Minimally-invasive treatment of high velocity intra-articular fractures of the distal tibia

Evaluation of Functional Outcome in Surgically Managed Tibial Pilon Fractures

Background Pilon fractures are infrequent and among the most challenging to manage. One reason is the extensive soft tissue injury surrounding the distal tibia. Second, the articular surface of the distal tibia with a complex fracture pattern needs anatomic reduction. These fractures occur due to high energy impaction of the talus into the distal tibia. The fracture patterns and extent of soft tissue involvement vary based on the intensity of the impact's energy. The management needs to be patient-specific to prevent complications. Proper pre-operative planning with the help of computer tomography scans aids in choosing the approach and proper reduction. Either single-stage early definitive fixation or two-staged protocols involving the application of spanning external fixation to maintain length and allow soft tissue healing followed by definitive open reduction and internal fixation is done. However, complications still remain inevitable in a significant subset of patients. Objective To evaluate the functional outcome in surgically managed tibial pilon fractures using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. Methods This prospective observational study included 20 patients who underwent surgery for pilon fractures of the tibia at Nizam's Institute of Medical Sciences between November 2020 and September 2022. The patients were between 18 and 65 years old and consented to participate in the study group. After undergoing patient-specific surgical management, all patients are followed for a minimum of six months. Their functional outcome is evaluated after fracture union and scheduled physiotherapy sessions every four weeks using the AOFAS scoring system. Ankle range of motion (ROM) is also evaluated. Results The average age of the patients was 40 years, and male predominance was present. Most of the patients (60%) underwent internal fixation. According to the AOFAS scoring system, six patients had an excellent outcome, 11 had a good outcome, and three had a fair outcome. Most of the patients (11 patients) had excellent to good ankle ROM. Complications were encountered in two patients with ankle stiffness and one with wound dehiscence. Conclusion Pilon fractures are more common in young adults due to road traffic accidents. The most common type of pilon fracture is a closed fracture, which can be treated with definitive internal fixation after the soft tissue has healed. Definitive internal fixation has shown excellent and good functional outcomes (according to the AOFAS score) with improved ankle ROM and no complications when compared to external fixation, which can result in ankle stiffness and delayed union.

Management of High-Energy Tibial Pilon Fractures

➤ Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.➤ Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.➤ Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.➤ Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.➤ Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.➤ The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.

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

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

Risk factors for infection in fixation of distal tibia fractures

BACKGROUND

The aim of this study is to evaluate risk factors for infection as well as infection rates after open reduction and internal fixation for distal tibia fractures with a distal tibia locking plate and/or isolated screws.

METHODS

This is a retrospective and descriptive study based on 55 patients treated in our Major Trauma Centre from January 2009 to December 2016. All patients were classified by age, sex, open or closed fracture, injury mechanism, comorbidities, fixation and time from injury to surgery. 22 extraarticular fractures AO/OTA 43-A and 33 intraarticular (14 cases 43-B and 19 43-C) were recorded. High energy trauma was related in 27 patients, while open fractures were observed in 10 patients. Splint until surgery was applied routinely while temporary external fixation (EF) was performed in 21 patients (7 extraarticular and 14 intraarticular). Patients were treated by 5 different consultant surgeons performing isolated screws (SC) in 20% of the surgeries, antero-medial locking distal tibia plate (AM) and anterolateral (AL) were used in 47% and 33% of the patients respectively. After assessing normality and homogeneity of the subgroups, statistical contrast tests were performed.

RESULTS

Infection rate was 31.5%, mainly caused by S. aureus. We obtained a statistically significant correlation between greater age and infection rate. In the same way, a positive statistical trend between infection and AL plating was found. The use of EF followed by ORIF was not observed as a risk factor for infection compared with splint followed by internal fixation, however, the group of patients in which a splint was used, a positive relationship was found between the infection rate and shorter time until the definitive fixation. No statistically significant associations were found between extra/intraarticular fracture pattern, use of corticosteroids or open fractures and infection rate.

CONCLUSION

Greater age was a predisposing factor for infection. The use of external fixation before definitive ORIF seems to be a safe procedure regarding risk infection, and if an external fixation is not used, we recommend longer waiting time until definitive ORIF. Screw fixation or antero-medial plates, if allowed by fracture pattern, can be an option to avoid infection.

Treatment of Distal Metaphyseal Tibial Fractures with Anterolateral Plates or with Anterolateral-Medial Plates: A Retrospective Series

Distal metaphyseal tibial fractures (3-5 cm from the joint with zones of comminution or <3 cm from the joint) are challenging to fix and are associated with many complications. The study objective was to evaluate the functional outcomes and complications after treating distal metaphyseal tibial fractures using anatomical anterolateral tibia locking plates or anterolateral-medial plates. This retrospective study included 57 patients with distal metaphyseal tibial fractures. Thirty patients were treated by open reduction internal fixation with anterolateral plates; 27 patients were treated with anterolateral-medial plates. Patients were followed at regular intervals. The time to fracture union and complications were recorded. We evaluated the stage of fracture healing using the Radiographic Union Score for Tibial fractures. The patients treated with anterolateral plates had significantly higher rates of loss of reduction and malunion than those treated with anterolateral-medial plates (p = .02 and p = .002, respectively). There were no significant differences in the radiographic union scores (p = .22), non-union (p = .17), incision necrosis (p = .91), or infection (p = .94) between the 2 groups. The functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot-ankle score at the 12-month follow-up. The mean hindfoot-ankle scores were 90.9 ± 5.0 (range 79 to 100, median 90) and 92.3 ± 5.1 (range 82 to 100, median 92) for the anterolateral plates and anterolateral-medial plates, respectively (p = .29). For distal metaphyseal tibial fractures, anterolateral-medial plates may be worthwhile for reducing loss of reduction and malunion.

A comparative finite element simulation of locking compression plate materials for tibial fracture treatment

The locking compression plate (LCP) system has several advantages in fracture fixation combining angular stability with the use of locking screws with traditional fixation techniques. However, the system is complex and requiring careful attention to biomechanical principles and good surgical technique. Due to the set of complicate stresses and strains in the LCP system after implantation, the material, which is being used here, is deemed important. However, so far the materials have been limited to the stainless steel (SS) or titanium (Ti). This study was therefore aimed at investigate the biomechanical performance of the internal tibial locked plates at different material properties, including SS, Ti, carbon/polyether ether ketone (PEEK) composite, in treating medial tibial fracture using patient-specific finite element (FE) model of the human tibia. The carbon/PEEK composite materials were used at three different fiber plies configurations. Simulated loading was applied at 60:40 ratios on the medial:lateral aspect. The model was fixed distally in all degrees of freedom. The results revealed the highest stress (307.10 MPa) and the lowest strain (0.14%) at Ti LCP system. The carbon/PEEK LCP system at configuration I and III showed low stress (∼60 MPa) and high strain (0.70%), which are suitable points for designing of an internal LCP system. On the other hand, the highest value of stress in callus region was 4.78 MPa (Carbon PEEK/Configuration I) and the strain variations of callus region were between 1.46% and 3.82% among all materials. These results implied the advantage of carbon/PEEK composite materials in LCP system as they can tolerate higher strains at lower stresses.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Minimally invasive medial plate osteosynthesis in tibial pilon fractures: Longterm functional and radiological outcomes

OBJECTIVE

The aim of this study was to evaluate the long-term follow-up and functional and radiological outcomes of minimally invasive medial plate osteosynthesis in distal tibia fractures.

METHODS

From January 2011 to November 2015, we reviewed the medical records of 60 patients with 62 tibia fractures (41 men and 19 women; mean age: 45.3±14.9 years) who were treated with open reduction and internal fixation for distal tibia pilon fractures. The mean follow-up time after surgery was 42.7±4.6 months. Union time, coronal plan deformity, complication rates and AOFAS and Olerud-Molander functional outcome scores were evaluated.

RESULTS

According to the AO/OTA classification, there were thirty four (54.8%) type 43-A fracture, eight (12.9%) type 43-B fractures, twenty (32.3%) type 43-C fractures. The average time for fracture union was 16.1 weeks. The mean AOFAS score was 86.6±9.1. The mean Olerud-Molander score was 85.6±9.8. There were four patients (6.5%) with a varus of less than 5°, two patients (3.2%) with a valgus of less than 5°, 39 patients (62.9%) with recurvatum (34 of them less than 5°; five of them less than 10°), and 14 patients (22.6%) with procurvatum (12 of them less than 5°; two of them less than 10°). The AOFAS and Olerud-Molander scores in the smoker and diabetic patients were significantly lower than the non-smoker (p=0.002; p=0.005) and non-diabetic patients (p=0.022, p=0.002). The duration of union was significantly higher in both diabetic (p=0.025) and smoker patients (p=0.041). There was no association between the fracture type and the presence of varus, valgus, recurvatum and rotation deformity. The AOFAS score, Olerud-Molander score and plantar-flexion were significantly higher in type A fractures than in type C fractures (p=0.021; p=0.030, and p=0.033, respectively). AOFAS score, Olerud-Molander score, plantar-flexion value did not differ between type B and type C fractures. There was no significant difference among the dorsi-flexion (p=0.211), the follow-up time (p=0.531) and duration of union (p=0.908) of type A, type B and type C fractures. Three patients with open fracture had delayed wound healing. One patient developed skin necrosis. They were treated by local wound care.

CONCLUSION

Minimally invasive medial plate osteosynthesis is a reliable method of treatment for tibial pilon fractures. This technique provides a high fracture healing rate and satisfying functional outcome with minimal wound healing complications. Sagittal plan deformity remains a common complication with minimally invasive medial plate osteosynthesis.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Autologous Osteochondral Graft for Early Posttraumatic Arthritis of Tibiotalar Joints After Comminuted Pilon Fractures in Young Patients

BACKGROUND

Posttraumatic arthritis of tibiotalar joints after AO/OTA type C3 pilon fractures, especially in young patients with a significant osteochondral defect in the tibial plafond joint surface, is a challenging situation. We report a joint-preserving technique using autologous osteochondral graft in combination with ankle distraction and supramalleolar osteotomy (SMOT), if necessary, to improve its outcome.

METHODS

Seventeen patients with an average age of 32.1 years with Takakura grade 1 to 3A posttraumatic arthritis of the tibiotalar joint after AO/OTA type C3 pilon fractures received osteochondral autograft transplantation, ankle distraction, and SMOT, when supramalleolar malalignment was present, between February 2010 and November 2015. The visual analog scale (VAS), Short-Form 36 (SF-36) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and ankle range of motion were used for outcome analysis. Radiographic assessment of any SMOT and the apparent joint space was performed. Fourteen patients were followed for an average of 18 months.

RESULTS

The VAS, SF-36, and AOFAS scores as well as the ankle range of motion all improved significantly at the last follow-up after the surgery (P < .01). No deep surgical site infection, donor site complication, nonunion, osteochondral block loosening, or resorption was noted. No secondary arthrodesis was needed at the end of follow-up.

CONCLUSION

Autologous osteochondral graft transplantation in combination with ankle distraction and SMOT was a promising joint-preserving technique for early posttraumatic arthritis of tibiotalar joint after severe pilon fractures in young patients.

LEVEL OF EVIDENCE

Level IV, case series.

High-energy tibial pilon fractures: an instructional review

High-energy tibial pilon fractures continue to represent a significant challenge to the treating orthopaedic surgeon. Pre-operative evaluation includes a careful clinical assessment of the associated soft tissue injury, which frequently dictates surgical management. Staged surgical reconstruction remains the standard treatment protocol at most trauma centres. This includes application of a temporary spanning external fixator for approximately one to four weeks, followed by open reduction and internal fixation once the surrounding soft tissues are amendable. Despite careful soft tissue management protocols, the risk of wound complications continues to be relatively high compared to other orthopaedic trauma procedures. The functional long-term outcomes of these injuries remain limited, and recent data has emphasised that the majority of patients do not regain their pre-operative work status. In addition, the health-related quality of life scores fare poorly when compared to other orthopaedic and non-orthopaedic patient populations, and many patients develop post-traumatic arthritis within the tibiotalar joint. It has been shown that the quality of fracture reduction may significantly correlate with the long-term functional outcomes. While the orthopaedic community has come a long way with regard to safe management of high-energy tibial pilon fractures, the clinical outcomes continue to remain limited. In particular, the persistently high rates of wound complications and the limited functional long-term outcomes leave significant room for improvement. Future investigators may focus on further innovations to minimise the risk of wound complications. The surgical team may emphasise the quality of fracture reduction as an important treatment goal.

Minimally Invasive Osteosynthesis of Distal Tibia Fractures using Anterolateral Locking Plate

Introduction: Plating in distal tibia fractures are associated with higher rate of soft tissue complications. As adequate soft tissue cover is available over anterolateral surface of the tibia, use of anterolateral plate fixation in distal tibia fractures has increased. The purpose of our research is to evaluate the outcomes of anterolateral locking plate fixation in distal tibia fractures using ORIF.

Materials and Methods: A retrospective analysis of 25 patients, who had distal tibia fractures and underwent open reduction and anterolateral plating. Bone and soft tissue healing and complications encountered were analysed.

Result: Full weight bearing was allowed at an average of 5.4 months (range: 3-12 months) after seeing radiological union. We have observed superficial wound infection in four cases. Two cases had marginal necrosis, two cases had sensory disturbance over dorsolateral aspect of foot and two cases had delayed non-union. Mean length of surgical incision was 9cm (range: 5-12 cm).

Conclusion: Open reduction internal fixation of distal tibia fractures with anterolateral plating is a reliable way of fracture fixation and stabilisation with proper surgical technique and aseptic precautions.

Arthroscopic-Assisted Open Reduction Internal Fixation

The indications for arthroscopy have expanded over the years. Arthroscopic-assisted open reduction internal fixation in the setting of acute trauma is gaining popularity with foot and ankle surgeons. It serves to facilitate direct visualization of fracture fragments and allows for precise articular reduction with minimal soft tissue insult. Current evidence reports a high incidence of chondral injury with ankle fractures. Arthroscopy performed at the time of open reduction internal fixation allows for joint inspection and potential treatment of these posttraumatic defects.

Medium-Long-Term Radiographic and Clinical Outcomes after Surgical Treatment of Intra-Articular Tibial Pilon Fractures by Three Different Techniques

Introduction

The goal of this retrospective, observational, case series study was to evaluate the medium-long-term clinical and radiographic results of the three most common surgical osteosynthesis techniques used for the treatment of articular tibial pilon fractures: ORIF, MIPO, and EF.

Materials and Methods

A consecutive series of patients with articular pilon fractures who underwent surgery at our institution were enrolled in this study. Fractures were classified according to the Müller AO classification system. Overall outcomes took the following into account: radiographic quality of reduction, evaluated using Ovadia and Beals' criteria; clinical assessment, evaluated using the AOFAS questionnaire; and general health, evaluated with the SF36-v2 Health Survey.

Results

A total of 94 articular pilon fractures (34 type 43-B and 60 43-C) were evaluated with a mean follow-up of 56.34 months (range 33–101). The techniques used were ORIF, MIPO, and EF in 63 (67%), 17 (18.9%), and 14 cases (14.1%), respectively. According to Ovadia and Beals' criteria, good, fair, and poor results were reported in 61 (64.89%), 26 (27.66%), and 7 (7.45%) cases, respectively. The mean AOFAS score was 82.41 for MIPO, 79.83 for ORIF, and 50.57 for EF, respectively. Thirty-nine patients (41.49%) presented early and/or late complications.

Conclusion

Satisfactory outcomes using the three different techniques were reported. In particular, the radiographic outcomes were inversely proportional to the fracture comminutions and statistically different between internal and external osteosynthesis, but comparable between ORIF and MIPO techniques. On the other hand, the clinical outcomes were closely related to the soft tissue conditions and the anatomical reconstruction of the joint.

Intra-articular fractures of the distal tibia: Current concepts of management

Results of the treatment of intra-articular fractures of the distal tibia have improved significantly during the last two decades.Recognition of the role of soft tissues has led to the development of a staged treatment strategy. At the first stage, joint-bridging external fixation and fibular fixation are performed. This leads to partial reduction of the distal tibial fracture and allows time for the healing of soft tissues and detailed surgical planning.Definitive open reduction and internal fixation of the tibial fracture is performed at a second stage, when the condition of the soft tissues is safe. The preferred surgical approach(es) is chosen based on the fracture morphology as determined from standard radiographic views and computed tomography.Meticulous atraumatic soft-tissue handling and the use of modern fixation techniques for the metaphyseal component such as minimally invasive plate osteosynthesis further facilitate healing. Cite this article: EFORT Open Rev 2017;2:352-361. DOI: 10.1302/2058-5241.2.150047.

Complications of Minimally Invasive Percutaneous Plating for Distal Tibial Fractures

Background

The management of distal tibia fractures continues to remain a source of controversy and debate.

Objectives

The aim of this study was to evaluate the various complications of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a locking plate for closed fractures of distal tibia in a retrospective study.

Patients and Methods

Twenty-five patients with distal tibial fractures, treated by minimally invasive percutaneous plate osteosynthesis, were evaluated in a retrospective study. We studied the rate, probable etiological factors and preventive and corrective measures of various complications associated with minimally invasive plating of distal tibia.

Results

Mean age of the patients was 41.16 years (range 22 - 65). There were 13 male and 12 female patients. All fractures united at an average duration of 16.8 weeks. There were two cases of superficial and two cases of deep infection, and deep infections required removal of hardware for cure. There were four cases of ankle stiffness, most of them occurring in intra-articular fractures, three cases of palpable implant, three cases of malunion, one case of loss of reduction and one patient required reoperation. The average AO foot and ankle score was 83.6.

Conclusions

We found MIPPO using locking plate to be a safe and effective method for the treatment of distal tibial fractures in properly selected patients yet can result in a variety of complications if proper precautions before, during and after surgery are not taken care of.

Mid-Term Results of Minimally Invasive Plate Osteosynthesis and Circular External Fixation in the Treatment of Complex Distal Tibia Fractures

BACKGROUND

The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators.

METHODS

We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score.

RESULTS

Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12-26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18-24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients.

CONCLUSIONS

Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.

Distal tibial fracture: An ideal indication for external fixation using locking plate

OBJECTIVE

To evaluate the feasibility and efficiency of one-stage external fixation by using locking plate in distal tibial fractures.

METHODS

In this non-control prospective study, 28 patients with distal tibial fractures were included and underwent one-stage external fixation by using locking plate. There were 21 males and 7 females, with a mean age of 43 years (19-63). According to AO/OTA fracture classification, there were 9 cases of Type A1, 9 of Type A2, 10 of Type A3 fractures. There were 21 close and 7 open fractures. The locking plate was placed on the anteromedial aspect of the tibia with 4-5 bicortical screws inserted in both distal met- aphysis and diaphysis. The radiographic and clinic results were evaluated.

RESULTS

All patients were followed up for the average of 16 months (ranging from 12 to 21 months). The average surgery duration was 38 (25-60) minutes. The mean time to fracture healing were 14.6 ± 2.67, 17.5 ± 3.66, and 18.4 ± 3.37 (p < 0.05) weeks in type A1, A2, and A3 fractures respectively. By the end of the follow-ups, the mean AOFAS score were 96.11 ± 2.32, 92.67 ± 1.80 and 92.00 ± 2.06 (p > 0.05) in type A1, A2, and A3 fractures respectively. None of nonunion, deep infection, or breakage of screw or plate were observed.

CONCLUSIONS

Distal tibial fracture was the ideal indication for external fixation using locking plate. The external plating is characterized by ease of performance, less invasive, fewer soft tissue impingement, improved cosmesis, and convenient for removal.

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.

One-Stage External Fixation Using a Locking Plate: Experience in 116 Tibial Fractures

The authors report the results of 1-stage external fixation using a locking plate in 116 tibial fractures (85 closed and 31 open). The patients were followed for an average of 22 months. The mean duration of surgery was 42 minutes. The mean fracture healing time was 12 weeks for proximal, 20 weeks for shaft, 14 weeks for distal, and 24 weeks for multisegmental tibial fractures. Nonunion, deep infection, and breakage of screws did not occur. External plate fixation is effective for tibial fractures and especially for metaphyseal fractures. It has the advantages of being easy to perform and less invasive, and the plate is conveniently located for removal.

Locking compression plate as an external fixator in the treatment of closed distal tibial fractures

BACKGROUND

Tibial fractures often follow high-energy trauma, and although soft tissue can remain intact, poor blood supply can lead to skin necrosis, infections and potential amputation. We used closed reduction and locking compression plates as external fixators for treating closed distal tibial fractures with soft tissue compromise. The method aims to avoid those potential complications.

METHODS

A retrospective series of 23 closed distal tibial fractures were treated using locking compression plates as external fixators. Protecting the blood supply was an essential intra-operative consideration, and postoperative physical therapy and partial weight bearing were encouraged early. Patients were followed at regular intervals and evaluated radiographically and clinically.

RESULTS

The average time to radiological bony union was 29.4 weeks (range, 14-52 weeks). No infections were seen. Fractures in 22 cases (95.65 %) united, and most fractures healed in an acceptable position. All patients had good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

CONCLUSIONS

Locking compression plates can be used as external fixators and provide a high rate of union, comfortable clinical course and excellent ankle-joint motion. Although indications are limited, this method is a suitable surgical approach for treating closed distal tibial fractures with soft tissue compromise.

Pathogenesis and Treatment Strategies for Pilon Fractures With Ankle Dislocation

The present study investigated the pathogenesis and treatment strategies for pilon fractures with ankle dislocation. A total of 58 patients (47 males and 11 females) who had sustained pilon fractures with ankle dislocation were treated. The mean patient age was 48.1 years. Using the AO classification, 8 cases were type B2, 17 were type B3, and 33 were type C3. The dislocation was medial in 13 cases, lateral in 9, anterior in 11, posterior in 14, and longitudinal in 9. Radiologic examinations were conducted to evaluate the postoperative reduction, dislocation correction, fracture healing, and internal fixation. Ankle function was evaluated according to the Kofoed and Danborg scoring system. The patients were followed up for 4 to 27 months. Anatomic reduction was achieved in 39 cases (67.24%), good reduction in 13 (22.41%), and poor reduction in 6 (10.34%). No internal implant failure occurred, and the fractures had healed after 2 to 4.3 (mean 2.8) months. The rate of good or excellent ankle recovery was 84.00% for those with type B fractures, 75.76% for those with type C, 76.92% for those with medial dislocation, 77.78% for lateral dislocation, 81.82% for anterior dislocation, 78.57% for posterior dislocation, and 81.82% for longitudinal dislocation. Pilon fractures often occur with ankle dislocation in different directions. In such cases, the original anatomy should be restored and the longitudinal alignment recovered to minimize complications as much as possible.

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.

Comparison of Early and Delayed Open Reduction and Internal Fixation for Treating Closed Tibial Pilon Fractures

BACKGROUND

The timing of surgery for osteosynthesis of type C pilon (AO/OTA) fractures remains controversial. The aim of this study was to determine the outcome of early and delayed open reduction and internal fixation (ORIF) for treating closed type C pilon fractures.

METHODS

Forty-six patients with closed type C pilon fractures matched according to age, gender, soft tissue conditions, and fracture pattern were divided into group A (early group: underwent surgery within 36 hours of the injury) or group B (delayed group: underwent surgery 10 days to 3 weeks postinjury after the soft tissue swelling subsided). In the delayed group, 9 patients were treated first by temporary external fixation. All the closed fractures were managed by ORIF with locking plates. At follow-up, the clinical and radiographic results were retrospectively analyzed. The mean follow-up time was 25.8 months (range, 14 to 48 months) in group A and 26.0 months (range, 15 to 44 months) in group B.

RESULTS

There was no significant difference (P > .05) between the 2 groups regarding the rate of soft tissue complication, the rate of fracture union, and the final functional score. The patients in group A had a significantly shorter mean time to fracture union (21.5 ± 4.0 weeks vs 23.3 ± 3.7 weeks, P < .05), operating time (84.3 ± 12.1 months vs 100.6 ± 13.7 months, P < .01), and hospital stay (7.6 ± 2.6 days vs 15.2 ± 4.2 days, P < .01).

CONCLUSION

If soft tissue conditions are acceptable, early ORIF for treating closed type C pilon fractures can be safe and effective, with similar rates of wound complication, fracture union, and final good functional recovery but shorter operative time, union time, and hospital stay. These results favorably compare with delayed ORIF treatment.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes

BACKGROUND AND PURPOSE

Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures.

PATIENTS AND METHODS

A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables.

RESULTS

27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03-0.57) and for malalignment it was 0.10 (95% CI: 0.02-0.42). Both values were statistically significant.

INTERPRETATION

This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

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.

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.

Reduction of pullout strength caused by reinsertion of 3.5-mm cortical screws

INTRODUCTION

Osteosynthesis of the tibia, tibial plafond, and calcaneus is commonly performed with plates and 3.5-mm self-tapping cortical screws. Screw insertion and reinsertion within the same hole in the bone may occur during surgery. Therefore, the purpose of this study was to evaluate the pullout strength of 3.5-mm self-tapping screws with up to 5 re-insertions in the diaphysis of the tibia, metaphysis of the distal tibia, calcaneus, and a polyurethane synthetic bone model.

METHODS

Screws were inserted into a synthetic bone model and 5 pairs of human cadaveric diaphyseal tibiae, distal tibiae, and calcanei. The bone was predrilled, and then 3.5-mm cortical self-tapping 316 L stainless steel screws with a washer were inserted bicortically. Screws were inserted from 1 to 5 times at each location. The screws were grasped and subjected to 5-mm/min tensional force via the biaxial material testing systems machine. Statistical significance was determined using a paired 2-tailed t test.

RESULTS

There was a significant difference in the pullout strength of the tibial diaphysis (1710 ± 550 N), tibial metaphysis (471 ± 266 N), and calcaneus (238 ± 90 N; P < 0.01). The tibial diaphysis pullout strength was 1710 ± 550 N for one insertion differing significantly relative to the groups with 4 (average 1030 ± 543 N, P = 0.004) or 5 (average 364 ± 209 N, P < 0.001) insertions. The tibial metaphyseal pullout strength for the single insertion group was 471 ± 266 N and differed significantly relative to the 3 (P = 0.026), 4 (P = 0.044), and 5 (P = 0.042) insertion groups. The calcaneal pullout strength for the single insertion group was 238 ± 90 N with a significant difference of the 1, 3, and 4, versus the 5 insertion group (P = 0.027, 0.040, and 0.033, respectively). The synthetic bone model pullout strength decreased significantly from the one insertion group relative to all other insertion groups (group 1, 1167 ± 263 N; group 2, 768 ± 199 N; group 3, 694 ± 295 N; group 4, 662 ± 356 N; and group 5, 154 ± 183 N; P < 0.02).

CONCLUSIONS

There is a significant decrease in relative pullout strength of 3.5-mm self-tapping cortical screws when comparing the tibial diaphysis, tibial metaphysis, and calcaneus. There is also a significant decrease in 3.5-mm self-tapping screw pullout strength after repeated reinsertions in the synthetic bone model, mid-shaft tibia, metaphyseal tibia, and calcaneus. We recommend that during osteosynthesis, careful screw insertion, and minimal reinsertion be performed.

Multifragmentary tibial pilon fractures: midterm results after osteosynthesis with external fixation and multiple lag screws

Osteosynthesis of intraarticular tibial pilon fractures is preferably achieved using locking plates via a minimally invasive technique. If combined with severe soft tissue damage there is a high risk of wound-healing deficits after plate osteosynthesis. Thus our aim was to find an alternative method of treatment for those cases with combined soft tissue injuries.

We report on five cases with comminuted fractures of the joint surface combined with critical soft tissue condition that were treated with lag screws and external fixation (AO) applied across the ankle joint. All five patients were followed up, undergoing clinical and radiological examination.

Using this approach we achieved fracture healing of comminuted fractures without further complications. Clinical follow-up after an average of 55.6 (36–75) months revealed a mean AOFAS score of 81 (62–100).

We therefore propose combined treatment using lag screws with external fixation as a practical treatment option for those fractures for which lag screws combined with a locking plate are not feasible or when there is a high risk of wound-healing deficits due to severe soft tissue damage.

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.

Arthroscopic management of C3 tibial plafond fractures: a technical guide

Tibial plafond fractures are technically challenging and have the potential for serious complications. Minimizing soft tissue trauma can compromise visualization of articular reduction. There has been recent interest in the use of arthroscopy to improve visualization of plafond fractures while preserving the soft tissue envelope. Here the authors offer some technical points in order to simplify a technically demanding procedure.

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.

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.

Distal tibia fractures: management and complications of 101 cases

Distal tibia fractures are complex injuries with a high complication rate. In this retrospective and multicentre study we attempted to detail complications and outcomes of this type of injury in order to determine predictive factors of poor results. Between 2002 and 2004, 104 patients were admitted for 105 distal tibia fractures. One hundred patients (101 fractures) were reviewed with an average follow-up of 19 months (range, 12-46). Internal fixation, external fixation, limited internal fixation (K-wires or screws), intramedullary nailing and conservative treatment were used. Outcome parameters included occurrence of complications, radiographic analysis, evaluation of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and measures of the ankle range of motion. The average functional score was 76 points (range, 30-100 points), and complications occurred in 30 patients. Predictive factors of poor results were fracture severity, complications, malunion and the use of external fixation. We believe that external fixation must be reserved for trauma with severe skin injury, as a temporary solution in a two-staged protocol. For other cases, we recommend ORIF with early mobilisation.

Stabilisation of the fractured fibula plays an important role in the treatment of pilon fractures: a retrospective comparison of fibular fixation methods

Ninety-eight pilon fractures associated with ipsilateral distal fibular fracture were included in this study. The pilon fractures were treated by open reduction and plating. The 98 fractures were divided into three groups based on the treatment method of fractured fibula. Group A was composed of 50 fibular fractures treated by open reduction and plate fixation. Group B was composed of 23 fibular fractures treated by open reduction and pin fixation. Group C was composed of 25 fibular fractures treated conservatively by closed reduction. The radiographs were reviewed for adequacy of fracture reduction and posttraumatic arthrosis. At the end of follow-up, the clinical outcomes were evaluated using a rating scale. The three groups were similar in respect to Ruedi type, open fracture grade, and demographics (all p values >0.25). Group A showed a decreasing trend of malunion and ankle arthrosis compared to group C (p = 0.091 and p = 0.099, respectively). Group A had a better clinical outcome than group C (p = 0.008). In addition, group A showed an increasing trend of satisfactory outcome compared to group B (p = 0.096). In conclusion, for pilon fractures associated with ipsilateral fibular fractures, stabilisation of the fractured fibula plays an important role in the decrease of distal tibial malunion and post-traumatic ankle arthrosis as well as improvement of clinical outcomes.