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Luo X, Wang W, Wang Z, Ma F. Below-knee amputation following internal fixation of a complex open Pilon fracture: A case report. Asian J Surg 2024:S1015-9584(24)02048-7. [PMID: 39353760 DOI: 10.1016/j.asjsur.2024.08.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/16/2024] [Accepted: 08/22/2024] [Indexed: 10/04/2024] Open
Affiliation(s)
- Xiaohai Luo
- Orthopedics Department, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Wei Wang
- Third Clinical Medical College, Ningxia Medical University, Yinchuan, China
| | - Zhaofu Wang
- The First Clinical Medical College, Lanzhou University, Lanzhou, China.
| | - Feng Ma
- Ningxia Medical University, Yinchuan, Ningxia, 750004, China.
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Sang C, Zeng L, Zhong H, Wang Q, Zeng L. Pilon fracture with central articular surface collapse treated by posterior tibial fenestration indirect reduction and compression technique: Two cases report. Medicine (Baltimore) 2024; 103:e39151. [PMID: 39151497 PMCID: PMC11332720 DOI: 10.1097/md.0000000000039151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/10/2024] [Indexed: 08/19/2024] Open
Abstract
RATIONALE Central collapsed fracture blocks traditionally require either an anteromedial or anterolateral approach for reduction. However, existing techniques face challenges such as soft tissue damage and compromised tibial strength, especially in pilon fractures with central articular surface collapse and an intact anterior cortex, as classified under 43B2.3 in the 2018 Orthopaedic Trauma Association/Association for the Study of Internal Fixation Fracture and Dislocation Classification Compendium. PATIENT CONCERNS We address the management of pilon fractures with central articular surface collapse, focusing on 2 cases where conventional reduction techniques posed a risk to soft tissues and tibial integrity. DIAGNOSES The patients presented with pilon fractures characterized by a central articular surface collapse and an intact anterior cortex, aligning with the 43B2.3 classification. INTERVENTIONS A novel approach was employed, utilizing posterior tibial fenestration and indirect reduction with compression techniques. This method leveraged the talus as a template for precise articular surface realignment. OUTCOMES Both cases demonstrated excellent reduction of the distal tibial articular surface and achieved favorable functional recovery of the ankle, evidenced by high American Orthopedic Foot and Ankle Society Ankle Hindfoot Scale scores during the 3-year follow-up. LESSONS The posterior tibial fenestration technique offers significant advantages for distal tibial pilon fracture reduction. It allows for precise articular realignment, facilitates bone grafting, and minimizes soft tissue and cortical bone disruption. This method is particularly effective for pilon fractures with an intact anterolateral cortex and central articular collapse, providing a valuable surgical alternative.
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Affiliation(s)
- Chaohui Sang
- Yixing People’s Hospital and Department of Orthopaedic Center, Wuxi, Jiangsu, China
| | - Langqing Zeng
- Zhuhai People’s Hospital (Zhuhai Clinical Medical College of Jinan University) and Department of Orthopaedics, Zhuhai, Guangdong, China
| | - Huafeng Zhong
- Zhuhai People’s Hospital (Zhuhai Clinical Medical College of Jinan University) and Department of Anesthesiology, Zhuhai, Guangdong, China
| | - Qiang Wang
- Yixing People’s Hospital and Department of Orthopaedic Center, Wuxi, Jiangsu, China
| | - Lulu Zeng
- Zhuhai People’s Hospital (Zhuhai Clinical Medical College of Jinan University) and Department of Nursing, Zhuhai, Guangdong, China
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Verbakel J, Boot MR, van der Gaast N, Dunning H, Bakker M, Jaarsma RL, Doornberg JN, Edwards MJR, van de Groes SAW, Hermans E. Symmetry of the left and right tibial plafond; a comparison of 75 distal tibia pairs. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02568-x. [PMID: 38874625 DOI: 10.1007/s00068-024-02568-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
PURPOSE Tibia plafond or pilon fractures present a high level of complexity, making their surgical management challenging. Three-Dimensional Virtual Planning (3DVP) can assist in preoperative planning to achieve optimal fracture reduction. This study aimed to assess the symmetry of the left and right tibial plafond and whether left-right mirroring can reliably be used. METHODS Bilateral CT scans of the lower limbs of 75 patients without ankle problems or prior fractures of the lower limb were included. The CT images were segmented to create 3D surface models of the tibia. Subsequently, the left tibial models were mirrored and superimposed onto the right tibia models using a Coherent Point Drift surface matching algorithm. The tibias were then cut to create bone models of the distal tibia with a height of 30 mm, and correspondence points were established. The Euclidean distance was calculated between correspondence points and visualized in a boxplot and heatmaps. The articulating surface was selected as a region of interest. RESULTS The median left-right difference was 0.57 mm (IQR, 0.38 - 0.85 mm) of the entire tibial plafond and 0.53 mm (IQR, 0.37 - 0.76 mm) of the articulating surface. The area with the greatest left-right differences were the medial malleoli and the anterior tubercle of the tibial plafond. CONCLUSION The tibial plafond exhibits a high degree of bilateral symmetry. Therefore, the mirrored unfractured tibial plafond may be used as a template to optimize preoperative surgical reduction using 3DVP techniques in patients with pilon fractures.
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Affiliation(s)
- Joy Verbakel
- Department of Trauma Surgery, Radboud University Medical Center, Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands.
| | - Miriam R Boot
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nynke van der Gaast
- Department of Trauma Surgery, Radboud University Medical Center, Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | - Hans Dunning
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Max Bakker
- Orthopaedic Research Laboratory, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ruurd L Jaarsma
- Department of Orthopaedic & Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Job N Doornberg
- Department of Orthopaedic & Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, Australia
- Department of Orthopaedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Michael J R Edwards
- Department of Trauma Surgery, Radboud University Medical Center, Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | | | - Erik Hermans
- Department of Trauma Surgery, Radboud University Medical Center, Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
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Zhao Q, Liu Z, Sun X, Zhang N, Xu W, Zhang T. The Clinical Application of Double Taylor Spatial Frame in Segmental Tibial Fracture. Orthop Surg 2024; 16:1344-1355. [PMID: 38664223 PMCID: PMC11144511 DOI: 10.1111/os.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 06/04/2024] Open
Abstract
OBJECTIVES Multi-planar external fixation has been used for the management of segmental tibial fractures with severe soft tissue injuries. However, fewer specialized studies have been reported. The primary aim of this study was to describe our experience of treating fractures of this type using the Taylor Spatial Frame and Ilizarov external fixation methods. METHODS We retrospectively analyzed 33 patients with segmental tibial fracture treated at our institution between January 2016 and December 2020. The patients were divided into double Taylor Spatial Frame (D-TSF) and Ilizarov groups based on the external fixation structure. Baseline demographic data included sex, age, injury side and cause, open or closed fracture, time from injury to surgery, complications, and external frame removal and fracture healing time. The hip-knee-ankle angle (HKA) was measured from preoperative, immediate postoperative, and final follow-up full-length X-rays of bilateral lower limbs. We determined the degree of deviation in the HKA by calculating the difference between the measured angle and the ideal value of 180°; the absolute value was used to assess recovery of the lower limb force line. At the final follow-up, Johner-Wruhs tibial fracture outcome criteria (J-W TFOC) were used to classify the postoperative function of the affected limb as excellent, good, moderate, or poor. Count data were analyzed with the chi-square test or Fisher's exact test; the Mann-Whitney U test was used for rank data. RESULTS No statistically significant differences were observed between the two groups in terms of sex, age, side of injury, cause of injury, closed or open fracture, or time between injury and surgery, which indicates that the groups were comparable (p > 0.05). A statistically significant difference was observed in external frame removal and fracture healing time between the D-TSF and Ilizarov groups (36.24 ± 8.34 vs 45.42 ± 10.21 weeks, p = 0.009; 33.33 ± 8.21 vs 42.00 ± 9.78 weeks, p = 0.011). The Johner-Wruhs criteria were used to assess the function of the affected limb, the D-TSF group performed better in correcting the lower limb force line than the Ilizarov group. A statistically significant difference in terms of excellent ratings was observed between the two groups (18/2/1/0 vs 5/5/1/1, p = 0.010). Postoperative follow-up X-rays demonstrated a significant improvement in the HKA in both groups immediately after surgery and at the final follow-up compared to the angle before surgery. At the final follow-up, a statistically significant difference was observed in the degree of deviation in the HKA between the two groups (1.58° ± 0.84° vs 2.37° ± 1.00°, p = 0.023). CONCLUSION The D-TSF treatment is associated with minimal secondary damage to soft tissue, a straightforward and minimally invasive procedure, multiplanar stable fracture fixation, and optimization of fracture alignment and lower limb force lines, therefore, it is highly effective therapeutic option for segmental tibial fracture.
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Affiliation(s)
- Qi‐Jun Zhao
- Clinical College of OrthopedicsTianjin Medical UniversityTianjinChina
- Department of OrthopedicsSinopharm North HospitalBaotouChina
| | - Zhao Liu
- Department of Orthopaedics Ward OneTianjin HospitalTianjinChina
| | - Xun Sun
- Department of Orthopaedics Ward OneTianjin HospitalTianjinChina
| | - Ning‐Ning Zhang
- Department of Orthopaedics Ward OneTianjin HospitalTianjinChina
| | - Wei‐Guo Xu
- Department of Orthopaedics Ward OneTianjin HospitalTianjinChina
| | - Tao Zhang
- Department of Orthopaedics Ward OneTianjin HospitalTianjinChina
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Chalidapong P, Vaseenon T, Chattipakorn N, Chattipakorn SC. Potential Roles of Inflammation on Post-Traumatic Osteoarthritis of the Ankle. Int J Mol Sci 2024; 25:5903. [PMID: 38892089 PMCID: PMC11173057 DOI: 10.3390/ijms25115903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/19/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Post-traumatic osteoarthritis of the ankle (PTOA) is frequently observed following a debilitating consequence of intra-articular ankle fractures. Numerous risk factors contribute to the pathogenesis of PTOA, including articular incongruity, joint malalignment, and concomitant soft tissue damage. Despite attempts to restore joint anatomy and manage soft tissues to avoid long-term complications after intra-articular ankle fractures, the incidence of PTOA remains markedly elevated. Inflammatory processes triggered by intra-articular ankle fractures have emerged as potential instigators that expedite the progression of PTOA. Injury to the articular cartilage and subchondral bone may lead to the release of inflammatory mediators, which can contribute to cartilage degradation and bone resorption. This study provides a narrative review on the current knowledge concerning the association between inflammation and the development of PTOA following intra-articular ankle fractures. We also discuss novel therapeutic agents that target inflammatory pathways to impede the progression of post-traumatic osteoarthritis after intra-articular ankle fractures. These medication and interventions were summarized within this review article.
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Affiliation(s)
- Pawee Chalidapong
- Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Tanawat Vaseenon
- Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Nipon Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Siriporn C Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai 50200, Thailand
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Gao Y, Peng X, Wang C, Jiang C, Yu X. Early posterior column internal fixation: A staged treatment of type C3 tibial pilon fracture. Injury 2024; 55:111385. [PMID: 38359710 DOI: 10.1016/j.injury.2024.111385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/23/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
Pilon fractures represent a challenging subset of tibial fractures. The management of AO/OTA Type C3 fractures remains complex due to associated complications and lack of clear guidelines for surgical timing and methods. A prospective cohort study was conducted to evaluate two staged treatment strategies for AO/OTA Type C3 tibial pilon fractures. The study focused on assessing surgical difficulty, complications, and patient prognosis. One group of patients received early internal fixation of the fibula and tibial posterior column combined with external fixation, while the other group received external fixation alone in the first stage. Patients who received early internal fixation of the fibula and tibial posterior column combined with external fixation had better outcomes, including lower rate of allogeneic bone grafting (67.74 % versus 94.64 %), reduced incidence of wound delay and skin necrosis (3.23 % versus 21.43 %), shorter surgical time (133.06 ± 23.99 min versus 163.04 ± 26.83 min), shorter hospital stay (13.77 ± 2.53 days versus 18.25 ± 3.67 days), and higher AOFAS (83.05 ± 8.68 versus 79.36 ± 8.92). Additionally, avoiding fibular shortening was shown to be crucial in preventing prolonged surgery and improving patient function. The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. The findings support the use of this treatment to optimize outcomes in AO/OTA Type C3 pilon fractures.
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Affiliation(s)
- Yanchun Gao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Xiaoyuan Peng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Chengchen Wang
- Shanghai Institute of Technology, Shanghai 201418, China
| | - Chengyi Jiang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China.
| | - Xingang Yu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China.
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Gao X, Liu F, Wang G, Gao Y, Suyalatu X. Serum caspase‑1 levels serve as a predictive biomarker for the prognosis of patients undergoing arthroscopic‑assisted locking plate internal fixation in the treatment of high‑energy pilon fractures. Exp Ther Med 2024; 27:77. [PMID: 38264430 PMCID: PMC10804377 DOI: 10.3892/etm.2023.12365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/24/2023] [Indexed: 01/25/2024] Open
Abstract
The present study aimed to investigate the serum levels of caspase-1 in patients with high-energy pilon fractures, and its correlation with prognosis and clinical results. In this prospective study, 136 patients with high-energy pilon fractures who were treated with a locking plate combined with ankle arthroscopy from July 2015 to July 2020 were included. The treatment efficacy was evaluated according to the Mazur ankle function score. Serum caspase-1, interleukin (IL)-6, IL-1β and C-reactive protein (CRP) levels were measured using enzyme-linked immunosorbent assay. Reverse transcription-quantitative PCR was used to measure the mRNA expression of caspase-1. Additionally, demographic data and clinical characteristics, such as sex, age, intraoperative blood loss, fracture healing time, fracture classification and complications were collected and analyzed. The study revealed that the intraoperative blood loss, proportion of Ruedi-Allgower III and the serum levels of caspase-1 in the poor prognosis group were significantly higher compared with those in the good prognosis group. Additionally, patients with high-energy pilon fractures in the poor prognosis group exhibited significantly higher levels of caspase-1 and IL-1β serum levels at all time points in contrast to those in the good prognosis group. Spearman's analysis revealed a significant association between caspase-1, IL-1β levels and Mazur scores. Furthermore, caspase-1 could serve as a potential diagnostic biomarker for poor prognosis of patients with high-energy pilon fractures. Caspase-1, IL-1β, intraoperative blood loss and Ruedi-Allgower grade were the risk factors for poor prognosis in patients with high-energy pilon fractures. In summary, this study demonstrated that serum caspase-1 levels were progressively reduced during the treatment of high-energy pilon fractures patients and prominently lowered in those with a favorable prognosis. These findings could provide novel targets and a comprehensive approach to protecting patients with high-energy pilon fractures.
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Affiliation(s)
- Xiaoyu Gao
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Feng Liu
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Gang Wang
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Yu Gao
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
| | - Xin Suyalatu
- Department of Orthopedics, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region 017000, P.R. China
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Gao Y, Zhao Y, Wang H, Xu X, Cheng Z, Lu T, Liu Y, Zhou J. Three-Dimensional Heat Map: The OTA/AO Type 43C Pilon Fracture Lines Distribution. Int J Gen Med 2024; 17:323-334. [PMID: 38314199 PMCID: PMC10838051 DOI: 10.2147/ijgm.s444977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/17/2024] [Indexed: 02/06/2024] Open
Abstract
Background This study aimed to create three-dimensional heat map and study the characteristic of fracture lines and represented fragments of OTA/AO type 43C pilon fractures. Methods CT scan was performed in105 fractures diagnosed with OTA/AO type 43C pilon fractures between January 2017 and December 2022. Three-dimensional pilon fracture maps were created and converted into fracture heat maps. CT scan graphic parameters including the fracture line height, α angle, β angle, the ratio of the area and size of bone fragment represented by the fracture line to the total articular surface were measured. Results The study included 105 patients with 91 males and 14 females. The fractures included C1 (n=16), C2 (n=23), and C3 (n=66). There was no statistically different among the most parameters except in the fracture-line height of the anterior fracture line (p=0.03) and the sagittal fracture line (p=0.02) between C2 and C3 pilon fractures. The average size of the anterolateral fragment, occupied approximately 13.5% of the articular surface area, was (11.5±2.8) mm × (20.5±6.3) mm with the average height of 29.8 mm. The average size of the posterolateral fragment, occupied approximately 13.0% of the articular surface area, was (15.7±4.6) mm × (19.3±4.0) mm with the average height of 19.1 mm. Conclusion This study demonstrates that the articular surface fracture lines in the C type pilon fracture are formed by fixed main fracture lines. The understand of morphological and distribution characteristics of the fracture lines and size of fragments in OTA/AO type 43C pilon fractures would help the surgeons take suitable approach and fixation.
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Affiliation(s)
- Yuling Gao
- Orthopedics Department, Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, People’s Republic of China
| | - Yanrui Zhao
- Orthopedics Department, Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, People’s Republic of China
| | - Hanzhou Wang
- Orthopedics Department, Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, People’s Republic of China
| | - Xiaopei Xu
- Orthopedics Department, Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, People’s Republic of China
| | - Zhexian Cheng
- Preventive Dentistry Department, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Tianchao Lu
- Orthopedics Department, Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, People’s Republic of China
| | - Yang Liu
- Orthopedics Department, Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, People’s Republic of China
| | - Junlin Zhou
- Orthopedics Department, Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, People’s Republic of China
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O'Leary B, Mitchell B, Thomas S, Onodera K, Huang B, Kent WT. Anterior Tibial Artery Danger Zone During Anterolateral Plate Fixation of the Distal Tibia: A 3D Computed Tomography Angiogram Modeling Study. J Orthop Trauma 2024; 38:e15-e19. [PMID: 37876218 DOI: 10.1097/bot.0000000000002718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVES The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique. METHODS 116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate. RESULTS The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens. CONCLUSIONS The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14.
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Affiliation(s)
- Brendan O'Leary
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA
| | - Brendon Mitchell
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA
| | - Sean Thomas
- University of California San Diego School of Medicine, La Jolla, CA; and
| | - Keenan Onodera
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA
| | - Brady Huang
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA
| | - William T Kent
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA
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Gan TJ, Ma XK, Li YX, Chen Y, Liu X, Li J, Zhang H. Osteoperiosteal Iliac Autograft Transplantation for Unreconstructable Tibial Plafond After Malunions of Pilon Fractures in Young Patients. Foot Ankle Int 2024; 45:33-43. [PMID: 37837388 DOI: 10.1177/10711007231201823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
BACKGROUND Malunion of tibial pilon fracture, especially with a large cartilage loss of the tibial plafond, is a tough clinical conundrum. This study describes a joint-preserving technique that mainly involves corrective intraarticular osteotomy and osteoperiosteal iliac autograft transplantation for treating these generally considered unreconstructable tibial plafond. METHODS Sixteen patients with an average age of 33.6 years who were treated with this joint-preserving method between 2013 and 2020 were retrospectively analyzed. Ankle distraction was applied in all patients. Additional osteochondral autograft transplantation for talus was performed in 4 patients and supramalleolar osteotomy in 2 patients. The visual analog scale (VAS) score, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the 36-Item Short Form Health Survey (SF-36) score, and the ankle range of motion (ROM) were used for outcome analysis. Radiographic assessment was conducted, and the complications were recorded. RESULTS At a mean follow-up of 41.1 months, the mean VAS, AOFAS, and SF-36 scores improved from 6.3, 47.6, and 38.0 to 1.7, 84.4, and 70.8, respectively (P < .001 for each). The ankle ROM improved from 27.5 to 32.2 degrees (P = .023). The mean area of ilium blocks was 3.5 cm2, and the mean external fixation time was 94.1 days. Radiographs showed that good osteointegration was found in all patients and no significant progression of osteoarthritis in 15 patients. The major complications included poor incision healing in 2 patients and severe ankle stiffness in 2 patients, with one of them developing considerable varus-type osteoarthritis but reporting no pain. No deep infection, nonunion, or malunion occurred, and no secondary arthrodesis was performed during the final follow-up. CONCLUSION Osteoperiosteal iliac autograft transplantation might be an alternative surgical option for reconstructing unreconstructable malunited pilon fractures with a large cartilage loss of the tibial plafond in young patients. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ting-Jiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xi-Kun Ma
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ya-Xing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jia Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Liang H, Zhang H, Chen B, Yang L, Xu R, Duan S, Cai Z. 3D printing technology combined with personalized plates for complex distal intra-articular fractures of the trimalleolar ankle. Sci Rep 2023; 13:22667. [PMID: 38114629 PMCID: PMC10730506 DOI: 10.1038/s41598-023-49515-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/08/2023] [Indexed: 12/21/2023] Open
Abstract
This study investigated the effectiveness of 3D printing technology in combination with personalized custom-made steel plates in the treatment of complex distal intra-articular trimalleolar fractures, with the aim of providing a new approach to improve ankle joint function in patients. The 48 patients with complex distal intra-articular trimalleolar fractures included in the study were randomly divided into two groups: the personalized custom-made steel plate group (n = 24) and the conventional steel plate group (n = 24). A comparison was made between the two groups in terms of preoperative preparation time, hospitalization duration, surgical time, fracture reduction and internal fixation time, intraoperative fluoroscopy instances, surgical incision length, fracture healing time, follow-up duration, degree of fracture reduction, ankle joint functional recovery, and the occurrence of complications. The personalized steel plate group exhibited longer preoperative preparation time and hospitalization duration compared to the conventional steel plate group (p < 0.001). However, the personalized steel plate group demonstrated significantly shorter surgical duration, time for fracture reduction and internal fixation, reduced intraoperative fluoroscopy frequency, and a shorter overall surgical incision length (p < 0.001). Both groups displayed similar fracture healing times and follow-up durations (p > 0.05). The personalized steel plate group showed a higher rate of successful fracture reduction (87.5% vs. 79.2%, p > 0.05) and a lower incidence of complications (8.3% vs. 20.8%, p = 0.22), although these differences did not reach statistical significance. Furthermore, the personalized steel plate group exhibited superior ankle joint function scores during follow-up compared to the conventional steel plate group (p < 0.05). By utilizing 3D printing technology in conjunction with personalized custom-made steel plates, personalized treatment plans are provided for patients with complex comminuted tri-malleolar ankle fractures, enabling safer, more efficient, and satisfactory orthopedic surgeries.
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Affiliation(s)
- Hairui Liang
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - He Zhang
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Beibei Chen
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Lei Yang
- School of Pharmacy, Inner Mongolia Medical University, 5 Xinhua Street, Hohhot, 010107, Inner Mongolia Autonomous Region, China
| | - Rongda Xu
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Siyu Duan
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Zhencun Cai
- Department of Orthopedics Surgery, Central Hospital Afliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China.
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Gan D, Jin X, Wang X, Tao C, Yan Q, Jia Q, Huo S, Chen D, Yao Q, Xiao G. Pathological progress and remission strategies of osteoarthritic lesions caused by long-term joint immobilization. Arthritis Res Ther 2023; 25:237. [PMID: 38062473 PMCID: PMC10702075 DOI: 10.1186/s13075-023-03223-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE While joint immobilization is a useful repair method for intra-articular ligament injury and periarticular fracture, prolonged joint immobilization can cause multiple complications. A better understanding how joint immobilization and remobilization impact joint function and homeostasis will help clinicians develop novel strategies to reduce complications. DESIGN We first determined the effects of long-term immobilization on joint pain and osteophyte formation in patients after an extraarticular fracture or ligament injury. We then developed a mouse model of joint immobilization and harvested the knee joint samples at 2, 4, and 8 weeks. We further determined the effects of remobilization on recovery of the osteoarthritis (OA) lesions induced by immobilization in mice. RESULTS We found that the long-term (6 weeks) joint immobilization caused significant joint pain and osteophytes in patients. In mice, 2-week immobilization already induced moderate sensory innervation and increased pain sensitivity and infiltration in synovium without inducing marked osteophyte formation and cartilage loss. Long-term immobilization (4 and 8 weeks) induced more severe sensory innervation and inflammatory infiltration in synovium, massive osteophyte formation on both sides of the femoral condyle, and the edge of the tibial plateau and significant loss of the articular cartilage in mice. Remobilization, which ameliorates normal joint load and activity, restored to certain extent some of the OA lesions and joint function in mice. CONCLUSIONS Joint immobilization caused multiple OA-like lesions in both mice and humans. Joint immobilization induced progressive sensory innervation, synovitis, osteophyte formation, and cartilage loss in mice, which can be partially ameliorated by remobilization.
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Affiliation(s)
- Donghao Gan
- Department of Biochemistry, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Xiaowan Jin
- Department of Biochemistry, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Xiangpeng Wang
- First College of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Chu Tao
- Department of Biochemistry, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Qinnan Yan
- Department of Biochemistry, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Qingyun Jia
- Department of Orthopedics, Linyi People's Hospital, Linyi, China
| | - Shaochuan Huo
- Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Di Chen
- Research Center for Computer-Aided Drug Discovery, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Qing Yao
- Department of Biochemistry, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, School of Medicine, Southern University of Science and Technology, Shenzhen, China.
| | - Guozhi Xiao
- Department of Biochemistry, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, School of Medicine, Southern University of Science and Technology, Shenzhen, China.
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13
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Bastías GF, Sepúlveda S, Bruna S, Contreras M, Hube M, Cuchacovich N, Bergeret JP, Fuentes P. Comparison of complications and reoperations in AO/OTA 43.C3 pilon fractures treated with conventional ORIF versus minimally invasive hexapod ring fixation. Injury 2023; 54 Suppl 6:110884. [PMID: 38143151 DOI: 10.1016/j.injury.2023.110884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/04/2023] [Accepted: 06/04/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Controversy exists regarding the optimal management of AO/OTA 43. C3 pilon fractures. Open reduction and internal fixation (ORIF) is the gold standard treatment, but serious soft tissue and infectious complications have been previously reported. Minimally invasive strategies using hexapod ring fixation (HRF) with supplemental limited internal fixation have been used to reduce the incidence of complications. Previous studies have included heterogeneous types of pilon fractures, with non-comminuted injuries being more likely to be treated with ORIF and complex fractures receiving HRF treatment. To our knowledge, no studies have compared the complications and reoperation rates between ORIF and HRF exclusively for C3 fractures. METHODS Retrospective study comparing 53 patients treated for AO/OTA 43.C3 pilon fracture with ORIF or HRF in a trauma level I center with at least a two-year follow-up. Patients treated between January 2015 and January 2019 received ORIF and those treated between January 2019 and January 2021 received HRF. Complications were divided into two groups: minor (superficial infection and malalignment) and major (non-union, deep infection, and amputation). Reoperations, prevalence of ankle osteoarthritis, and requirement for ankle arthrodesis/total ankle replacement were registered. RESULTS We included 30 and 23 patients in the ORIF and HRF groups, respectively. The overall complication rate was similar in both groups, with 50% and 56,5% of the patients having complications in the ORIF and HRF groups, respectively (p:0,63). Minor complications were significantly more prevalent in the HRF group (p<0,001) whilst the ORIF group had a significantly higher rate of major complications (p<0,01). Superficial infections were highly prevalent in the HRF group (47,8%), as they were related to half-pin or K-wire infections. Deep infection was present only in the ORIF group, with 20% of the patients developing this major complication (p:0,03). Non-union rate, reoperations, ankle osteoarthritis, and the need for arthrodesis or ankle replacement showed no significant differences. CONCLUSION In AO/OTA 43.C3 fractures, HRF is safe and effective, achieving high union rates with a significantly lower rate of major complications compared to ORIF. According to our results, ORIF should be used cautiously for these types of fractures, considering the increased risk of deep infection.
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Affiliation(s)
- Gonzalo F Bastías
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Santiago, Chile; Centro de Excelencia en Reconstrucción Ósea, Santiago, Chile.
| | - Sebastián Sepúlveda
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital de Puerto Montt; Clínica Andes Salud Puerto Montt, Puerto Montt, Chile
| | - Sergio Bruna
- Department of Orthopedic Surgery, Hospital del Trabajador, Santiago, Chile
| | - Martin Contreras
- Department of Orthopedic Surgery, Hospital del Trabajador, Santiago, Chile
| | - Maximiliano Hube
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Santiago, Chile; Centro de Excelencia en Reconstrucción Ósea, Santiago, Chile
| | - Natalio Cuchacovich
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Santiago, Chile; Centro de Excelencia en Reconstrucción Ósea, Santiago, Chile
| | - Juan Pedro Bergeret
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Santiago, Chile
| | - Patricio Fuentes
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Santiago, Chile; Centro de Excelencia en Reconstrucción Ósea, Santiago, Chile
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Sun C, Zhang W, Liang Y, Wang J. Application of 3D-printing combined with virtual surgery in plate pre-bent of a pilon fracture. Asian J Surg 2023; 46:4641-4642. [PMID: 37295987 DOI: 10.1016/j.asjsur.2023.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023] Open
Affiliation(s)
- Chenhao Sun
- Clinical Medical College of Yangzhou University, Yangzhou University, Yangzhou, 225001, China; Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Wendong Zhang
- Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Yuan Liang
- Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, 225001, China.
| | - Jingcheng Wang
- Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, 225001, China.
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15
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Cursaru A, Popa M, Lupu A, Iordache S, Costache M, Cretu B, Serban B, Cirstoiu C. An Examination of Personalized Approaches in the Management of Ankle Fractures: A Thorough Evaluation of Soft Tissue Factors, Treatment Methods, and Patient Adherence. Cureus 2023; 15:e45507. [PMID: 37868385 PMCID: PMC10585051 DOI: 10.7759/cureus.45507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
This study offers a thorough analysis of tibial pilon fractures, accounting for patient compliance, diverse treatment options, and soft tissue implications. The article discusses varied treatment pathways, ranging from single-stage interventions to two-stage methods for open fractures by presenting seven clinical cases. The emphasis is on the intricate interplay of trauma intensity, bone damage, and adjacent soft tissue in dictating treatment plans and patient outcomes. The challenges posed by non-compliant patients rejecting advised treatments are underscored, illuminating the inherent risks. Drawing from varied patient demographics, comorbidities, and fracture types, a comprehensive guide for clinicians emerges. The findings underscore the importance of a tailored, patient-centric approach, considering the multifaceted nature of ankle fractures, local soft tissue health, patient's overall well-being, and their adherence to the proposed treatment regimen.
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Affiliation(s)
- Adrian Cursaru
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Mihnea Popa
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Alexandru Lupu
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Sergiu Iordache
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Mihai Costache
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Cretu
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Serban
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
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16
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Murawski CD, Mittwede PN, Wawrose RA, Belayneh R, Tarkin IS. Management of High-Energy Tibial Pilon Fractures. J Bone Joint Surg Am 2023; 105:1123-1137. [PMID: 37235679 DOI: 10.2106/jbjs.21.01377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
➤ 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.
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Affiliation(s)
- Christopher D Murawski
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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17
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Gao Y, Zhu H, Guo Y, Yu X. Early Reduction of the Posterior Column: A Surgical Technique in AO/OTA C3 Tibial Pilon Fractures. J Pers Med 2023; 13:jpm13030551. [PMID: 36983732 PMCID: PMC10051139 DOI: 10.3390/jpm13030551] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Staged treatment for pilon fractures is widely accepted. It remains to be discussed how to reduce and fix posterior column fractures while avoiding clinical complications. We provided a staged treatment protocol with detailed surgical techniques for closed AO Foundation/Orthopaedic Trauma Association (AO/OTA) C3 tibial pilon fractures with fibular fractures. In the first stage, the internal fixation of the fibula and distal tibial posterior column is accompanied by an external fixator. After swelling, the medial and anterior columns were fixed via the posteromedial approach in the second stage. We advocate early reduction and fixation of the posterior column and lateral column. The right timing of surgery can ensure well-reduced articular surface and alignment while minimizing soft tissue complications.
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Affiliation(s)
- Yanchun Gao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Hongyi Zhu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Yanjie Guo
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
| | - Xingang Yu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
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18
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Stamatos NJ, Ostrowski TJ, Mori BV, Fiscella K, Anoushiravani AA, Rosenbaum A. Team Approach: Perioperative Management of Pilon Fractures. JBJS Rev 2023; 11:01874474-202303000-00002. [PMID: 36913508 DOI: 10.2106/jbjs.rvw.22.00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
» Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse. » A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes. » The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.
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Affiliation(s)
| | - Tyler J Ostrowski
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | | | - Kimberly Fiscella
- Department of Surgery, Division of Plastic Surgery, Albany Medical Center, Albany, New York
| | | | - Andrew Rosenbaum
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
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19
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Piña-Rivas A, Mut-Pons R, Llopis E. Presurgical Perspective and Postsurgical Evaluation of Tibial Pilon Fractures. Semin Musculoskelet Radiol 2022; 26:623-634. [PMID: 36791732 DOI: 10.1055/s-0042-1760122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Tibial pilon fractures represent only a small percentage of all fractures of the lower limb. But they are a feared entity, both for the interpreting radiologist and the treating surgeon and, ultimately, for the patient because they involve the weight-bearing area of the joint and often have associated soft tissue injury. These factors make them technically challenging, with poor clinical and functional results in many patients, even when a perfect joint reduction is achieved. Presurgical evaluation with computed tomography and individualized staged management is critical for the prognosis, a definitive treatment strategy, and the prevention of future complications.
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Affiliation(s)
| | - Raul Mut-Pons
- Department of Radiology, Hospital de La Ribera, Valencia, Spain
| | - Eva Llopis
- Department of Radiology, Hospital de La Ribera, Valencia, Spain
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20
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Hong CC, Saha S, Tan SHS, Tan KJ, Murphy DP, Pearce CJ. Should the location of distal tibial plating be influenced by the varus or valgus fracture pattern of tibial pilon fracture? Arch Orthop Trauma Surg 2022; 142:2999-3007. [PMID: 33864133 DOI: 10.1007/s00402-021-03901-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Operative treatment of tibial pilon fracture is challenging. There is a lack of consensus and only one clinical study on the optimal location of distal tibial plating for fixation of pilon fractures based on varus or valgus fracture patterns. We hypothesize that complications rates, specifically mechanical complications, are not influenced by the location of the tibial plating in the fixation of pilon fractures with respect to varus or valgus fracture patterns. MATERIALS AND METHODS Sixty-nine patients who had single plating for tibial pilon from 2007 to 2017 were recruited. They were divided into two groups, transverse fibular fracture (varus fracture pattern) and comminuted fibular fracture (valgus fracture pattern). Our primary outcome measure was any mechanical complications as a result of the location of plating (medial vs lateral) on varus or valgus fracture patterns. RESULTS There were 38 (55.1%) patients with varus fracture pattern and 31 (44.9%) patients with valgus fracture pattern tibial pilon fractures. In the varus fracture pattern group, mechanical complications were not significantly different between the two plating locations (27.3 vs 33.3%, p > 0.05). Notably, there were more fibula fixations performed in patients with medial plating (74.1 vs 45.5%, p = 0.092) when compared those with lateral plating in the varus fracture pattern group. There were also no statistically significant differences found although 10 (40%) out of 25 patients had mechanical complications in the medial plating group compared to 1 (16.7%) out of 6 patients with lateral plating (p = 0.383) in the valgus fracture pattern group. CONCLUSION There were no differences in mechanical complications for medial vs lateral plating in tibial pilon fracture based on varus or valgus deforming forces. As much as we should consider the fracture patterns and deforming forces when deciding on plating location, other factors such as careful soft tissue management and fragment-specific fixation should be prioritized.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Soura Saha
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Si Heng Sharon Tan
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Ken Jin Tan
- OrthoSports-Clinic for Orthopedic Surgery and Sports Medicine, Mt Elizabeth Novena Specialist Centre, Singapore, Singapore
| | - Diarmuid Paul Murphy
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Christopher Jon Pearce
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore
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21
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Huang CW, Wu WT, Yu TC, Chen IH, Wang JH, Yeh KT. Retrograde Intramedullary Kirschner Wire Fixation as an Alternative for Treating Distal Fibular Shaft Fractures Combined with Distal Tibial Pilon Fractures. J Pers Med 2022; 12:jpm12071124. [PMID: 35887621 PMCID: PMC9315716 DOI: 10.3390/jpm12071124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
Treatment or management techniques for pilon fractures are associated with high complication rates and poor outcomes. No consensus exists regarding the optimal surgical option for pilon fractures, especially for pilon fractures combined with distal fibular fractures. Accordingly, we explored the use of fibular fixation for treating pilon fractures involving distal fibular shaft fractures. We hypothesized that retrograde intramedullary Kirschner wire (K-wire) fixation is a suitable alternative technique for distal fibular fixation. We retrospectively reviewed the data of 156 patients who underwent surgery for pilon fractures at our hospital from May 2013 to May 2021. The radiographic and functional outcomes were comparable between the fibular intramedullary nailing (Group A; n = 80) and the fibular plating (Group B; n = 76) groups. Groups A and B differed significantly in total hospitalization time (11.4 vs. 18.2 days, p = 0.024), length of postoperative admission (6.8 vs. 11.4 days, p = 0.012), and total admission cost (USD 3624 vs. USD 6145, p = 0.004). We also noted that poor Olerud and Molander ankle scores were significantly associated with age (p = 0.008), smoking (p = 0.012), and preoperative admission length (p = 0.018). Retrograde intramedullary K-wire fixation produced a comparable 12-month functional outcome to plate fixation for distal fibular shaft fractures, rendering it a viable alternative method based on soft tissue condition.
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Affiliation(s)
- Cheng-Wei Huang
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan; (C.-W.H.); (W.-T.W.); (T.-C.Y.); (I.-H.C.)
| | - Wen-Tien Wu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan; (C.-W.H.); (W.-T.W.); (T.-C.Y.); (I.-H.C.)
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Tsai-Chiu Yu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan; (C.-W.H.); (W.-T.W.); (T.-C.Y.); (I.-H.C.)
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Ing-Ho Chen
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan; (C.-W.H.); (W.-T.W.); (T.-C.Y.); (I.-H.C.)
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan;
| | - Kuang-Ting Yeh
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970473, Taiwan; (C.-W.H.); (W.-T.W.); (T.-C.Y.); (I.-H.C.)
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
- Correspondence: ; Tel.: +886-3-8561825-14713
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22
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Effect Evaluation of Perioperative Fast-Track Surgery Nursing for Tibial Fracture Patients with Computerized Tomography Images under Intelligent Algorithm. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2629868. [PMID: 35845737 PMCID: PMC9249477 DOI: 10.1155/2022/2629868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/23/2022]
Abstract
This study aimed to study the application value of computerized tomography (CT) images under the graph cut algorithm in the effect evaluation of perioperative fast-track surgery (FTS) nursing in tibial fracture. In this study, 80 tibial fracture patients in the perioperative period were selected as the research objects. These objects were randomly divided into two groups according to the examination method. In group A, routine CT examination was performed; in group B, CT examination under the graph cut algorithm was applied. The imaging results showed that there were still 16 cases with collapse of group A and 34 cases with collapse of group B; the difference was statistically significant (P < 0.05). As for 16 cases with collapse in both groups, the average collapse shown in group A was about 2.79 ± 1.31 mm, while that in group B was 5.51 ± 1.88 mm, with a statistically significant difference (P < 0.05). The average broadening in the images of group A was 3.17 ± 1.41 mm and that of group B was 5.72 ± 1.83 mm, suggesting that the difference was statistically significant (P < 0.05). The broadening distance of 3-4 mm was mainly shown in the images of group A and that of 5-8 mm was shown in group B, with a statistical difference (P < 0.05). In terms of the total score, there were 26, 44, 8, and 2 cases that were assessed as excellent, good, common, and bad, respectively, in group A, while 44 cases were assessed as good and 36 cases were assessed as common in group B, which were significantly different (P < 0.05). In summary, the graph cut algorithm not only had a good segmentation effect and segmentation efficiency but also could improve the evaluation of CT images for perioperative FTS nursing effect in patients with tibial fracture.
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Utomo P, Idulhaq M, Abdulhamid M. A Current Concepts Update in Pilon Fracture Management. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A review of the existing literature, related to treatment options and management principles of pilon fractures, was performed, and its results are presented. Pilon fractures have a very diverse pattern, but there are general characteristics to help diagnose and plan therapy. The choice of therapy is highly dependent on the surrounding soft-tissue environment. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopedic surgeon can face. This review focuses on the general aspects of the pilon fracture management as well as its complications and possible solutions.
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Abdelgaid SM, Hatata DMZ, Elshafey AE, Alsharkawy WM. Minimally Invasive Reduction and Fixation Techniques of Pilon Fractures Based on the Preoperative CT Findings. J Foot Ankle Surg 2022; 61:590-603. [PMID: 34810084 DOI: 10.1053/j.jfas.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 05/25/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
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.
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Hong CC, Tan SHS, Saha S, Pearce CJ. Morbidities and prognostic factors after tibial pilon fracture: impact on patients. Arch Orthop Trauma Surg 2022; 143:2855-2862. [PMID: 35522317 DOI: 10.1007/s00402-022-04456-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/15/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION This study aims primarily to characterize the sequelae and morbidity associated with tibial pilon injuries from the patients' perspectives in terms of multiple surgical interventions, duration of hospital stay, downtime from work, loss of productivity and impact on patients' lives. The secondary aim is to review the associated risk factors for these morbidities. MATERIALS AND METHODS All patients with surgically treated tibial pilon fractures from 1st July 2007 to 30th June 2017 were included. The morbidities reviewed focused on delay to surgery, numbers of surgeries, limb amputation, length of stay (LOS), readmissions, duration of medical leave (ML), follow-up and number of outpatient visits. RESULTS There were 102 patients included in the review and up to 70% of them had an average 7 days delay to definitive surgery. They also required an average hospital LOS of at least 2 weeks extending up to 3 more weeks if soft tissue reconstruction was necessitated. Up to a third of patients were readmitted with 15% of them needing further treatment. These patients required a notable period of downtime from work as shown in the long ML (mean 152.6 days [S.D. = 110.7]). Multiple conditional regression models showed AO/OTA classification (B and C) and open fracture as independent predictors of delay to surgery. Predictors for increased LOS were high velocity mechanism of injury at 4 days longer and patients who needed soft tissue reconstruction at 21 days longer. In terms of downtime from work, only work injury has been identified as an independent predictor of ML at 88.5 days longer. CONCLUSION Tibial pilon fractures leads to significant morbidities with profound negative impact on patients' lives in terms of multiple surgical interventions required, prolonged hospital stay, need for readmissions and prolonged downtime from work. These morbidities from patients' perspective should be emphasized to patients and employers to manage their expectations and potential limitations.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Si Heng Sharon Tan
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore
| | - Soura Saha
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore
| | - Christopher Jon Pearce
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore
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Zitsch BP, James CR, Crist BD, Stoker AM, Della Rocca GJ, Cook JL. A prospective randomized double-blind clinical trial to assess the effects of leukocyte-reduced platelet-rich plasma on pro-inflammatory, degradative, and anabolic biomarkers after closed pilon fractures. J Orthop Res 2022; 40:925-932. [PMID: 34185333 DOI: 10.1002/jor.25123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 01/19/2021] [Accepted: 06/09/2021] [Indexed: 02/04/2023]
Abstract
Posttraumatic osteoarthritis (PTOA) significantly affects patients with pilon fractures even after adequate anatomical reduction, and treatment strategies targeting the biologic mediators of PTOA are needed. This study was designed to determine the effects of intra-articular injection of platelet-rich plasma (PRP) on synovial fluid (SF) biomarkers for patients undergoing open reduction and internal fixation (ORIF) of pilon fractures. Patients undergoing staged management of pilon fractures were enrolled in a prospective, double-blinded, randomized, and placebo-controlled clinical trial to determine the effects of a single intra-articular injection of leukocyte-reduced PRP on SF biomarkers. Arthrocentesis of the injured and uninjured ankles was performed at the time of external skeletal fixation (ESF) and ORIF. Patients were randomized to receive either autogenous leukocyte-reduced PRP or saline (control) via intra-articular injection into the injured ankle at the time of ESF. SF biomarker concentrations were compared-uninjured, injured pretreatment, and saline-injected or PRP-injected. Eleven patients (PRP, n = 5; saline, n = 6) completed the study. Twenty-one uninjured, and 11 injured pretreatment, five PRP-treated, and six saline-treated SF samples were analyzed. PRP-treated SF contained significantly higher levels of PDGF-AA (p = 0.046) and significantly lower levels of MMP-3 (p = 0.042), MMP-9 (p = 0.009), IL-1β (p = 0.049), IL-6 (p < 0.01), IL-8 (p = 0.048), and PGE2 (p < 0.04). This study provided mechanistic data to suggest that a single intraarticular injection of leukocyte-reduced PRP is associated with anti-inflammatory, anti-degradative, and anabolic responses compared with saline control. These findings provide the impetus for investigating long-term clinical outcomes after PRP injection as an orthobiologic adjunct to ORIF for mitigating the incidence and severity of PTOA after pilon fractures.
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Affiliation(s)
| | - Christopher R James
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Aaron M Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | | | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
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Abstract
Management of posttraumatic ankle arthritis due to tibial plafond fracture is technically demanding. The distal tibial plafond-plasty could be an alternative to preserve the ankle joint for young patients with limited ankle arthritis. The surgical principles are to realign the mechanical axis, reconstruct the articular surface of the distal tibial plafond, and achieve a congruent and stable ankle joint. In addition to the anteroposterior view of the ankle joint, the lateral view was also paramount for surgeons to fully evaluate the reduction quality. The revision procedures are as follows: osteotomy for exposure, articular surface reconstruction, bone grafting, and osteotomy fixation.
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Affiliation(s)
- Xingchen Li
- Department of Orthopaedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No. 999, Xiwang Road, Jiading District, Shanghai, China
| | - Xiangyang Xu
- Department of Orthopaedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No. 999, Xiwang Road, Jiading District, Shanghai, China.
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28
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Chen Y, Li Y, Ouyang X, Zhang H. Ankle joint salvage and reconstruction by limited ORIF combined with an Ilizarov external fixator for complex open tibial pilon fractures (AO 43-C3.3) with segmental bone defects. BMC Musculoskelet Disord 2022; 23:97. [PMID: 35090407 PMCID: PMC8800251 DOI: 10.1186/s12891-022-05060-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/24/2022] [Indexed: 11/28/2022] Open
Abstract
Background Open pilon fractures combined with sizeable segmental bone defects are rare, difficult to treat, and often result in the loss of ankle joint function. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures and sizeable segmental bone defects treated by limited ORIF combined with an Ilizarov external fixator. Methods We conducted a retrospective analysis of open pilon fractures with sizeable segmental bone defects treated by limited ORIF combined with the Ilizarov external fixator strategy between July 2014 and August 2019. All patients were included for assessments of fracture healing and infection rates. Ankle functional outcomes were assessed in all patients according to the Paley criteria and American Orthopedic Foot and Ankle Society Score (AOFAS) at least 24 months post-injury. Results All patients were followed up for a mean of 41.09 months. The mean bone defect size was 5.64 ± 1.21 cm. The average EFI and BTI were 1.56 ± 0.28 months/cm and 11.12 ± 0.74 days/cm, respectively. According to the Paley evaluation system, the success rate of ankle joint reconstruction was 64% (7/11). The mean score based on the AOFAS functional assessment was 77.73 ± 8.87. Five patients showed posttraumatic arthritis, one of whom required ankle arthrodesis. Three patients developed pin site infections, and one patient developed a deep infection after bone grafting. Conclusion The strategy of limited ORIF combined with an Ilizarov external fixator can restore ankle function in most patients with complex open tibial pilon fractures. Ankle stiffness, pin tract infection, and traumatic arthritis were the most common complications associated with this therapy.
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Luo P, Zhang Y, Wang X, Wang J, Chen H, Cai L. A nomogram for predicting skin necrosis risk after open reduction and internal fixation for tibia fractures. Int Wound J 2022; 19:1551-1560. [PMID: 35037403 PMCID: PMC9493222 DOI: 10.1111/iwj.13754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/17/2021] [Accepted: 01/06/2022] [Indexed: 11/28/2022] Open
Abstract
The purpose of our study was to determine the risk factors for skin necrosis after open reduction and internal fixation (ORIF) for tibia fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from tibia fractures and had been surgically treated by ORIF in our institution between August 2015 and October 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of skin necrosis, and a nomogram model was constructed to predict the risk of skin necrosis. The predictive performance and consistency of the model were evaluated by the Hosmer‐Lemeshow (H‐L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.906 (95% confidence interval 0.88~0.94). The H‐L test revealed that the nomogram prediction model had good calibration ability (P = .467). Finally, we found a correlation between skin necrosis and limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) after ORIF for tibia fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high‐risk patients, as interventions could be taken early to reduce the incidence of skin necrosis.
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Affiliation(s)
- Peng Luo
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yingying Zhang
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xingyu Wang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianshun Wang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hua Chen
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Leyi Cai
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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30
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Mair O, Pflüger P, Hoffeld K, Braun KF, Kirchhoff C, Biberthaler P, Crönlein M. Management of Pilon Fractures-Current Concepts. Front Surg 2022; 8:764232. [PMID: 35004835 PMCID: PMC8732374 DOI: 10.3389/fsurg.2021.764232] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/29/2021] [Indexed: 11/23/2022] Open
Abstract
Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.
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Affiliation(s)
- Olivia Mair
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Patrick Pflüger
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kai Hoffeld
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Center for Orthopedic and Trauma Surgery, University Medical Center, Cologne, Germany
| | - Karl F Braun
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Trauma Surgery, Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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31
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Mohanty K, Agarwal R. Trauma. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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Tarkin IS, Murawski CD, Mittwede PN. Temporizing Care of Acute Traumatic Foot and Ankle Injuries. Orthop Clin North Am 2022; 53:95-103. [PMID: 34799027 DOI: 10.1016/j.ocl.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Temporizing care has become a critical part of the treatment armamentarium for select foot and ankle injuries. Indications for performing temporizing care are based on the specific injury pattern, the host, associated injuries, as well as surgeon resources. Foot and ankle injuries are often associated with severe adjacent injury to the soft tissue sleeve. An acute procedure performed through a traumatized soft tissue envelope will often lead to the failure of wound healing and/or infectious complications. Thus, delayed reconstruction of acute foot and ankle injuries is often advisable in these cases.
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Affiliation(s)
- Ivan S Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Suite 1010, Pittsburgh, PA 15213, USA.
| | | | - Peter N Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Shu W, Hu X, Yang X. Comparison Between the Modified External Fixation and Calcaneal Traction in Ruedi-Allgower Type II/III Pilon Fractures. Med Sci Monit 2021; 27:e933385. [PMID: 34276043 PMCID: PMC8299870 DOI: 10.12659/msm.933385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background To compare the effect of modified external fixation and calcaneal traction in a staged management of Ruedi-Allgower type II/III tibial pilon fractures. Material/Methods The data of 62 patients with Ruedi-Allgower type II/III tibial pilon fractures who were treated in Liuzhou People’s hospital from January 2017 to December 2018 were extracted in this retrospective analysis. There were 32 patients in the temporary external fixation (TEF) group and 30 patients in calcaneal traction (CT) group. Outcomes, including the duration of the surgical procedure, pin track infection, degree of limb swelling, time to second-stage operation, postoperative comfort score, and visual analog scale (VAS) score, were compared. Results The effective rate of swelling reduction after treatment was 85% in the TEF group and 60% in the CT group; the average time to the second-stage operation was 8.34±1.29 days in the TEF group and 10.60±2.27 days in the CT group; the postoperative comfort scores were 70.1±3.2 and 61.3±3.5 in the TEF group and CT group, respectively; the postoperative VAS scores at 24 h, 48 h, and 7 days were 7.90±1.06, 4.88±0.83, 2.72±1.14 in TEF group, and 8.50±0.86, 6.27±1.36, 3.57±1.19 in CT group, respectively. There were 1 case of pin tract infection identified in the TEF group and 4 in the CT group. All differences were statistically significant (P<0.05). Conclusions The modified external fixation is more effective than calcaneal traction in treatment of Ruedi-Allgower type II/III tibial pilon fractures in the first-stage of combined management.
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Affiliation(s)
- Wen Shu
- Department of Trauma Orthopedics, Liuzhou People's Hospital, Liuzhou, Guangxi, China (mainland)
| | - Xiaodong Hu
- Department of Trauma Orthopedics, Liuzhou People's Hospital, Liuzhou, Guangxi, China (mainland)
| | - Xiaofan Yang
- Department of Trauma Orthopedics, Liuzhou People's Hospital, Liuzhou, Guangxi, China (mainland)
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34
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Zheng Y, Zhang JD, Shen JM, Chen JJ, Toy L, Huang JF. A Modified 2-Stage Treatment for AO/OTA 43-C1 Pilon Fractures Accompanied by Distal Fibular and Posterior Lip of the Distal Tibia Fracture. J Foot Ankle Surg 2021; 59:972-978. [PMID: 32482581 DOI: 10.1053/j.jfas.2020.03.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 02/08/2023]
Abstract
The management of pilon fractures remains challenging owing to the high-energy axial loading mechanism that produces comminution of the articular surface, displacement of tibia metaphysis, and severe soft tissue injury. How to preserve the vitality of soft tissue and achieve anatomic reduction has become a timely issue. We report and evaluate the effect of a modified staging treatment for AO Foundation/Orthopaedic Trauma Association (AO/OTA) 43C1 pilon fracture accompanied by distal fibular and posterior lip of the distal tibia fracture. We performed a modified 2-stage treatment of type C1 pilon fracture with distal fibular and posterior malleolar fractures. In the first stage, the posterolateral incision was used for simultaneous reduction of fibula and posterior malleolus, and the tibia was fixed with an external fixator. In the second stage, the external fixator was removed, and the medial malleolus and tibia were fixed after the edema of soft tissue had subsided. The following data were collected: Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short Form 36 (SF-36) score, Burwell-Charnley fracture reduction score, and postoperative complications. Twenty-seven patients were monitored for an average of 31.70 ± 7.38 months. The Burwell-Charnley fracture reduction scores had anatomic and fair ratings of 92.59%. SF-36 physical component score was 42.94 ± 12.47 and mental component score was 48.73 ± 9.79. Score data from the multiple scales of FAOS included pain, 88.79 ± 8.59; activities of daily living, 91.89 ± 7.50; quality of life, 90.26 ± 10.52; sports, 87.93 ± 11.64; and symptoms, 85.32 ± 8.65. The AOFAS ankle-hindfoot scores were 87.30 ± 13.45. Complications were reported in 5 patients (18.52%). Our study provides a good alternative to the existing protocol for type C1 pilon fractures with distal fibular and posterior lip of the distal tibia fracture and effectively reduces soft tissue complications.
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Affiliation(s)
- Yang Zheng
- Surgeon, Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jiu-Dan Zhang
- Attending Doctor, Department of Endocrinology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jin-Ming Shen
- Surgeon, Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jun-Jie Chen
- Registrar, Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Lucinda Toy
- Physician, American College of Traditional Chinese Medicine at California Institute of Integral Studies, San Francisco, CA
| | - Jie-Feng Huang
- Associate Registrar, Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China.
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35
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Mehta N, Graham S, Lal N, Wells L, Giotakis N, Nayagam S, Narayan B. Fine wire versus locking plate fixation of type C pilon fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:875-882. [PMID: 34159481 DOI: 10.1007/s00590-021-03048-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The successful treatment of high energy pilon fractures (AO-OTA 43C) can be achieved with a fine wire circular external fixator (CEF) or locking plate construct (ORIF). There is no consensus on whether ORIF or CEF achieves superior outcomes, and both have unique complications. We report early to mid-term outcomes comparing type C pilon fractures treated with ORIF and CEF. METHODS An 8-year retrospective review was performed on all patients who underwent ORIF or CEF for closed 43C fractures in a tertiary orthoplastic centre. Outcomes included unplanned return to theatre prior to union including superficial and deep surgical site infections (SSI), non-union and post-traumatic osteoarthritis (PTOA) needing fusion. RESULTS 76 patients underwent ORIF and 59 patients had CEF, with a mean follow-up of 2 years. 7/76 (9.2%) patients who underwent ORIF had a superficial SSI; 2 patients (2.6%) required a formal debridement for deep SSI; none required a flap. 13/59 patients (22%) had a pin track infection following CEF. With the numbers available, there was no significant difference in rates of unplanned return to theatre before bone healing (ORIF 7/76, 9.2%, CEF 9/59, 15.2%, p = 0.7), rates of mal-union (1.7% CEF, 3.9% ORIF, p = 0.7), deep SSI (p = 0.9), time to union (ORIF: 8.1 months v CEF 10.8 months, p = 0.51), non-union (p = 0.24) and fusion for PTOA (ORIF: 6/76, CEF 2/59, p = 0.46). CONCLUSION With correct patient selection, both ORIF and CEF offer equivalent and favourable early to mid-term outcomes with regard to deep SSI, non-union, mal-union and PTOA. Although statistically insignificant, ORIF with more than 2 plates carries a risk of superficial and deep SSI, whilst CEF is associated with a 22% pin track infection rate. These unique risks must be discussed with the patient as part of a shared decision-making process.
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Affiliation(s)
- Nisarg Mehta
- ST6 in Trauma and Orthopaedics Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, UK.
| | - Simon Graham
- Consultant in Trauma and Orthopaedic Surgery, Wellcome Trust Clinical Research Fellow, Department of Orthopaedic and Trauma Surgery, Liverpool University Teaching Hospital Trust, Lower Lane, Liverpool, L9 7AL, UK
| | - Nikhil Lal
- Academic ST1 in General Surgery, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Lauren Wells
- Foundation Year 2 Trainee, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - Nikolaos Giotakis
- Consultant in Trauma and Orthopaedic Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, UK
| | - Selvadurai Nayagam
- Consultant in Trauma and Orthopaedic Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, UK
| | - Badri Narayan
- Consultant in Trauma and Orthopaedic Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, UK
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Daniels NF, Lim JA, Thahir A, Krkovic M. Open Pilon Fracture Postoperative Outcomes with Definitive Surgical Management Options: A Systematic Review and Meta-analysis. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:272-282. [PMID: 34239954 PMCID: PMC8221448 DOI: 10.22038/abjs.2020.53240.2641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/15/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Different techniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole, very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgical management options can influence postoperative complications, and if this can influence future management protocols. METHODS We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications and functional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD42020184213). The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation, osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was also measured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions. RESULTS The search yielded 309 results and a total of 18 studies consisting of 484 patients were included. All fractures included were open, and consisted of 64 Gustilo-Anderson Type I, 148 Type II, 103 Type IIIa, 90 Type IIIb and 9 Type IIIc. 60 Type III fractures could not be further separated and 12 were ungraded. Both ORIF and Ex-Fix were found to have statistically similar AOFAS scores (P=0.682). For all included studies, the Ex-Fix group had significantly higher rates of superficial infections (P=0.001), non-unions (P=0.001), osteoarthritis (P=0.001) and bone grafting (P=0.001). The meta-analysis found no significant difference in non-union (pooled OR=0.25, 95% CI: 0.03 to 2.24, P=0.44) or deep infection rates (pooled OR=1.35, 95% CI: 0.11 to 16.69, P=0.12) between the ORIF and Ex-fix groups. CONCLUSION Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to have a significantly higher risk of postoperative complications which must be considered by surgeons when choosing surgical management options. Further research, ideally in a randomised control trial format, is required to definitively demonstrate ORIF superiority in the management of open pilon fractures.
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Affiliation(s)
- Natasha Faye Daniels
- Faculty of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Jiang An Lim
- Faculty of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Cambridge University Hospital, Addenbrookes Major Trauma Centre, Cambridge, UK
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Cambridge University Hospital, Addenbrookes Major Trauma Centre, Cambridge, UK
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Wei D, Xu Y, Xiang F, Ye J. Secondary below-knee amputation following open reduction and internal fixation of a closed pilon fracture: A case report and algorithm for management. Medicine (Baltimore) 2021; 100:e24791. [PMID: 33607836 PMCID: PMC7899896 DOI: 10.1097/md.0000000000024791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/29/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Despite significant advances in surgical techniques and implants, the clinical outcome of high-energy pilon fractures remains unsatisfactory, which continues to represent numerous challenges for orthopedic trauma surgeons. PATIENT CONCERNS A 62-year-old man injured his right ankle after falling from a 3 m high place. There were no open wounds or other complications. DIAGNOSES According to the X-ray and CT scans, the patient was diagnosed with pilon fracture (type AO-43-C2) and lateral malleolus fracture of the right limb. INTERVENTIONS The patient was initially treated with calcaneal traction upon admission to a primary hospital. Five days after the injury, the patient underwent open reduction and internal fixation (ORIF) of the fracture and vacuum sealing drainage (VSD) for wound closure. OUTCOMES The patient presented to our hospital on the 9th day after the first ORIF operation because of critical ischemia of the affected foot and distal lower leg. Blood circulation did not improve after a series of salvage treatments, and below-knee amputation was ultimately performed. LESSONS This is a rare case of complete ischemic necrosis following ORIF surgery of a closed pilon fracture due to iatrogenic damage. Standardized treatment that strictly follows the guidelines, instructions, or expert consensus should be promoted in this kind of complicated pilon fracture.
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Affiliation(s)
- Daiqing Wei
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, China
| | - Yangbo Xu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, China
| | - Feifan Xiang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, China
| | - Junwu Ye
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University
- Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, China
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Liu T, Cheng Y, Qu W. A fibular notch approach for the treatment of ankle fractures involving the distal tibial plafond. J Orthop Surg Res 2021; 16:120. [PMID: 33557899 PMCID: PMC7869212 DOI: 10.1186/s13018-021-02270-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/28/2021] [Indexed: 11/22/2022] Open
Abstract
Background Although efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here, we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes. Methods Twenty-two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment. Results All surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3 ± 3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last follow-up. Conclusions The fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.
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Affiliation(s)
- Tong Liu
- Department of Orthopaedics, Yantaishan Hospital, NO.91 Jiefang Road, Zhifu District, Yantai, 264001, Shandong Province, China
| | - Yiheng Cheng
- Department of Orthopaedics, Yantaishan Hospital, NO.91 Jiefang Road, Zhifu District, Yantai, 264001, Shandong Province, China
| | - Wenqing Qu
- Department of Orthopaedics, Yantaishan Hospital, NO.91 Jiefang Road, Zhifu District, Yantai, 264001, Shandong Province, China.
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Mishra A, Das S, Prasad H, Kumar A, Agrawal P. An Unexpected Intra-operative Encounter of Anterior Tibial Vessels Entrapment in the Fracture of Tibial Pilon: A Case Report and Literature Review. Indian J Orthop 2020; 55:775-779. [PMID: 33995887 PMCID: PMC8081804 DOI: 10.1007/s43465-020-00305-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/26/2020] [Indexed: 02/04/2023]
Abstract
We present a rare case of a comminuted tibial pilon fracture with entrapment of anterior tibial vessels in fracture site, which was unexpectedly discovered intra-operatively. Following safe extrication of vessels and fracture fixation through minimally invasive approach, the patient recovered uneventfully. Phenomenon of anterior neurovascular entrapment should be kept in mind while dealing with high-energy tibial pilon fractures. Astute clinical examination, judicious use of imaging modality, and strict intra-operative vigilance are key to successful outcome.
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Affiliation(s)
- Abhinav Mishra
- Orthopaedics, Rajendra Institute of Medical Sciences (RIMS), Bariatu, Ranchi, 834009 India
| | - Saubhik Das
- Orthopaedics, Rajendra Institute of Medical Sciences (RIMS), Bariatu, Ranchi, 834009 India
| | - Hariom Prasad
- Orthopaedics, Rajendra Institute of Medical Sciences (RIMS), Bariatu, Ranchi, 834009 India
| | - Arvind Kumar
- Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Prabhat Agrawal
- Orthopaedics, All India Institute of Medical Sciences (AIIMS), Patna, India
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Yang JZ, Zhu WB, Li LB, Dong QR. Early complications of preoperative external traction fixation in the staged treatment of tibial fractures: A series of 402 cases. World J Clin Cases 2020; 8:4743-4752. [PMID: 33195642 PMCID: PMC7642547 DOI: 10.12998/wjcc.v8.i20.4743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Different external skeletal fixators have been widely used in preoperative traction of high-energy tibial fractures prior to a definitive surgical treatment. However, the early complications associated with this staged treatment for traction and soft tissue injury recovery have rarely been discussed.
AIM To analyze the early complications associated with preoperative external traction fixation in the staged treatment of tibial fractures.
METHODS A total of 402 patients with high-energy tibial fractures treated using preoperative external traction fixation at a Level 1 trauma center from 2014 to 2018 were enrolled in this retrospective study. Data regarding the demographic information, Tscherne soft tissue injury, fracture site, entry point placement, and duration of traction were recorded. Procedure-related complications such as movement and sensation disorder, vessel injury, discharge, infection, loosening, and iatrogenic fractures were analyzed.
RESULTS The mean patient age was 42.5 (18-71) years, and the mean duration of traction was 7.5 (0-26) d. In total, 19 (4.7%) patients presented with procedure-related complications, including technique-associated complications in 6 patients and nursing-associated complications in 13. Differences in the incidence of complications with respect to sex, affected side, soft tissue injury classification, and fracture sites were not observed. However, the number of complications due to hammer insertion was significantly reduced than those due to drill insertions (2.9% vs 7.4%).
CONCLUSION We found a low incidence of early complications related to the fixation. Furthermore, the complications were not significantly associated with the severity of the soft tissue injury and fracture site. Although relatively rough and more likely to cause pain, the number of complications associated with hammer insertion was significantly smaller than that of complications associated with drill insertion.
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Affiliation(s)
- Jia-Zhao Yang
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
- Department of Traumatic Orthopedics, The First Affiliated Hospital of USTC, Hefei 230000, Anhui Province, China
| | - Wan-Bo Zhu
- Department of Traumatic Orthopedics, Affiliated Anhui Provincial Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Liu-Bing Li
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Qi-Rong Dong
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
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Li D, Li JJ, Zhu Y, Hou F, Li Y, Zhao B, Wang B. Large autologous ilium with periosteum for tibiotalar joint reconstruction in Rüedi-Allgöwer III or AO/OTA type C3 pilon fractures: a pilot study. BMC Musculoskelet Disord 2020; 21:632. [PMID: 32977786 PMCID: PMC7519531 DOI: 10.1186/s12891-020-03659-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Management of Rüedi-Allgöwer III or AO/OTA type C3 pilon fracture presents numerous challenges to the orthopaedic surgeon. A joint preservation technique using a large autologous ilium with periosteum in combination with internal implant fixation was reported to improve the outcome of reconstruction. METHODS Twenty-five patients according to Tscherne/Oestern FxCO-I closed fracture and FxOI open fractures classification after Rüedi-Allgöwer III or AO/OTA type C3 pilon fracture received a large autologous ilium with periosteum for tibiotalar joint reconstruction and open reduction and internal fixation (ORIF), between March 2015 and September 2018. The visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Burwell and Charnley criteria were used for outcome analysis. RESULTS Twenty patients with an average age of 45.2 years were followed for an average of 18.3 months. The VAS and AOFAS scores, and Burwell and Charnley ratings were recorded at the last follow-up after reconstructive surgery. Two patients developed redness and swelling at the wound site, but recovered after local care and dressing changes. No patient displayed deep surgical site infection, donor site complication, non-union or local complication during the final follow-up. The average bone union time was 18.3 months (range 3-36). CONCLUSIONS Large autologous ilium with periosteum in combination with ORIF can be performed for tibiotalar joint reconstruction. This experimental procedure reduces the risk of post-operative complications following articular reconstruction for Rüedi-Allgöwer III or AO/OTA type C3 pilon fractures in short follow-up. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Dong Li
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Yuanyuan Zhu
- Department of Pharmacy, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Fushan Hou
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yuan Li
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Bin Zhao
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, China.
| | - Bin Wang
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, China.
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Prabhakar G, Bullock TS, Martin CW, Ryan JC, Cabot JH, Makhani AA, Griffin LP, Shah K, Zelle BA. Skin closure with surgical staples in ankle fractures: a safe and reliable method. INTERNATIONAL ORTHOPAEDICS 2020; 45:275-280. [PMID: 32951119 DOI: 10.1007/s00264-020-04816-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/15/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures. METHODS Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication. RESULTS The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups. CONCLUSION The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.
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Affiliation(s)
- Gautham Prabhakar
- Department of Orthopaedics, UT Health San Antonio, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229, USA
| | - Travis S Bullock
- Long School of Medicine, UT Health San Antonio, San Antonio, TX, 78229, USA
| | - Case W Martin
- Department of Orthopaedics, UT Health San Antonio, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229, USA
| | - James C Ryan
- Department of Orthopaedics, UT Health San Antonio, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229, USA
| | - John H Cabot
- Long School of Medicine, UT Health San Antonio, San Antonio, TX, 78229, USA
| | - Ahmed A Makhani
- Long School of Medicine, UT Health San Antonio, San Antonio, TX, 78229, USA
| | - Leah P Griffin
- Medical Solutions Division, 3M Health Care, San Antonio, TX, 78249, USA
| | - Kush Shah
- Department of Orthopaedics, UT Health San Antonio, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229, USA
| | - Boris A Zelle
- Department of Orthopaedics, UT Health San Antonio, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229, USA.
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Mitkovic MM, Bumbasirevic M, Milenkovic S, Gajdobranski D, Bumbasirevic V, Mitkovic MB. Influence of coronavirus disease 2019 pandemic state of emergency in orthopaedic fracture surgical treatment. INTERNATIONAL ORTHOPAEDICS 2020; 45:815-820. [PMID: 32728928 PMCID: PMC7389160 DOI: 10.1007/s00264-020-04750-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/23/2020] [Indexed: 12/23/2022]
Abstract
Purpose After the appearance of first COVID-19 cases in Serbia, state of emergency was declared on 15 March 2020 and lasted for 54 days. The aim of this report is to compare orthopaedic fracture frequencies in this period, when the walk was limited at the home mostly, with those during the same part in the previous year with regular state, thus to examine staying at home as a factor influencing the frequency of different fracture types. Methods There were 86 patients during the state of emergency in year 2020 and 106 patients during the same part of year 2019 with a regular state, having orthopaedic trauma surgery. Number of fractures, gender distribution, and age of patients have been compared between these periods. Results Total number of fractures decreased for about 19% during the state of emergency. There was nonsignificant difference in fracture frequency for all skeletal areas (p > 0.05), except for distal femoral fractures which occurred more often during the state of emergency (p < 0.05). Female ratio was higher during state of emergency than in regular state for femoral neck fractures. Conclusion Restricted going outside the home for 54 days has the influence in total number of fractures and gender distribution in femoral neck fractures. The method of external fixation used could be assumed as a reducing factor of intraoperative virus pandemic propagation among medical staff.
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Affiliation(s)
- Milan M Mitkovic
- Clinic for Orthopaedics and Traumatology, Clinical Center Nis, Nis, Serbia.
- Faculty of Medicine, University of Nis, Nis, Serbia.
| | - Marko Bumbasirevic
- Clinic for Orthopaedics and Traumatology, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sasa Milenkovic
- Clinic for Orthopaedics and Traumatology, Clinical Center Nis, Nis, Serbia
- Faculty of Medicine, University of Nis, Nis, Serbia
| | | | | | - Milorad B Mitkovic
- Clinic for Orthopaedics and Traumatology, Clinical Center Nis, Nis, Serbia
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Abstract
Malunion of ankle and pilon fractures has significant detrimental effect on function and development of post-trauma osteoarthritis. Unfortunately, the incidence of malunion has been reported to be increasing. It is important to assess the ankle for congruency, because this determines the level where correction will occur. A plethora of techniques are available, with low-level evidence supporting each, and therefore it is important that the treating surgeon is fully prepared and comfortable in the techniques they are to use. Supplementary procedures are common and should be expected. This article provides a review of current methods of treatment and their outcomes.
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Wu D, Peng C, Ren G, Yuan B, Liu H. Novel anterior curved incision combined with MIPO for Pilon fracture treatment. BMC Musculoskelet Disord 2020; 21:176. [PMID: 32188447 PMCID: PMC7081689 DOI: 10.1186/s12891-020-03207-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/11/2020] [Indexed: 12/26/2022] Open
Abstract
Backgrounds Poor prognosis was reported for complex Pilon fractures involving severe soft tissue damage. It is therefore useful to explore the evolution of different treatment strategies in an effort to reconstruct the axial alignment and articular surface, while minimizing additional damage to the surrounding soft tissues. Methods Seventeen patients with Pilon fractures were enrolled in this retrospective study from December 2009 to October 2014. The injuries were graded according to AO Classification and the Gustilo-Anderson system. Patients were treated with minimally invasive plate osteosynthesis (MIPO) combined with curved incision on the anterior area of ankle. The ankle function and radiological outcome were assessed by the modified Mazur ankle score and Burwell-Charnley criteria, respectively. Visual analogue score (VAS) score was used to assess the degree of patient’s ankle pain, and related complications were also recorded. Results The mean time for fracture healing was 3.6 months (range: 3–6 months). According to Mazur’s criteria, surgical treatment achieved good or excellent outcome in 15 (88.2%) cases, and the average VAS score was 1.19 ± 0.52. On the basis of Burwell-Charnley score, 12 (70.5%) patients achieved anatomic recovery, 4 (23.5%) obtained good reduction, and only 1 (5.9%) patient was diagnosed with valgus deformity. Additionally, 1 (5.9%) patient developed a superficial infection around incision, and 2 (11.8%) experienced superficial peroneal nerve damage. In addition, 2 (11.8%) patients showed radiographic evidence of existing ankle osteoarthritis at the final follow-up. Conclusions This retrospective study is the first to assess the application of a curved incision on the anterior area of ankle with MIPO for the treatment of Pilon fractures, which achieves high functional recovery with a low complication rate. However, large randomized controlled trials comparing different approaches and fixation methods are still needed to conclusively identify the optimal treatment protocol.
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Affiliation(s)
- Dankai Wu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, 130041, China
| | - Chuangang Peng
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, 130041, China
| | - Guangkai Ren
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, 130041, China
| | - Baoming Yuan
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, 130041, China
| | - He Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, 130041, China. .,Orthopaedic Research Institute of Jilin Province, Changchun, 130041, People's Republic of China.
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Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation. J Orthop Trauma 2019; 33:601-607. [PMID: 31356446 DOI: 10.1097/bot.0000000000001583] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP). DESIGN Retrospective observational cohort study. SETTING Level I academic trauma center. PATIENTS Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring. INTERVENTION Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87). MAIN OUTCOME MEASURE Incidence of postoperative surgical site infections of the pelvic space. RESULTS Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures. CONCLUSIONS These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Chen Y, Zhang H, Liu X, Li Y, Qin B, Ren Y, Wu S, Huang F. [Modified staging strategy in treatment of type C3 Pilon fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1358-1362. [PMID: 31650748 PMCID: PMC8337458 DOI: 10.7507/1002-1892.201903100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/11/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the safety, feasibility, and effectiveness of modified staging strategy in treatment of type C3 Pilon fractures. METHODS The clinical data of 23 patients with type C3 Pilon fractures treated with modified staging strategy between January 2012 and January 2018 was retrospectively analyzed. There were 14 males and 9 females with an average age of 47.9 years (range, 22-61 years). Twenty-three cases were high-energy injuries, including 11 cases of traffic accidents and 12 cases of falling from height. One case was an open fracture of Gustilo type ⅢA with no obvious sign of infection on the wound after early treatment. The remaining patients were closed fractures. The time from injury to admission was 3-40 hours with an average of 16.4 hours. The preoperative pain visual analogue scale (VAS) score was 7.22±1.17 and American Orthopaedic Foot and Ankle Society (AOFAS) score was 0. The flexion and plantar flexion activities of ankle joint were (1.13±0.26) and (4.79±0.93)°, respectively. Twenty-two patients had a tibiofibular fracture. In the first-stage operation, the posterior approach was used to reduce the posterior column fracture and the external stent was temporarily assisted. After the soft tissue crisis was removed, the final fracture reduction and internal fixation was performed through the anterior approach in the second-stage operation. RESULTS All 23 patients were followed up 12-84 months with an average of 26.6 months. The waiting time before the first-stage operation was 4-47 hours with an average of 23.4 hours. The interval between the two stage operations was 6-11 days with an average of 7.9 days. The first-stage operation time was 60-90 minutes with an average of 67.8 minutes; the second-stage operation time was 110-160 minutes with an average of 124.1 minutes. The hospital stay was 15-28 days with an average of 23.5 days. One patient (4.35%) had a tourniquet paralysis symptom after the second-stage operation, and two patients (8.7%) had delayed anterior incision healing. The other patients had incision healing without early complications. The radiographic review showed that the quality of articular surface reduction was excellent in 19 cases, good in 2 cases, and poor in 2 cases, with an excellent and good rate of 91.3%. At last follow-up, the fractures healed with no bone nonunion and malunion; the different degrees of osteoarthritis occurred in 7 cases. At last follow-up, the VAS score was 0.89 ±0.88 and the AOFAS score was 81.3±7.8. The flexion and plantar flexion activities of ankle joint were (10.23±5.05) and (20.97±3.92)°, respectively, and the differences between pre- and post-operation were significant ( P<0.05). CONCLUSION The midified staging strategy can not only provide a template for articular surface reduction for the second-stage anterior surgery, but also improve the quality of the reduction. It can also reduce the interval between the two operations and the operation time of the second-stage operation through the first-stage posterior fascial decompression, and can obtain satisfactory effectiveness.
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Affiliation(s)
- Yu Chen
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Hui Zhang
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R.
| | - Xi Liu
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Yaxing Li
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Boquan Qin
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Yi Ren
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Shizhou Wu
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - Fuguo Huang
- Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
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