, two with deep infection, one with symptomatic hardware and one with deep vein thrombosis.

CONCLUSION

Simple articular fractures of the tibial plafond (AO/OTA type 43C) treated via IMN can achieve excellent alignment and union rates with proper patient selection and surgical indication. One should not hesitate to use additional bone screws or plating options to help achieve better anatomic reduction. However, larger, prospective randomised trials comparing plating versus nailing, in experienced hands, are needed to completely delineate the utility of this treatment modality.

Predictive model for surgical site infection risk after surgery for high-energy lower-extremity fractures: development of the risk of infection in orthopedic trauma surgery score

BACKGROUND

Current infection risk scores are not designed to predict the likelihood of surgical site infection after orthopedic fracture surgery. We hypothesized that the National Nosocomial Infections Surveillance (NNIS) System and the Study on the Efficacy of Nosocomial Infection Control (SENIC) scores are not predictive of infection after orthopedic fracture surgery and that risk factors for infection can be identified and a new score created (Emerg Infect Dis. 2003;9:196-203).

METHODS

We conducted a secondary analysis of data from a trial involving internal fixation of 235 tibial plateau, pilon, and calcaneus fractures treated between 2007 and 2010 at a Level I trauma center. The predictive value of the NNIS System and SENIC scores was evaluated based on areas under the receiver operating characteristic (ROC) curve. Bivariate and multiple logistic regression analyses were used to build an improved prediction model, creating the Risk of Infection in Orthopedic Trauma Surgery (RIOTS) score. The predictive value of the RIOTS score was evaluated via the ROC curve.

RESULTS

NNIS System and SENIC scores were not predictive of surgical site infection after orthopedic fracture surgery. In our final regression model, the relative odds of infection among patients with AO [Arbeitsgemeinschaft für Osteosynthesefragen] type C3 or Sanders type 4 fractures compared with fractures of lower classification was 5.40. American Society of Anesthesiologists class 3 or higher and body mass index less than 30 were also predictive of infection, with odds ratios of 2.87 and 3.49, respectively. The area under the ROC curve for the RIOTS score was 0.75, significantly higher than the areas for the NNIS System and SENIC scores.

CONCLUSION

The NNIS System and SENIC scores were not useful in predicting the risk of infection after fixation of fractures. We propose a new score that incorporates fracture classification, American Society of Anesthesiologists classification, and body mass index as predictors of infection.

LEVEL OF EVIDENCE

Prognostic study, level II.

Management of high-energy foot and ankle injuries in the geriatric population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

Treatment of type C pilon fractures by external fixator combined with limited open reduction and absorbable internal fixation

INTRODUCTION

This study was conducted to evaluate the clinical outcome of the treatment of type C pilon fractures by using an external fixator combined with limited open reduction and absorbable internal fixation.

PATIENTS AND METHODS

Twenty-five type C pilon fractures, including 4 open fractures, were included in this retrospective study. The procedure of first-stage manipulation and external fixation spanning the ankle joint was conducted as early as possible. For the second stage, the tibial and fibular fractures were reduced and fixed with absorbable screws or rods through a limited incision. Clinical and radiographic evaluations were performed. The American Orthopaedic Foot & Ankle Society score (AOFAS) was obtained for evaluation of function. Twenty-one patients were followed postoperatively for a minimum of 18 months.

RESULTS

The mean time of union was 4.8 months. Delayed union of the distal tibia occurred in 1 patient. Minor infection occurred in 8 patients and deep infection in 1 patient. No skin necrosis, malunion, loss of reduction, nonunion, or fixation failure was observed during the follow-up period. No hardware removal was needed, nor was adverse tissue reaction to the implants observed. An excellent or good AOFAS outcome was obtained in 81% (17/21) of the patients.

CONCLUSIONS

External fixator combined with limited open reduction and absorbable internal fixation was a reliable treatment for closed and open AO/OTA type C pilon fractures of the distal tibia.

Locked plate fixation of the comminuted distal fibula: a biomechanical study

BACKGROUND

The purpose of this study was to compare the biomechanical properties of locked versus nonlocked lateral fibular bridge plating of comminuted, unstable ankle fractures in a mode of catastrophic failure.

METHODS

We created comminuted Weber C fractures in 8 paired limbs from fresh cadavers. Fractures were plated with either standard or locked one-third tubular bridge plating techniques. Specimens were biomechanically evaluated by external rotation to failure while subjected to a compressive load approximating body weight. We measured the angle to failure, torque to failure, energy to failure and construct stiffness.

RESULTS

There was no significant difference in construct stiffness or other biomechanical properties between locked and standard one-third tubular plating techniques.

CONCLUSION

We found no difference in biomechanical properties between locked and standard bridge plating of a comminuted Weber C fibular fracture in a model of catastrophic failure. It is likely that augmentation of fixation with K-wires or transtibial screws provides a construct superior to locked bridge plating alone. Further biomechanical and clinical analysis is required to improve understanding of the role of locked plating in ankle fractures and in osteoporotic bone.

Trans-syndesmotic fibular plating for fractures of the distal tibia and fibula with medial soft tissue injury: report of 6 cases and description of surgical technique

This report presents a retrospective review of several cases of distal fractures of the tibia and fibula with significant injury to the medial soft tissues treated either primarily or in staged fashion with fixed-angle trans-syndesmotic fixation. This fixation strategy was used in an effort to minimize further surgical trauma and implant load in the zone of soft tissue injury. Ten patients were identified between September 2002 and November 2010 who presented to a level I trauma center with fractures of the distal tibia and fibula associated with open medial wounds (9 patients) or extensive closed medial degloving injury (1 patient). They were all treated with trans-syndesmotic plating of the distal fibula. Two patients were lost to follow-up after initial treatment, and an additional 2 patients had follow-up durations of only 6.5 and 3 months, respectively. This left 6 patients with an average of 23.3 months of follow-up (range: 14-36 months). Radiographs and medical records were reviewed, and clinical and radiographic results were evaluated. All 6 patients had radiographic evidence of bony healing and had resumed weight bearing. Two patients required additional bone graft surgery to encourage healing, 1 of whom also required free-flap coverage as a component of the nonunion repair. One patient resumed weight bearing earlier than instructed and experienced mild but acceptable loss of reduction. No patients developed wound infections of either the medial traumatic or lateral surgical wounds, although, as noted above, 1 of the patients with a nonunion required medial free-flap coverage as a component of the nonunion repair because of incompetent medial soft tissues. Trans-syndesmotic fixation has previously been described as providing enhanced fixation of diabetic and osteoporotic ankle fractures but has not, to our knowledge, been described for the treatment of higher energy traumatic injuries. Specifically, the valgus distal tibial fracture, frequently associated with medial traction wounds, can present challenges to the treating surgeon in terms of obtaining adequate fixation although minimizing wound complications associated with the soft tissue injury. In a select subset of injuries, trans-syndesmotic fixation can provide a viable means of obtaining and maintaining either definitive fixation or enhancing the provisional fixation supplied by spanning external fixation.

Treatment of distal tibial fractures with the Ilizarov external fixator--a prospective observational study in 39 consecutive patients

BACKGROUND

The management of displaced distal tibial fractures is still controversial. The different internal fixation techniques are often burdened by relatively high complication rates. Minimally invasive techniques with ring fixators have been introduced as an alternative allowing immediate reduction and stabilization, avoiding a staged protocol. The aim of this prospective study was to analyze the clinical and radiographic outcome the Ilizarov technique in patients with distal metaphyseal tibial fractures, with or without intra-articular involvement.

METHODS

Thirty-nine consecutive patients with isolated fractures treated with the Ilizarov technique were followed prospectively for one year. Depending on the type of fracture, 4 or 5 rings were used, in some cases with additional foot extension. Unrestricted weight-bearing was allowed in all cases. Pre- and post-operatively conventional radiographs, post-operative pain assessment and complications were evaluated. The function was evaluated clinically and with self-appraisal protocols: EQ-5D, NHP and FAOS.

RESULTS

No patient developed compartment syndrome or deep venous thrombosis. Pin infections were frequent, but they were mostly superficial and were treated with antibiotics and/or the removal of isolated pins. Two patients required debridement. One of them had a deep infection and developed a residual deformity which was corrected and healed after re-operation. Another patient had a severe residual deformity. The fixator was removed after a median period of 16 weeks (range 11-30). The radiological results were poor in 5 patients but the overall self-appraisal showed satisfactory results in 36 patients.

CONCLUSIONS

The Ilizarov method allowed early definitive treatment with a low complication rate and a good clinical outcome.

The operative treatment of complex pilon fractures: A strategy of soft tissue control

BACKGROUND

Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. The soft tissue injury and handling of the soft tissue envelope are crucial in pilon fracture outcomes. The purpose of this study was to evaluate the early rate of complications using the strategy of "soft tissue control" for operative treatment of complex pilon fractures.

MATERIALS AND METHODS

36 complex pilon fractures were treated with the "soft tissue control" strategy. Patients followed the standard staged protocol, anterolateral approach to the distal tibia, the "no-touch" technique and incisional negative pressure wound therapy for pilon fractures. Patients were examined clinically at 2-3 weeks and then 8 weeks for complications associated with the surgical technique.

RESULTS

All fractures were AO/OTA (Orthopaedic Trauma Association) type C fractures (61% C3, 22% C2 and 16% C1). Only one patient developed superficial infection and resolved with antibiotics and local wound care. None developed deep infection.

CONCLUSIONS

The strategy of soft tissue control for treatment of pilon fractures resulted in relatively low incidence of early wound complications in patients with complex pilon fractures.

Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report

PURPOSE

The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate.

METHODS

Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate.

RESULTS

For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient.

CONCLUSION

Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.

Decisions and staging leading to definitive open management of pilon fractures: where have we come from and where are we now?

Historically, the treatment and outcomes related to pilon fractures have been variable despite anatomical reduction and fixation. However, with the advent of newer implant technologies, improved surgical techniques, and the management via a staged protocol, results have indicated encouraging clinical outcomes with minimization of postoperative complications. This review focuses and outlines the current strategies, decision-making processes, and definitive treatment options regarding the notoriously difficult to treat pilon fracture.

LEVEL OF EVIDENCE

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

External fixation versus ORIF for distal intra-articular tibia fractures

Tibia plafond fractures have historically demonstrated high complication rates. The purpose of this study was to assess the outcomes of tibia plafond fractures following treatment with definitive external fixation vs delayed open reduction and internal fixation (ORIF). Sixty patients were enrolled in a prospective cohort trial at 1 Level I trauma center. No differences were noted between the 2 treatment groups in terms of age, smoking history, presence of comorbidities, mechanism of injury, incidence of open fractures, or Orthopaedic Trauma Association fracture classification. Complete 12-month follow-up was available for 18 patients in the definitive external fixation group and 27 patients in the ORIF group. No difference was noted in articular reduction between the groups at 6 and 12 months postoperatively. Delayed union or non-union occurred in 4 (22.2%) of 18 patients in the external fixation group and 1 (3.7%) of 27 patients in the ORIF group (P=.05). Deep infection was equally likely in either group (P=.33). The ORIF group had improved Iowa Ankle Scores at 6 (23.6 ± 12.1 vs 11.1 ± 7.7; P<.05) and 12 months (5.5 ± 2.2 vs 3.1 ± 1.7; P<.05) postopertively and improved Short Form-36 Physical Function scores at 6 months (49.7 ± 30.1 vs 25.5 ± 8.0; P<.05) postoperatively compared with the external fixation group.External fixation and ORIF can attain bony union with adequate articular reduction and similar infection rates. Patients treated with ORIF appeared to have improved union rates and early outcomes with ankle function and Short Form-36 Physical Function scores.

Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures

OBJECTIVE

Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures.

DESIGN

Prospective clinical cohort.

SETTING

A Level I trauma and tertiary referral center.

PATIENTS/PARTICIPANTS

From January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months).

INTERVENTION

All patients were treated with open reduction and internal fixation for their pilon fractures.

MAIN OUTCOME MEASUREMENTS

Quality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications.

RESULTS

There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group.

CONCLUSIONS

The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.

Pilon fractures

The nature of the pilon fracture has caused evolution of treatment methods and its historically high rate of complication and poor outcome continue to direct choice of treatment. Attention to the delicate soft tissue envelope surrounding the ankle and recognition of the severity of the initial injury is crucial to ensure a satisfactory outcome and to minimize complications. Understanding the importance of staging surgical interventions will help to improve outcomes, but even optimal treatment may result in less than satisfactory results.

Anterolateral approach for tibial pilon fractures

The anterolateral approach to the tibia has been popularized for management of tibial pilon fractures. This approach offers the benefit of improved soft tissue coverage and the potential for a lower rate of wound-healing complications by avoiding incision placement over the subcutaneous border of the tibia. Although the fracture pattern dictates specific plate use, antomically designed anterolateral plates are useful for fixation of common fracture patterns. Additional exposures may be required to address other areas of the fracture, such as the medial malleolus, which cannot be accessed through this approach.

Infection after spanning external fixation for high-energy tibial plateau fractures: is pin site-plate overlap a problem?

OBJECTIVES

The purpose of this study was to determine whether overlap between temporary external fixator pins and definitive plate fixation correlates with infection in high-energy tibial plateau fractures.

DESIGN

Retrospective chart and radiographic review.

SETTING

Academic medical center.

PATIENTS

Seventy-nine patients with unilateral high-energy tibial plateau fractures formed the basis of this report.

INTERVENTION

Placement of knee-spanning external fixation followed by delayed internal fixation for high-energy tibial plateau fractures treated at our institution between 2000 and 2008.

METHODS

Demographic patient information was reviewed. Radiographs were reviewed to assess for the presence of overlap between the temporary external fixator pins and the definitive plate fixation. Fisher exact and t test analyses were performed to compare those patients who had overlap and those who did not and were used to determine whether this was a factor in the development of a postoperative infection.

MAIN OUTCOME MEASUREMENTS

Development of infection in those whose external fixation pin sites overlapped with the definitive internal fixation device compared with those whose pin sites did not overlap with definitive plate and screws.

RESULTS

Six knees in six patients developed deep infections requiring serial irrigation and débridement and intravenous antibiotics. Of these six infections, three were in patients with closed fractures and three in patients with open fractures. Two of these six infections followed definitive plate fixation that overlapped the external fixator pin sites with an average of 4.2 cm of overlap. In the four patients who developed an infection and had no overlap, the average distance between the tip of the plate to the first external fixator pin was 6.3 cm. There was no correlation seen between infection and distance from pin to plate, pin-plate overlap distance, time in the external fixator, open fracture, classification of fracture, sex of the patient, age of the patient, or healing status of the fracture.

CONCLUSION

Fears of definitive fracture fixation site contamination from external fixator pins do not appear to be clinically grounded. When needed, we recommend the use of a temporary external fixation construct with pin placement that provides for the best reduction and stability of the fracture, regardless of plans for future surgery.

Pilon fractures: advances in surgical management

Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. Variables such as fracture pattern, soft-tissue injury, and preexisting patient factors can lead to unpredictable outcomes. Avoiding complications associated with the soft-tissue envelope is paramount to optimizing outcomes. In persons with soft-tissue compromise, the use of temporary external fixation and staged management is helpful in reducing further injury and complications. Evidence in support of new surgical approaches and minimally invasive techniques is incomplete. Soft-tissue management, such as negative-pressure dressings, may be helpful in preventing complications.

Open reduction with internal fixation versus limited internal fixation and external fixation for high grade pilon fractures (OTA type 43C)

BACKGROUND

The optimal treatment for high energy pilon fractures is controversial. Good clinical and functional results have been reported with traditional open reduction techniques and minimally invasive techniques utilizing external fixation (EF). The purpose of this study was to critically evaluate clinical, radiographic and functional outcomes following high-energy fractures of the tibial plafond.

METHODS

Between 2000 and 2006, 62 patients who were diagnosed with 63 Type 43C pilon fractures were treated surgically by a single surgeon and retrospectively reviewed. Twenty-seven patients were treated with a hinged bridging external fixator (EF) with supplemental limited internal fixation and 35 were treated with open reduction and internal fixation (ORIF) utilizing traditional small fragment plates and screws. Out of the 62 patients, a total of 46 patients were available for review. Charts and radiographs were reviewed and a Short Musculoskeletal Function Assessment (SMFA) questionnaire was administered by a trained interviewer. Seventy-four percent of both the ex-fix patients and ORIF patients were available for followup with a mean of 18 and 22 months, respectively. Results were compared using student's T-tests.

RESULTS

There were no differences between the cohorts with respect to mechanism of injury, presence of an open wound and age. Functional outcomes were similar between the two groups based on the American Orthopaedic Foot and Ankle Society (AOFAS) score and the "function" index of the SMFA. The overall complication and union rates were similar between the two groups.

CONCLUSION

Both ORIF and EF appear to be comparable for treatment of OTA type 43C (pilon) fractures with regard to final range of ankle motion, development of arthritis and hindfoot scores.

Advancements in percutaneous fixation for foot and ankle trauma

Operative fixation of foot and ankle trauma can be challenging. Often times, the soft tissue envelope can have extensive damage as a result of the fracture. In these cases, percutaneous fixation may be used. Percutaneous fixation can benefit both soft tissue and osseous healing when used correctly. Many techniques have been described in the literature that may help to preserve blood supply, minimize soft tissue dissection, and restore a functional limb. This article reviews general guidelines for fracture and soft tissue management, osseous healing of fractures, and how certain techniques influence fracture healing. It also illustrates certain techniques for specific fracture reduction.

High energy tibial plateau fractures treated with hybrid external fixation

Management of high energy intra-articular fractures of the proximal tibia, associated with marked soft-tissue trauma, can be challenging, requiring the combination of accurate reduction and minimal invasive techniques. The purpose of this study was to evaluate whether minimal intervention and hybrid external fixation of such fractures using the Orthofix system provide an acceptable treatment outcome with less complications. Between 2002 and 2006, 33 patients with a median ISS of 14.3 were admitted to our hospital, a level I trauma centre, with a bicondylar tibial plateau fracture. Five of them sustained an open fracture. All patients were treated with a hybrid external fixator. In 19 of them, minimal open reduction and stabilization, by means of cannulated screws, was performed. Mean follow-up was 27 months (range 24 to 36 months). Radiographic evidence of union was observed at 3.4 months (range 3 to 7 months). Time for union was different in patients with closed and grade I open fractures compared to patients with grade II and III open fractures. One non-union (septic) was observed (3.0%), requiring revision surgery. Pin track infection was observed in 3 patients (9.1%).

Compared to previously reported series of conventional open reduction and internal fixation, hybrid external fixation with or without open reduction and minimal internal fixation with the Orthofix system, was associated with satisfactory clinical and radiographic results and limited complications.

Anterolateral and medial locking plate stiffness in distal tibial fracture model

BACKGROUND

The purpose of this study was to compare the axial and torsional stiffness between anterolateral and medial distal tibial locking plates in a pilon fracture model.

MATERIALS AND METHODS

The biomechanical stiffness of anterolateral or medial plated pilon fracture models was evaluated. Six Sawbones Composite Tibiae with a simulated pilon fracture representing varus or valgus comminution (OTA 43-A2.2) were plated with a Synthes 3.5-mm contoured LCP anterolateral or medial locking distal tibia plate. Load as a function of axial displacement and torque as a function of angular displacement were recorded. Each tibia was tested with a fracture wedge in place and removed with a medial and then anterolateral plate.

RESULTS

Loading the tibial plateau medial to the central axis, no significant difference in mean stiffness between the anterolateral and medial plates was demonstrated with the fracture wedge in place. A significant difference was demonstrated with the wedge removed. Loading the plateau posterior to the central axis, no significant difference in mean stiffness between plates was demonstrated with the wedge in place or removed. With the wedge in place, there was a significant difference in mean torsional stiffness for clockwise rotation, but not counterclockwise rotation. With the wedge removed, no significant difference appeared in mean stiffness for clockwise and counterclockwise rotation.

CONCLUSION

Distal tibia extra-articular fractures stabilized with anterolateral or medial locking plate constructs demonstrated no statistically significant difference in biomechanical stiffness in compression and torsion testing.

CLINICAL RELEVANCE

We believe this study indicates the primary concern when treating a pilon fracture may be soft-tissue considerations. Further clinical studies are required before definitive changes can be recommended regarding pilon fracture fixation.

Arthroscopically assisted treatment of ankle injuries

Ankle arthroscopy is a valuable tool in the treatment of certain intra-articular fractures involving the ankle, as it provides the ability to address osteochondral injury and aids in the direct visualization for joint reduction through minimal intervention. It can sometimes be complimented by a more minimally invasive approach to fracture reduction and internal fixation. It should be noted that to perform arthroscopically assisted minimally invasive fracture approaches, the surgeon must have significant experience with traditional open techniques.

Reduction strategies through the anterolateral exposure for fixation of type B and C pilon fractures

The surgical management of pilon fractures has evolved over the last several years with treatment shifting from acute definitive fixation to delayed fixation. One of the driving forces behind this change was the high incidence of soft tissue complications in those patients with high-energy pilon fractures (Orthopaedic Trauma Association 43B and 43C) managed with acute stabilization. Meticulous soft tissue handling along with delayed definitive fixation based on the soft tissue envelope has decreased the short-term complications associated with treatment of these injuries. Anterolateral exposure to the distal tibial articular surface allows for adequate visualization of most fracture patterns, novel reduction strategies, and successful implant placements. This exposure is useful in certain Type C pilon fractures, anterior and anterolateral Type B pilon fractures, and some extra-articular distal tibial fractures. The anterolateral exposure is not suitable in fractures with medial comminution, medial crush, impaction at the medial shoulder of the joint, segmental medial malleolar injuries, or varus deformity at the time of injury. The exposure has the advantage of excellent visualization of the articular surface up to the medial shoulder of the plafond while avoiding dissection of the anteromedial tibial surface.

Lateral ankle radiographs: do we really understand what we are seeing?

OBJECTIVES

To evaluate the validity of using lateral intraoperative fluoroscopic imaging to assess the reduction of the tibial plafond articular surface, two hypotheses were tested: 1) the distal tibial subchondral shadow on the lateral ankle radiograph is created equally by the medial, central, and lateral portions of the distal tibia; and (2) displacement of a 5-mm width osteochondral fragment is consistently recognizable on lateral fluoroscopic imaging.

METHODS

Six human fresh-frozen tibial plafond cadaveric specimens were sagitally sectioned in 5-mm increments after removal of the anterior soft tissue and stabilization of the position of the ankle through external fixation. To test the first hypothesis, a perfect lateral radiograph was taken after sectioning the specimens. The sagittal sections were then removed sequentially from medial to lateral. A perfect lateral radiograph was taken after each change. The sagittal sections were then removed beginning laterally and moving medially. A perfect lateral radiograph was taken after each change. The images were then compared with specific evaluation of the change in the subchondral shadow density. To test the second hypothesis, three malreductions were created by displacing a 5-mm osteochondral segment. After each malreduction, a perfect lateral radiograph was saved. These saved fluoroscopic images were placed in random order with lateral images of normal specimens. Four experienced ankle surgeons were then asked to determine whether the radiographs revealed displacement. Inter- and intraobserver reliability was then evaluated.

RESULTS

First, the subchondral shadow of the distal tibia appears to be created by an equal confluence of the subchondral bone of the medial, central, and lateral aspects of the tibial plafond. Second, fellowship-trained observers experienced in pilon fracture treatment correctly identified malreduction only 45% of the time. Intraclass correlation coefficient revealed very poor interobserver reliability with an alpha reliability statistic of 0.183. Intraobserver reliability across all four observers yielded an alpha statistic of 0.474, indicating inconsistencies in observers' evaluation of identical images at separate viewings.

CONCLUSIONS

It is difficult to discern rotational or translational displacement of a 5-mm osteochondral fragment on a perfect lateral fluoroscopic view of the ankle. Even with what appears to be a perfect lateral fluoroscopic view intraoperatively, displacement may still be present. When small osteochondral fragments are present, direct visualization of the articular surface is necessary to confidently establish that an anatomic reduction has been achieved.

Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes

BACKGROUND

Patients with diabetes who sustain an ankle fracture are at increased risk for complications including higher rates of in hospital mortality, in-hospital postoperative complications, length of stay and non-routine discharges. The purpose of this study was to retrospectively compare the complications associated with operatively treated ankle fractures in a group of patients with uncomplicated diabetes versus a group of patients with complicated diabetes. Complicated diabetes was defined as diabetes associated with end organ damage such as peripheral neuropathy, nephropathy and/or PAD. Uncomplicated diabetes was defined as diabetes without any of these associated conditions. Our hypothesis was that patients with uncomplicated diabetes would experience fewer complications than those patients with complicated diabetes.

MATERIALS AND METHODS

We compared the complication rates of ankle fracture repair in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes and calculated odds ratios (OR) for significant findings.

RESULTS

At a mean followup of 21.4 months we found that patients with complicated diabetes had 3.8 times increased risk of overall complications 3.4 times increased risk of a non-infectious complication (malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis when compared to patients with uncomplicated diabetes. Open ankle fractures in this diabetic population were associated with a three times higher rate of complications and 3.7 times higher rate of infection.

CONCLUSION

Patients with complicated diabetes have an increased risk of complications after ankle fracture surgery compared to patients with uncomplicated diabetes. Careful preoperative evaluation of the neurovascular status is mandatory, since many patients with diabetes do not recognize that they have neuropathy and/or peripheral artery disease.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

Comparison of two-staged ORIF and limited internal fixation with external fixator for closed tibial plafond fractures

OBJECTIVE

To compare the results of two-staged open reduction and internal fixation (ORIF) and limited internal fixation with external fixator (LIFEF) for closed tibial plafond fractures.

METHODS

From January 2005 to June 2007, 56 patients with closed type B3 or C Pilon fractures were randomly allocated into groups I and II. Two-staged ORIF was performed in group I and LIFEF in group II. The outcome measures included bone union, nonunion, malunion, pin-tract infection, wound infection, osteomyelitis, ankle joint function, etc. These postoperative data were analyzed with Statistical Package for Social Sciences (SPSS) 13.0.

RESULTS

Incidence of superficial soft tissue infection (involved in wound infection or pin-tract infection) in group I was lower than that in group II (P < 0.05), with significant difference. Group I has significantly less radiation exposure (P < 0.001). Group II had higher rates of malunion, delayed union, and arthritis symptoms, with no statistical significance. Both groups resulted similar ankle joint function. Logistic regression analysis indicated that smoking and fracture pattern were the two factors significantly influencing the final outcomes.

CONCLUSIONS

In the treatment of closed tibial plafond fractures, both two-staged ORIF and LIFEF offer similar results. Patients undergo LIFEF carry significantly greater radiation exposure and higher superficial soft tissue infection rate (usually occurs on pin tract and does not affect the final outcomes).

Bone and wound healing in the diabetic patient

Impaired soft tissue regeneration and delayed osseous healing are known complications associated with diabetes mellitus with regard to orthopedic surgery, making the management and treatment of diabetic patients undergoing foot and ankle surgery more complex and difficult. At the moment several options are available to address the known issues that complicate the clinical outcomes in these high-risk patients. Using a multifaceted approach, with close attention to intraoperative and perioperative considerations including modification of surgical technique to supplement fixation, local application of orthobiologics, tight glycemic control, administration of supplementary oxygen, and biophysical stimulation via low-intensity pulsed ultrasound and electrical bone stimulation, the impediments associated with diabetic healing can potentially be overcome, to yield improved clinical results for diabetic patients after acute or elective foot and ankle surgery.

Intramedullary fixation of fibular fractures associated with pilon fractures

OBJECTIVES

The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures.

DESIGN

Retrospective study.

SETTING

Level I university trauma center.

PATIENTS/PARTICIPANTS

From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months.

INTERVENTION

A retrospective chart and radiograph review was conducted of all patients for data extraction.

MAIN OUTCOME MEASUREMENTS

Fibular fixation type and length, fibular healing, and complications.

RESULTS

Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3 degrees of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1 degrees in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months.

CONCLUSIONS

In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.

Pilon fracture complicated by compartment syndrome: a case report

Pilon fractures associated with compartment syndrome are rare occurrences despite the relatively high-energy mechanisms that cause many pilon fractures. We report an unusual case of pilon fracture in an adult, which was complicated by development of compartment syndrome. It was successfully treated with four-compartment leg fasciotomy with good results. A high index of suspicion for compartment syndrome should be maintained in patients with intractable pain after pilon fracture.

The pilon fracture

Treatment of the ‘pilon’ fracture provides one of the greatest challenges to orthopaedic surgeons today. The force required to fracture the distal tibia can lead to complex fracture configurations and significant soft tissue compromise that challenge subsequent repair. High complication rates have encouraged extensive research over decades into an operative method that limits the insult to the surrounding soft tissue envelope whilst maintaining the stability of the fixation obtained. Two main techniques of fixation that meet such criteria have evolved more than others namely, open reduction and internal fixation (ORIF — two-staged protocol) and external fixation (ankle sparing hybrid fixation). Advances in these techniques have seen a significant reduction in the rate of catastrophic complications such as amputation, osteomyelitis and arthrodesis. The legacy of the pilon fracture, however, is such that it is hard to decide which treatment method is best and indeed severe fractures (AO classification type C2 or 3 or Reudi and Allgower type III) are better treated with primary arthrodesis and even amputation in some cases. Both methods have their drawbacks. A high prevalence of pin tract infections and possibly inadequate reduction may occur in some cases treated with external fixators. There is considerable variability of outcome with the two-staged protocol depending on the patients treated, the judgement and skill of the surgeon operating and risk of soft tissue compromise. The two-staged protocol seems to have a greater following and seems on the surface to get over many typical complications. No one treatment method is best for all fractures; in fact both are equally good for simpler fractures. It is their outcome in treating severe fractures that will determine which of the two methods is best and which could be adequately tested with a randomised controlled trial.

Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.