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Pande H, Meisheri H. Case Report: A Rare Case Of Bilateral Tibial Plafond Fracture In A Young Soldier. J Orthop Case Rep 2024; 14:7-13. [PMID: 39253676 PMCID: PMC11381069 DOI: 10.13107/jocr.2024.v14.i09.4710] [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: 06/10/2024] [Revised: 07/15/2024] [Indexed: 09/11/2024] Open
Abstract
Introduction Tibial pilon fractures, involving the weight-bearing surface of the distal tibia,present a formidable challenge for orthopedic surgeons due to their complex nature and the delicate soft tissue envelope surrounding the ankle joint.Early approaches to pilon fracturesoften resulted in poor outcomes, but modern principles of internal fixation and anatomicalreconstruction have significantly improved patient prognosis. Despite advancements in surgicaltechniques and implants, achieving anatomical reduction of the articular surface remains asignificant hurdle. Case Report This article presents a case report of a 27-year-old male soldier who sustained bilateral tibial pilon fractures following a fall from height. The patient underwent surgical intervention with differing approaches due to the complexity of the fractures. A combination of minimally invasive plate osteosynthesis (MIPPO) and external fixation was employed to address the fractures. The patient was followed up for 06 months post-op. Conclusion The importance of respecting the soft tissue envelope in surgical planning and timing, as well as the role of advanced imaging techniques such as CT scanning in preoperative assessment is crucial to achieving a successful outcome.While tibial pilon fractures remain complex injuries, advancements in surgical management have led to improved outcomes. However, ongoing research and innovation are necessary to address the multifaceted challenges associated with these fractures and optimize patient care.
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Affiliation(s)
- Hrishikesh Pande
- Department of Orthopedics, Armed Forces Medical College, Pune, Maharashtra, India
| | - Hardik Meisheri
- Department of Orthopedics, Military Hospital Chennai, Chennai, Tamil Nadu, India
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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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Wang BH, Zhang BB, Gong ZL, Mei J, Luo CF, Zhu Y. Biomechanical evaluation of different medial column fixation patterns for valgus pilon fractures. BMC Musculoskelet Disord 2024; 25:533. [PMID: 38992608 PMCID: PMC11238518 DOI: 10.1186/s12891-024-07660-2] [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: 03/09/2024] [Accepted: 07/04/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND The purpose of this study was to perform a biomechanical analysis to compare different medial column fixation patterns for valgus pilon fractures in a case-based model. METHODS Based on the fracture mapping, 48 valgus pilon fracture models were produced and assigned into four groups with different medial column fixation patterns: no fixation (NF), K-wires (KW), intramedullary screws (IS), and locking compression plate (LCP). Each group contained wedge-in and wedge-out subgroups. After fixing each specimen on the machine, gradually increased axial compressive loads were applied with a load speed of one millimeter per minute. The maximum peak force was set at 1500 N. Load-displacement curves were generated and the axial stiffness was calculated. Five different loads of 200 N, 400 N, 600 N, 800 N, 1000 N were selected for analysis. The specimen failure was defined as resultant loading displacement over 3 mm. RESULTS For the wedge-out models, Group-IS showed less displacement (p < 0.001), higher axial stiffness (p < 0.01), and higher load to failure (p < 0.001) than Group-NF. Group-KW showed comparable displacement under loads of 200 N, 400 N and 600 N with both Group-IS and Group-LCP. For the wedge-in models, no statistical differences in displacement, axial stiffness, or load to failure were observed among the four groups. Overall, wedge-out models exhibited less axial stiffness than wedge-in models (all p < 0.01). CONCLUSIONS Functional reduction with stable fixation of the medial column is essential for the biomechanical stability of valgus pilon fractures and medial column fixation provides the enough biomechanical stability for this kind of fracture in the combination of anterolateral fixation. In detail, the K-wires can provide a provisional stability at an early stage. Intramedullary screws are strong enough to provide the medial column stability as a definitive fixation. In future, this technique can be recommended for medial column fixation as a complement for holistic stability in high-energy valgus pilon fractures.
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Affiliation(s)
- Bing-Hao Wang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Bin-Bin Zhang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Zi-Ling Gong
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Jiong Mei
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Cong-Feng Luo
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
| | - Yi Zhu
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
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Wustro L, Silva JLVD, Moura BAB, Schoenberger HS, Takito D, D'Agostini JCH. Use of Three-dimensional Printing for Tibial Pilon Fracture Diagnosis and Treatment. Rev Bras Ortop 2024; 59:e456-e461. [PMID: 38911898 PMCID: PMC11193579 DOI: 10.1055/s-0044-1785514] [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: 08/08/2023] [Accepted: 11/06/2023] [Indexed: 06/25/2024] Open
Abstract
Objective To evaluate whether three-dimensional (3D) printing increases agreement in the classification of tibial pilon fractures. Methods Orthopedists and traumatologists reviewed radiographs, computed tomography scans with 3D reconstruction, and prototyping 3D printing, and classified the fractures based on the Rüedi-Allgöwer and Arbeitsgemeinschaft für Osteosynthesefragen (AO, Association for the Study of Internal Fixation) Foundation/Orthopedic Trauma Association (AO/OTA) classification systems. Next, data evaluation used Kappa agreement coefficients. Results The use of the 3D model did not improve agreement for tibial pilon fractures regarding the treatment proposed by the groups. Regarding the classification systems, the agreement only improved concerning the AO/OTA classification when the 3D model was used in the assessment by the foot and ankle specialists. Conclusion Although 3D printing is statistically relevant for surgeons specializing in foot and ankle, its values remain lower than optimal.
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Affiliation(s)
| | | | | | | | - Debora Takito
- Complexo Hospitalar do Trabalhador, Curitiba, PR, Brasil
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Daas S, Jlidi M, Baghdadi N, Bouaicha W, Mallek K, Lamouchi M, Khorbi A. Risk factors for malunion of distal tibia fractures treated by intramedullary nailing. J Orthop Surg Res 2024; 19:5. [PMID: 38169392 PMCID: PMC10762967 DOI: 10.1186/s13018-023-04472-3] [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: 10/12/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The treatment of distal tibia fractures (DTF) has historically been a difficult challenge for orthopedic surgeons because of the particular characteristics of this anatomical region. Intra medullary nailing (IMN) remains the best treatment option. However, achieving and maintaining perfect reduction and stable fixation with IMN can be technically challenging due to the large medullary cavity within a short distal fragment. The aim of our study is to determine the risk factors for malunion in DTF treated with IMN. METHODS It is a retrospective study including DTF treated surgically by IMN in the Orthopedics and Trauma Department at a tertiary hospital over a period of 7 years. The quality of reduction was evaluated by radiological assessment of the antero-posterior (AP) and lateral views of the tibia and ankle at the last follow-up. RESULTS Our series included 90 patients with an average age of 44.8 years. Sex-ratio was 2.6. Tobacco use was reported in 35.6% of the patients. Diabetes was present in 11.1% of the patients, and 12.2% of them had open fractures. According to the OTA/AO classification, the majority of injuries were classified as type A1 (76.7%). Fibula fractures were present in 86.7% of cases. The mean follow-up was 48 months. Malunion occurred in 13 cases. Based on the univariate analysis, smoking and dynamic fixation were significantly associated with malunion. In the multiple logistic regression analysis, dynamic fixation was found to be a significant factor that increased the risk of malunion by 7.5 times. CONCLUSION Neither patient demographics nor fracture characteristics were risk factors for malunion. Nevertheless, it should be noted that dynamic nailing must be avoided as it is associated with a higher risk of malunion. Furthermore, one to two medial to lateral distal locking screws provide sufficient stability without the need for additional fibular fixation. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Selim Daas
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Jlidi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Nahla Baghdadi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Walid Bouaicha
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Karim Mallek
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Mouldi Lamouchi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Adel Khorbi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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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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Bolovan AD, Onofrei RR, Hogea GB, Abu-Awwad A, Lazarescu EA, Abu-Awwad SA, Tapardea AR, Suba MI, Amaricai EC. Comparison between Exercise Program-Foot Orthoses Treatment and Exercise Program Alone after Pilon Fracture Surgery: Study Protocol for a Randomized Controlled Trial. Life (Basel) 2023; 13:2187. [PMID: 38004327 PMCID: PMC10672240 DOI: 10.3390/life13112187] [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: 09/06/2023] [Revised: 10/20/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
The management of tibial pilon fractures is challenging and often leads to complications and limitations in ankle function. The study aims to investigate myotonometric parameters and muscle strength of ankle muscles, as well as gait pattern and balance among patients following surgical treatment of pilon fractures. The randomized controlled study will analyze the differences between the patients who will follow a 3-month physical exercise program and will wear customized foot orthoses (i.e., customized orthotic arch support insoles) versus patients who will attend only the physical exercise program. For each group, at least 21 patients will be required. The assessment involves four different testing procedures: myotonometry (anterior tibialis, medial and lateral gastrocnemius, and longus peroneus assessed using MyotonPRO), muscle strength testing (ankle dorsiflexors, plantar flexors, and peroneal muscles assessed using MicroFET2 dynamometer), analysis of gait parameters (using Scheinworks treadmill), and double-leg and single-leg balance tests (using K-Force plate). After 3 months, the assessments will record which of the two treatments (physical exercise program with or without wearing customized foot orthoses) has better outcomes in regaining ankle muscle properties and tone, as well as the restoration of gait and balance.
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Affiliation(s)
- Andrei-Daniel Bolovan
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.-D.B.); (S.-A.A.-A.); (A.-R.T.); (M.-I.S.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (G.-B.H.); (E.-A.L.)
| | - Roxana-Ramona Onofrei
- Department of Rehabilitation, Physical Medicine and Rheumatology, Research Center for Assessment of Human Motion, Functionality and Disability, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (R.-R.O.); (E.-C.A.)
| | - Gheorghe-Bogdan Hogea
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (G.-B.H.); (E.-A.L.)
- Department XV—Discipline of Orthopedics—Traumatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
- Research Center University Professor Doctor Teodor Șora, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Ahmed Abu-Awwad
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (G.-B.H.); (E.-A.L.)
- Department XV—Discipline of Orthopedics—Traumatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
- Research Center University Professor Doctor Teodor Șora, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Emil-Adrian Lazarescu
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (G.-B.H.); (E.-A.L.)
- Research Center University Professor Doctor Teodor Șora, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
- Department of Anatomy and Embryology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Simona-Alina Abu-Awwad
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.-D.B.); (S.-A.A.-A.); (A.-R.T.); (M.-I.S.)
- Department XII—Discipline of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Alexandra-Roxana Tapardea
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.-D.B.); (S.-A.A.-A.); (A.-R.T.); (M.-I.S.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (G.-B.H.); (E.-A.L.)
| | - Madalina-Ianca Suba
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.-D.B.); (S.-A.A.-A.); (A.-R.T.); (M.-I.S.)
| | - Elena-Constanta Amaricai
- Department of Rehabilitation, Physical Medicine and Rheumatology, Research Center for Assessment of Human Motion, Functionality and Disability, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (R.-R.O.); (E.-C.A.)
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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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Hill DS, Davis JR. What is a tibial pilon fracture and how should they be acutely managed? A survey of consultant British Orthopaedic Foot and Ankle Society members and non-members. Ann R Coll Surg Engl 2023. [PMID: 37909410 DOI: 10.1308/rcsann.2023.0049] [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: 11/03/2023] Open
Abstract
INTRODUCTION Controversy exists around which distal tibial fractures are pilon fractures. We evaluated views to define a pilon fracture and support the development of standards of care. METHODS Views regarding the characteristics of a pilon fracture and acute soft tissue management were determined through a questionnaire. This was trialled, approved by the British Orthopaedic Foot and Ankle Society and distributed to its members. This was also distributed nationally as part of the ENFORCE study. RESULTS In total, 282 consultants from 27 units responded, of whom 24% (69/282) were foot and ankle specialists. Some 58% (163/282) agreed that a pilon fracture is primarily a soft tissue injury, 81% (228/282) that pilon fractures occur though high-energy transfer, 81% (228/282) that pilon fractures are sustained through an axial compression mechanism and 93% (265/282) that they are a potentially limb-threatening injury. Overall, 83% (234/282) agreed that in a length-unstable pilon fracture it is not possible to maintain the talus near anatomically under the tibial plafond without rigid fixation to control length - with 87% (246/282) agreeing that the acute first-line management should be a spanning external fixator. Opinions were that the time frame between diagnosis and intervention should be: less than 6h (63%; 154/246), 6-12h (31%; 77/246) and 12-24h (6%; 15/246). CONCLUSION Consensus supports defining a pilon fracture as a potentially limb-threatening high-energy axial compression injury, and a spanning external fixator as the first-line management of a length-unstable injury less than 12h from diagnosis.
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Affiliation(s)
- D S Hill
- Torbay and South Devon NHS Foundation Trust, UK
| | - J R Davis
- Torbay and South Devon NHS Foundation Trust, UK
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Mair O, Pflüger P, Hanschen M, Biberthaler P, Crönlein M. Treatment strategies for complex ankle fractures-current developments summarized in a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:387. [PMID: 37970612 PMCID: PMC10632576 DOI: 10.21037/atm-23-1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/26/2023] [Indexed: 11/17/2023]
Abstract
Background and Objective Ankle fractures occur frequently in patients throughout all ages. Due to the many pitfalls associated with their treatment, complex ankle and especially tibial pilon fractures remain a challenge for surgeons. As there is still need for improvement in treating complex ankle fractures and treatment options are steadily increasing this review aims to summarize current practice and aims to highlight current developments by reviewing the literature. Methods We conducted a thorough search of PubMed database in December 2022 to identify relevant articles on complex ankle and tibial pilon fractures. Articles in English and German were included in this study. Key Contents and Findings Complication rates, especially wound infection are still high, emphasizing the need for careful preoperative planning. Soft tissue management is crucial to reduce complication rates and will often dictate the treatment plan utilized. Open reduction and internal fixation (ORIF) remains the treatment of choice. Nevertheless, in select cases alternative methods such as external fixation, tibiotalocalcaneal nailing or conservative treatment need to be considered as well. Furthermore, additional treatment options such as arthroscopically assisted surgery might help to improve functional outcome after complex ankle fractures. The incidence of complex ankle fractures in geriatric patients keeps rising with our aging population. This group of patients demands particular care and further high-quality studies are needed to warrant best results. Conclusions However, more randomized controlled trials are need in order to enhance evidence of newly developed treatment options.
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Affiliation(s)
- Olivia Mair
- Department of Trauma Surgery, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, Germany
| | - Patrick Pflüger
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marc Hanschen
- Department of Trauma Surgery, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, Germany
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11
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RANDELLI F, BERLUSCONI M, BUONO C, CHIODINI F, MENOZZI M, ALBANO F, LADOGANA T, SANTOLINI E, BIZZOCA D, OTTAVIANI G, ZAVATTINI G, LUNINI E, PATERLINI M, VICENTI G. The management of acute tibio-fibular syndesmotic injuries: an expert survey of AO Trauma Italy members and evidence-based treatment recommendations. MINERVA ORTHOPEDICS 2023; 74. [DOI: 10.23736/s2784-8469.23.04329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
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12
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Shafiq B, Zhang B, Zhu D, Gupta DK, Cubberly M, Stepanyan H, Rezzadeh K, Lim PK, Hacquebord J, Gupta R. Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters. J Orthop Trauma 2023; 37:532-538. [PMID: 37226911 DOI: 10.1097/bot.0000000000002637] [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: 05/19/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures. DESIGN Retrospective cohort study. SETTING 3 Level 1 tertiary academic trauma centers. PATIENTS/PARTICIPANTS The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures. MAIN OUTCOME MEASUREMENTS Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal. RESULTS The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating. CONCLUSIONS While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Bo Zhang
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Diana Zhu
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Deven K Gupta
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Mark Cubberly
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Hayk Stepanyan
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Kevin Rezzadeh
- Department of Orthopaedic Surgery, New York University Langone Health, New York, NY
| | - Philip K Lim
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Jacques Hacquebord
- Department of Orthopaedic Surgery, New York University Langone Health, New York, NY
| | - Ranjan Gupta
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
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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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14
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Emmelot MP, Wagner RK, Janssen SJ, Kloen P. Blade Plate With Autogenous Bone Grafting to Salvage Peri Ankle Nonunions. Foot Ankle Int 2023; 44:516-527. [PMID: 37114908 PMCID: PMC10248309 DOI: 10.1177/10711007231165303] [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: 04/29/2023]
Abstract
BACKGROUND Salvage surgery for a nonunion around the ankle is challenging. Poor bone stock, stiffness, scarring, previous (or persistent) infection, and a compromised soft tissue envelope are common in these patients. We describe 15 cases that underwent blade plate fixation as salvage for a nonunion around the ankle, including patient/nonunion characteristics, Nonunion Scoring System (NUSS), surgical technique, healing rate, complications, and long-term follow-up with 2 patient-reported outcome measures. METHODS This is a retrospective case series from a level 1 trauma referral center. We included all patients that underwent blade plate fixation for a long-standing nonunion of the distal tibia, talus, or failed subtalar fusion. All patients had autogenous bone grafting, including 14 with posterior iliac crest grafts and 2 with femoral reamer irrigator aspirator grafting. Median follow-up was 24.4 months (interquartile range [IQR], 7.7-40). Main outcome measures were (time to) union, and functional outcomes using the 36-item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), and the Foot and Ankle Outcome Score (FAOS). RESULTS We included 15 adults with a median age of 58 years (IQR, 54-62). The median NUSS score at the time of index surgery was 46 (IQR, 34-54). Union was achieved after the index procedure in 11 of 15 patients. Additional surgery was performed in 4 of 15 patients. Union was achieved in all patients at a median of 4.2 months (IQR, 2.9-11). The median score for the PCS was 38 (IQR, 34-48, range 17-58, P = .009), for the MCS 52 (IQR, 45-60, range 33-62, P = .701), and for the FAOS 73 (IQR, 48-83). CONCLUSION In this series, our use of blade plate fixation with autogenous grafting was an effective method for managing a nonunion around the ankle allowing for alignment correction, stable compression and fixation, union, and fair patient-reported outcome scores. LEVEL OF EVIDENCE Level IV, therapeutic.
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Affiliation(s)
- Mees Paulus Emmelot
- Department of Orthopedic Surgery and
Sports Medicine, Amsterdam UMC location Meibergdreef, Amsterdam, the
Netherlands
- Amsterdam Movement Sciences,
Musculoskeletal Health, Amsterdam, the Netherlands
| | - Robert Kaspar Wagner
- Department of Orthopedic Surgery and
Sports Medicine, Amsterdam UMC location Meibergdreef, Amsterdam, the
Netherlands
- Amsterdam Movement Sciences,
Musculoskeletal Health, Amsterdam, the Netherlands
| | - Stein Jasper Janssen
- Department of Orthopedic Surgery and
Sports Medicine, Amsterdam UMC location Meibergdreef, Amsterdam, the
Netherlands
- Amsterdam Movement Sciences,
Musculoskeletal Health, Amsterdam, the Netherlands
| | - Peter Kloen
- Department of Orthopedic Surgery and
Sports Medicine, Amsterdam UMC location Meibergdreef, Amsterdam, the
Netherlands
- Amsterdam Movement Sciences,
Musculoskeletal Health, Amsterdam, the Netherlands
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15
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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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16
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[Effectiveness of new Pilon plate in treatment of type C Pilon fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:31-36. [PMID: 36708112 PMCID: PMC9883635 DOI: 10.7507/1002-1892.202208013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Objective By comparing with traditional L-shaped plate, to explore the effectiveness of new Pilon plate in the treatment of type C Pilon fracture. Methods A clinical data of 57 patients with type C Pilon fractures who met the selection criteria between May 2018 and January 2020 was analyzed retrospectively. Thirty-two patients were treated with new Pilon plate (trial group) and 25 patients with traditional L-shaped plate (control group). There was no significant difference in gender, age, cause of injury, fracture side and type, the interval between injury and operation between the two groups (P>0.05). The operation time and complications of the two groups were recorded. X-ray films were taken after operation to assess the quality of fracture reduction according to the Burwell-Charnley classification and fracture healing. Ankle function was evaluated according to Johner-Wruhs scoring standard and American Orthopaedic Foot and Ankle Society (AOFAS) score. Results The operations of the two groups were completed successfully, and the operation time of the trial group was significantly shorter than that of the control group (t=-3.025, P=0.005). After operation, the incision necrosis occurred in 2 cases of the control group, and the incisions of other patients in both groups healed by first intention. All patients were followed up 8-16 months, with an average of 10.1 months. There was no significant difference in follow-up time between the two groups (t=0.433, P=0.667). X-ray films showed that the ankle reduction of the trial group was rated as excellent in 28 cases and good in 4 cases, with an excellent and good rate of 100%, while in the control group, the ankle reduction was rated as excellent in 15 cases, good in 5 cases, and fair in 5 cases, with an excellent and good rate of 80.0%. There was a significant difference in the excellent and good rate of fracture reduction between the two groups (Z=-2.565,P=0.010). The fracture healed in both groups, and the healing time was (16.59±3.78) weeks in the trial group and (17.80±3.81) weeks in the control group, and there was no significant difference between the two groups (t=-1.191, P=0.239). At last follow-up, according to Johner-Wruhs scoring standard, the ankle joint function in the trial group was evaluated as excellent in 25 cases and good in 7 cases, with an excellent and good rate of 100%; the AOFAS score was 90.9±4.5. In the control group, 16 cases were excellent, 5 cases were good, and 4 cases were fair, and the excellent and good rate was 84.0%; the AOFAS score was 85.2±10.0. The ankle function scores of the trial group was superior to that of the control group (P<0.05). During follow-up, except for 1 case of ankle traumatic arthritis in the control group, there was no complication such as ankle malunion, plate loosening and fracture, or fracture reduction loss in both groups. Conclusion Compared with the traditional L-shaped plate, the new Pilon plate in the treatment of type C Pilon fracture has the advantages of high reduction quality, reliable fixation, less irritation to soft tissue, high fracture healing rate, and satisfactory functional recovery of ankle joint.
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Outcomes of Tibiotalocalcaneal Hindfoot Fusion Nails Used for Acute Lower Extremity Trauma in a High-Risk Patient Population. J Orthop Trauma 2023; 37:e7-e12. [PMID: 36518067 DOI: 10.1097/bot.0000000000002466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 07/21/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails. DESIGN Retrospective case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening. INTERVENTION Tibiotalocalcaneal hindfoot fusion nail. MAIN OUTCOME MEASUREMENTS Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years. RESULTS Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%-91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%-67%). CONCLUSIONS Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Pankratov AS, Lartsev YV, Rubtsov AA, Ogurtsov DA, Kim YD, Shmel'kov AV, Knyazev NA. Application of 3D modeling in a personalized approach to bone osteosynthesis (A literature review). BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2022. [DOI: 10.20340/vmi-rvz.2023.1.ictm.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Three-dimensional printing opens up many opportunities for use in traumatology and orthopedics, because it takes into account personal characteristics of the patients. Modern methods of high-resolution medical imaging can process data to create threedimensional images for printing physical objects. Today, three-dimensional printers are able to create a model of any complexity of shape and geometry. The article provides a review of the literature about three-dimensional digital modeling in shaping implants for osteosynthesis. Data search was carried out on the Scopus, Web of Scince, Pubmed, RSCI databases for the period 2012–2022. The effectiveness of three-dimensional printing for preoperative modeling of bone plates has been confirmed: implants perfectly corresponds with the unique anatomy of the patient, since the template for it is based on the materials of computed tomography. Individual templates can be useful when the geometry of patients' bones goes beyond the standard, and when improved results of surgery are expected due to better matching of implants to the anatomical needs of patients.
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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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Incidence and risk factors of ankle fusion after pilon fracture: a retrospective review. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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21
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Can Laser-Assisted Indocyanine Green Angiography Be Used to Quantify Perfusion Changes During Staged Fixation of Pilon Fractures? A Pilot Study. J Orthop Trauma 2022; 36:e388-e392. [PMID: 35580330 DOI: 10.1097/bot.0000000000002405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To quantify soft tissue perfusion changes in pilon fractures during staged treatment using laser-assisted indocyanine green angiography (LA-ICGA). SETTING Level 1 trauma center. DESIGN Prospective cohort study. PATIENTS/PARTICIPANTS Twelve patients with 12 pilon fractures participated in the study. Seven patients had OTA/AO classification of 43-C3, 3 had 43-C2, and 2 had 43-B2. MAIN OUTCOME MEASURES LA-ICGA was performed with the SPY fluorescence imaging platform. Analysis via ImageJ was used to generate a fractional area of perfusion (FAP) based on fluorescent intensity to objectively quantify soft tissue perfusion. Anterior, medial, and lateral measurements were performed at the time of initial external fixation (EF) application and then at the time of definitive fixation. RESULTS FAP within the region of interest was on average 64% medially, 61% laterally, and 62% anteriorly immediately before EF placement. Immediately before definitive open reduction internal fixation, fractional region of interest perfusion was on average 86% medially, 87% laterally, and 86% anteriorly. FAP increased on average 24% medially ( P = 0.0004), 26% laterally ( P = 0.001), and 19% anteriorly ( P = 0.002) from the time of initial EF to the time of definitive open reduction and internal fixation. CONCLUSIONS Quantitative improvement in soft tissue perfusion was identified through the course of staged surgical management in pilon fractures. LA-ICGA potentially may be used to determine appropriate timing for definitive surgical intervention based on the readiness of the soft tissue envelope. Ultimately, these findings may influence clinical outcomes with respect to choice of surgical approach, soft tissue management, surgical timing, and wound healing. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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22
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Sen MK. Combined limited internal fixation and multiplanar external fixation for immediate weight bearing of fractures around the foot and ankle. OTA Int 2022; 5:e194. [PMID: 36425086 PMCID: PMC9580047 DOI: 10.1097/oi9.0000000000000194] [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: 12/22/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 06/16/2023]
Abstract
Treatment of fractures around the foot and ankle can be challenging in patients who are unable to remain non weight bearing on their lower extremity. Traditional implants are not sufficient to resist loads incurred during weight bearing and can also lead to complications related to wound healing and infection. We describe a technique for fracture fixation of the foot and ankle that uses low profile implants to minimize soft tissue insult combined with multiplanar external fixation to allow for immediate weight bearing.
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Affiliation(s)
- Milan K Sen
- Chief of Orthopedic Surgery, Director of Orthopedic Surgery, NYC Health +Hospitals/Jacobi
- Assoicate Professor, The Albert Einstein College of Medicine, The Bronx, NY
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23
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Okelana B, McMillan L, Huyke-Hernandez FA, Only AJ, Parikh HR, Cunningham BP. Cost Variation in Temporizing External Fixation of Tibial Plateau and Pilon Fractures: Is There Room to Improve? Injury 2022; 53:2872-2879. [PMID: 35760640 DOI: 10.1016/j.injury.2022.06.016] [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: 04/01/2022] [Accepted: 06/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION External fixator costs have been shown to be highly variable. Current information on external fixator costs and cost drivers is limited. The aim of this study was to examine the cost variation as well as the patient-, injury-, and surgeon-related cost drivers associated with temporizing external fixation constructs in tibial plateau and pilon fracture management. MATERIALS AND METHODS A retrospective review was conducted to identify isolated tibial plateau and pilon fractures treated with temporizing external fixation from 2006-2018 at a level 1 trauma center. Inclusion criteria were based on fractures managed with primary external fixation, skeletal maturity, and isolated ipsilateral fracture fixation. Fracture patterns were identified radiographically using Schatzker, Weber, and OTA classification systems. Implant costs were determined using direct purchase price from the institution. The primary outcome was the external fixator total construct cost. Clinical covariates and secondary outcomes, namely unplanned reoperations, were extracted. Factors associated with cost (i.e. cost drivers) were identified via multivariable regression analysis. RESULTS A total of 319 patients were included in this study (121 tibial plateau and 198 pilon fractures). Mean plateau construct cost was $5,372.12 and mean pilon construct cost was $3,938.97. Implant cost correlated poorly with demographic (r2=0.01 & r2=0.01), injury-independent (r2<0.01 & r2=0.03), and fracture pattern classifications (r2=0.03 & r2=0.02). Traumatologists produced significantly cheaper implants for pilon fractures (p=0.05) but not for plateau fractures (p=0.85). There was no difference in construct cost or components between patients that underwent unplanned reoperation and those that did not for both tibial plateau (p>0.19) and pilon (p>0.06). Clamps contributed to 69.9% and 77.3% of construct costs for tibial plateau and pilon, respectively. The most cost-efficient fixation constructs for tibial plateau and pilon fractures were the following respectively: of 5 clamps, 2 bars, and 4 pins; and of 4 clamps, 2 bars, and 3 pins. CONCLUSIONS There is large cost variation in temporizing external fixation management. Cost drivers included surgeon bias and implant preference as well as use of external fixator clamps. Introducing construct standardization will contain healthcare spending without sacrificing patient outcomes. LEVEL OF EVIDENCE Level III. Retrospective Cohort.
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Affiliation(s)
- Bandele Okelana
- Department of Orthopaedic Surgery, The University of Texas at Austin, Austin, TX, USA
| | - Logan McMillan
- Department of Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Fernando A Huyke-Hernandez
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA; Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
| | - Arthur J Only
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA; Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA; Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA.
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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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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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Chen Y, Wang H, Li N, Xu L, Liu F, Xu Q, Zhou Q, Chen X. A Novel Approach Combined with MIPO Technique for the Treatment of Type C Pilon Fractures. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:7427255. [PMID: 35746961 PMCID: PMC9213148 DOI: 10.1155/2022/7427255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
Objective Type C fracture is a complete intra-articular fracture, and the mainstay of treatment remains open reduction and internal fixation. The purpose of the study is to observe the clinical effect of an anterior ankle C approach (ankle-C) combined with minimal invasive plate osteosystems (MIPO) for tibial pilon fractures (AO/OTA 43C, combined with fibula fractures). Methods A retrospective comparative analysis was performed on the clinical data of 33 patients with C-type pilon fractures (combined fibula fractures) admitted to our department from July 2018 to July 2021, including 12 cases treated with ankle-C (a-C) approach and 21 cases with conventional approach (including combined approach). All patients were followed up for over 6 months. Visual Analogue Scale (VAS), AOFAS Ankle-Hindfoot Scale (AOFAS-AHS), wound healing time, fracture healing time, and complications were used to evaluate the clinical efficacy. Results The scores of VAS and AOFAS in the a-C group scored better than the conventional group (P < 0.05), especially in the extent of limited range of motion (LROM) of ankle dorsiflexion-plantarflexion in 1 month after operation and at the last follow-up (P < 0.01). Bone healing was achieved in both groups 6 months after operation, with no implant exposure or infection. Among them, 4 cases in the conventional approach group had wound healing time exceeding 2 weeks. Conclusions For type C pilon fractures (combined with fibula fractures), ankle-C approach combined with MIPO technique has certain advantages in ankle function recovery and soft tissue repair, which provides an alternative for the treatment of type C pilon fractures.
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Affiliation(s)
- Youhao Chen
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Haoming Wang
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Department of Orthopedics, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 401120, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Nan Li
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Lixin Xu
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Feng Liu
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Qiu Xu
- Health Center of Sunjia Town, Wanzhou District, Chongqing 404000, China
| | - Qiang Zhou
- Department of Orthopedics, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 401120, China
| | - Xiaohua Chen
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
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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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Visualization of the distal tibial plafond articular surface using four established approaches and the efficacy of instrumented distraction: a cadaveric study. Eur J Trauma Emerg Surg 2022; 48:4031-4041. [PMID: 35296908 PMCID: PMC9532318 DOI: 10.1007/s00068-022-01927-w] [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: 11/10/2021] [Accepted: 02/20/2022] [Indexed: 11/17/2022]
Abstract
Purpose Direct visualization is a very effective method in accomplishing adequate articular surface reconstruction in fracture repair. This study investigates distal tibial plafond articular surface visibility using the anteromedial, anterolateral, posteromedial, and posterolateral approaches, the effect of instrumented distraction on visibility, and which zones of the articular surface are visible for each approach. Methods The anteromedial, anterolateral, posteromedial, and posterolateral approaches to the distal tibial plafond were performed on 16 cadaveric ankle specimens. The articular surface visualization for each approach was marked using an electrocautery device with manual and instrumented distraction. Articular surface visualization was photographically documented. Digital axial segmentation and quantitative analysis of the visualized distal tibial plafond articular surface were performed. Results With manual distraction, distal tibial plafond articular surface visualization, expressed in percent of overall articular surface, was limited to 9% (SD ± 9) for the anteromedial, 24% (SD ± 18) for the anterolateral, 26% (SD ± 10) for the posteromedial, and 30% (SD ± 18) for the posterolateral approaches. Using instrumented distraction significantly improved articular surface visualization in all instances (p < 0.001). The anteromedial approach visible articular surface increased to 63% (SD ± 13), the anterolateral to 72% (SD ± 22), the posteromedial to 62% (SD ± 11), and the posterolateral to 50% (± 17). Conclusion This study demonstrates the efficacy of instrumented distraction when attempting surgical visualization of the distal tibial plafond articular surface. Knowledge of approach specific articular surface visibility may assist the surgeon in choosing the appropriate approach(es) based on case-specific distal tibial plafond fracture patterns. Level of evidence IV, cadaver study. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-022-01927-w.
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Khurana A, Sethi A, Gupta SC, Malik K, Arora S, Jain V. Expanding Indications of Primary Arthrodesis in Selected Individuals for Managing Complex Hindfoot Trauma During COVID-19 Pandemic. Indian J Orthop 2022; 56:485-491. [PMID: 34667332 PMCID: PMC8517065 DOI: 10.1007/s43465-021-00535-x] [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: 08/19/2021] [Accepted: 09/17/2021] [Indexed: 02/04/2023]
Abstract
Background During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of outdoor activities, organized sports, and schools/colleges. Neglected hindfoot fractures have emerged as a consequence with increased frequency. Similarly, complex ankle and pilon fractures that require staged management, prolonged hospital stay, and soft-tissue care have emerged as a potential concern as prolonged exposure to healthcare setting adds to risk of acquiring as well as transmitting COVID-19 infection. The authors present their experience with expanding these indications for hindfoot arthrodesis as they encounter a greater number of neglected ankle and hindfoot trauma. Methods This was a retrospective observational study of collected data from the trauma unit of our hospital. Inclusion criteria included all trauma classified by the AO/OTA as occurring at locations 43, and who underwent subtalar and ankle arthrodesis. This included distal tibia, malleolar, talus, and calcaneus fractures. These patients were followed up to at least 6 months till complete fracture union. Results A total of 18 patients underwent arthrodesis of either the ankle or subtalar joint between March and October 2020. Mean age of patients undergoing arthrodesis of the hindfoot was 69.2 years (43-84 years). Indications for the procedure included Displaced and comminuted intra-articular distal tibia fractures in elderly (6 patients), Malunited ankle fractures (2 patients), Neglected Ankle fractures managed conservatively (3 patients), Calcaneus fractures (5 patients), and neglected Talus body fracture (2 patients). All patients were followed up to at least 6 months and everyone went onto successful painless union between 3 and 6 months of the arthrodesis procedure without any significant complications. Conclusion In summary, COVID-19 pandemic has led to a change in paradigm of trauma management and foot and ankle management is no different than other musculoskeletal trauma systems. The authors propose an expansion of indications for hindfoot arthrodesis in managing complex hindfoot trauma in pandemic situation.
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Affiliation(s)
- Ankit Khurana
- Department of Orthopaedics, ESI Hospital Rohini, Delhi, India
| | - Ankita Sethi
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | | | - Kuldeep Malik
- Department of Orthopaedics, ESI Hospital Rohini, Delhi, India
| | - Sakshi Arora
- Department of Anaesthesia, ESI Hospital Rohini, Delhi, India
| | - Vishal Jain
- Department of Orthopaedics, ESI Hospital Rohini, Delhi, India
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Sukpanichyingyong S, Wongkaewpotong J, Sangkomkamhang T. Osteochondral allograft in the treatment of an extruded osteoarticular segment of the distal tibia: A case report. Trauma Case Rep 2022; 38:100627. [PMID: 35242989 PMCID: PMC8881710 DOI: 10.1016/j.tcr.2022.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/06/2022] Open
Abstract
Open tibial plafond fracture with massive bone loss presents a challenge for orthopedic surgeons. Particularly unusual is extrusion of an osteoarticular segment of the distal tibia. Here we present the case of such a patient, who was treated using osteochondral allograft (OCA) and fusion procedures. The patients can regain independent walking without pain within 6 months, indicating that OCA may be a sensible option for the treatment of open tibial plafond fracture with extrusion of the osteoarticular distal tibia in cases in which the surrounding soft tissue is intact but bone reimplantation is not possible due to severe damage and contamination.
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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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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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Gulbrandsen TR, Wynn M, Garrone AJ, Hulick RM, Spitler CA, Crist BD. Does Anterior Impaction Affect Radiographic Outcomes of Pilon Fractures? THE IOWA ORTHOPAEDIC JOURNAL 2022; 42:30-35. [PMID: 36601235 PMCID: PMC9769345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background The outcomes of pilon fractures are multifactorial. Anterior articular impaction requires sagittal plane correction (anterior distal tibia angle (ADTA)) with articular reduction. However, there is a risk of avascular necrosis of the articular fragments and postoperative tibiotalar arthritis. The purpose of this study was to determine if the presence of anterior impaction affects radiographic alignment after definitive fixation. Methods Retrospective cohort study of patients who underwent operative management for pilon fractures at two academic, level 1 trauma centers between September 2005-September 2016. Fractures were categorized as having anterior impaction or no anterior impaction after review of preoperative radiographic and computer tomography imaging. Patient demographics and postoperative time to union was recorded. Quality of reduction was measured using (ADTA) (degrees), lateral distal tibia angle (LDTA) (degrees), and lateral talar station (LTS) (millimeters) from postoperative radiographs. Statistical analysis compared fracture patterns with anterior impaction to those without. Results 208 patients met inclusion criteria. 132 fractures (63.4%) were determined to have anterior impaction. Cohorts were similar in demographics and medical comorbidities (p>0.05). Mean ADTA, LTDA, and LTS for the anterior impaction group 83.5°, 89.7°, and 2.4mm versus 84.6°, 89.9°, and 2.0mm in the group without anterior impaction. Cohorts significantly differed in ADTA(p=0.01), but not LDTA(p=0.12) or LTS(p=0.44). No significant differences were found between cohorts with infection (>0.05), nonunion(p=0.76), unplanned reoperation(p=0.56), or amputation(p=0.34). Conclusion This study demonstrated no significant differences in the coronal or sagittal plane alignment when comparing definitively fixed pilon fractures with and without anterior impaction. Additional studies are needed to evaluate the longterm clinical impact of failing to restore ADTA. Level of Evidence: III.
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Affiliation(s)
- Trevor R Gulbrandsen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malynda Wynn
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Robert M Hulick
- University of Mississippi Medical Center Department of Orthopedics, Jackson, Mississippi, USA
| | - Clay A Spitler
- University of Alabama at Birmingham Department of Orthopedics, Birmingham, Alabama, USA
| | - Brett D Crist
- University of Missouri-Columbia Department of Orthopaedic Surgery, Columbia, Missouri, USA
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Medial Column Support in Pilon Fractures Using Percutaneous Intramedullary Large Fragment Fixation. J Orthop Trauma 2021; 35:e502-e506. [PMID: 33675625 DOI: 10.1097/bot.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 02/02/2023]
Abstract
Pilon fractures are complex injuries to the tibial plafond requiring stable fixation in the setting of effective soft tissue management, particularly in high-energy injuries, open fractures, or in geriatric individuals. Medial column support of the distal tibial metaphysis is often an essential component when applying balanced fixation. However, the biologic implications of multiple surgical approaches in the setting of damaged tissue, devitalized bone, or significant bone loss may contribute to increased complications. Percutaneous intramedullary large fragment screws offer both stability and a soft tissue-friendly approach for stabilizing the medial column. Here, we present our technique and indications for medial column support in pilon fractures using percutaneous large fragment fixation, along with our early clinical experience in a case series of 7 patients. At minimum 6-month follow-up, all patients healed their injuries with maintained alignment and without complications or further reoperation. Medial column support with percutaneous large fragment fixation in pilon fractures is a viable option to provide mechanical stability while effectively managing tenuous soft tissue envelopes.
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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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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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Poutoglidou F, Metaxiotis D, Vasiliadis AV, Mpeletsiotis A. Plate fixation versus percutaneous rush pinning for osteosynthesis of the fibula in pilon fractures. A retrospective comparative study. Hippokratia 2021; 25:63-68. [PMID: 35937519 PMCID: PMC9347338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pilon fractures are complex injuries of the ankle associated with many postoperative complications. The optimal treatment for pilon fractures has not yet been established. This study aimed to determine the efficacy and compare the results of percutaneous rush pinning of the associated fibular fracture to the conventional open reduction and internal fixation. METHODS We included in the study all patients admitted in our department with the diagnosis of pilon fracture and associated fracture of the distal fibula and treated with primary open reduction and internal fixation between 2012 and 2018. We excluded patients treated with a two-stage approach, and those with an open fracture or neurovascular insufficiency. RESULTS The study included 87 patients; 45 had their distal fibular fracture operatively fixed with a one-third tubular plate (ORIF group), and the remaining 42 patients underwent percutaneous intramedullary pinning of the fibula fracture with a rush nail (Rush group). There were no statistically significant differences between the groups regarding age, gender, mechanism of injury, operating, and hospitalization time. The superficial infection rate was lower in the Rush group (p =0.039), but there were no statistically significant differences in the deep tissue infection, nonunion, and malunion incidence between the groups. CONCLUSION Percutaneous intramedullary rush pinning of the concomitant fibular fracture is a safe and reliable alternative treatment option in managing pilon fractures that could reduce the incidence of postoperative wound complications HIPPOKRATIA 2021, 25 (2):63-68.
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Affiliation(s)
- F Poutoglidou
- Orthopedic Department, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - D Metaxiotis
- Orthopedic Department, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - A V Vasiliadis
- Orthopedic Department, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - A Mpeletsiotis
- Orthopedic Department, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
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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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Is Definitive Plate Fixation Overlap With External Fixator Pin Sites a Risk Factor for Infection in Pilon Fractures? J Orthop Trauma 2021; 35:e7-e12. [PMID: 32618814 DOI: 10.1097/bot.0000000000001884] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if overlap of definitive plate fixation with external fixator pin sites is a risk factor for infection in pilon fractures. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS One hundred forty-six patients with pilon fractures treated between 2012 and 2018. INTERVENTION Staged treatment with ankle-spanning external fixation, followed by delayed open reduction and internal fixation. MAIN OUTCOME MEASURES Demographic, radiographic, and operative data were reviewed, and the distance between the temporary external fixator pin sites and the definitive plate was measured. The primary outcome measure was the development of a deep postoperative infection. RESULTS Overall, 22 (15%) patients developed deep wound infections. Overlap of definitive plate and external fixation pin site occurred in 58 (40%) of ankles. Of these, 7 (12%) developed deep wound infection compared with 15 (17%) patients without overlap (P = 0.484). There was no significant difference in amount of overlap (P = 0.636) or distance from plate to pin site (P = 0.607) in patients with and without deep infection. Of the patients with deep infection, 11 (50%) occurred in patients with open fractures. CONCLUSIONS Overlap of definitive plate fixation with primary spanning external fixator pin sites is not a risk factor for development of deep infection in a staged treatment of high-energy pilon fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Gitajn IL, Slobogean GP, Henderson ER, von Keudell AG, Harris MB, Scolaro JA, O’Hara NN, Elliott JT, Pogue BW, Jiang S. Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery. JOURNAL OF BIOMEDICAL OPTICS 2020; 25:JBO-200070-PER. [PMID: 32869567 PMCID: PMC7457961 DOI: 10.1117/1.jbo.25.8.080601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
SIGNIFICANCE Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues. AIM The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery. APPROACH The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative. RESULTS Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management. CONCLUSION While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.
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Affiliation(s)
- Ida L. Gitajn
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire, United States
| | - Gerard P. Slobogean
- University of Maryland, Orthopaedic Associates, Baltimore, Maryland, United States
| | - Eric R. Henderson
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire, United States
| | - Arvind G. von Keudell
- Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, United States
| | - Mitchel B. Harris
- Massachusetts General Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, United States
| | - John A. Scolaro
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, California, United States
| | - Nathan N. O’Hara
- University of Maryland, Orthopaedic Associates, Baltimore, Maryland, United States
| | - Jonathan T. Elliott
- Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, New Hampshire, United States
| | - Brian W. Pogue
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Shudong Jiang
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
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Campbell ST, Goodnough LH, Salazar B, Lucas JF, Bishop JA, Gardner MJ. How do pilon fractures heal? An analysis of dual plating and bridging callus formation. Injury 2020; 51:1655-1661. [PMID: 32434713 DOI: 10.1016/j.injury.2020.04.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES 1) To determine the effect of single versus dual plate metaphyseal fixation for pilon fractures on callus formation and reoperation rates, 2) to determine the effect of biomechanically matched versus unmatched fixation, and 3) to determine whether patient or surgical factors were independent predictors of bridging callus formation or need for reoperation. DESIGN Retrospective comparative study. SETTING Single level one trauma center. PATIENTS Fifty patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation. INTERVENTION Internal fixation with a plate and screw construct, with comparisons made between patients with single versus dual plate fixation, and patients treated with biomechanically matched or unmatched fixation. MAIN OUTCOME MEASUREMENTS Modified RUST (mRUST) scores at three and six months and reoperation rate. RESULTS At six months, mean mRUST scores were significantly lower in patients treated with dual metaphyseal plates compared to a single plate (8.7 vs 10.4, p=0.046) There were 15 open fractures; eight were treated with supplemental fixation, while seven were treated with single-column fixation. Open fracture (OR 51.05, p=0.008) was a risk factor for reoperation. Screw density between 0.4 and 0.5 was a protective factor against reoperation (OR 0.03, p=0.026). Biomechanically unmatched fixation did not affect mRUST scores or reoperation rates. CONCLUSIONS Pilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. Screw density between 0.4-0.5 was protective against reoperation. These data may serve as the basis of future work to determine the ideal fixation construct for the frequently comminuted metaphysis in pilon fractures. Further work is necessary to determine whether callus formation in these injuries is desirable. LEVEL OF EVIDENCE Three.
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Affiliation(s)
- Sean T Campbell
- Department of Orthopaedic Surgery, Stanford University Hospital, 300 Pasteur Drive Room R144, Stanford, CA, USA.
| | - L Henry Goodnough
- Department of Orthopaedic Surgery, Stanford University Hospital, 300 Pasteur Drive Room R144, Stanford, CA, USA
| | - Brett Salazar
- Department of Orthopaedic Surgery, Stanford University Hospital, 300 Pasteur Drive Room R144, Stanford, CA, USA
| | - Justin F Lucas
- Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, USA
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University Hospital, 300 Pasteur Drive Room R144, Stanford, CA, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Hospital, 300 Pasteur Drive Room R144, Stanford, CA, USA
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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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Abstract
The treatment of tibial pilon fractures has evolved substantially over the past decades due to ever-increasing high-energy injuries. Open reduction and internal fixation of these intra-articular fractures requires an appreciation for a number of basic principles: respect the soft tissues, understand the fracture pattern, use safe surgical approaches, and provide stability that allows for early motion of the ankle. Surgical strategy should be customized based on the fracture pattern, access needed for fracture visualization and reduction, and status of the soft tissues. Given the ability to obtain an accurate stable reduction, smaller implants are typically adequate using multiple small incisions. We view this surgical tactic as continuing the evolution of complex fracture treatment whose origins lie in the influences of pioneers such as Dr Sigvard T. Hansen Jr.
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Abstract
PURPOSE OF REVIEW Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures. RECENT FINDINGS Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.
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Affiliation(s)
- Marianne Hollensteiner
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Sabrina Sandriesser
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Emily Bliven
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
- Department of Trauma Surgery, BG Klinikum Murnau, Murnau, Germany
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany.
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria.
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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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Harada S, Teramoto T, Takaki M, Asahara T, Katoh N, Takenaka N, Matsushita T. Ankle joint reconstruction by circular frame external fixator for a severely comminuted and contaminated open tibial pilon fracture (AO 43-C3.3). Case report. Trauma Case Rep 2019; 23:100234. [PMID: 31388542 PMCID: PMC6669874 DOI: 10.1016/j.tcr.2019.100234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2019] [Indexed: 11/19/2022] Open
Abstract
A severely comminuted and contaminated open tibial pilon fracture is one of the most challenging fractures we face. Although nowadays conducting multiple operations over various stages is a common treatment option taking into account the possibility of soft tissue damage, a gold standard protocol for severe pilon fractures has not yet been established. This case concerns a 56-year-old gentleman who suffered a severely comminuted and contaminated Gustilo 3b open tibial pilon fracture (AO 43C3.3) that was successfully treated using a circular frame external fixator without flap. Two years six months after the injury, there were no indications of any skin conditions at the site of the open wound, the range of ankle motion had been maintained and independent walking was possible. The score under the JSSF (Japanese Society of Surgery of the foot) ankle/hind foot scale was 81. This indicates that use of a circular frame external fixator is a useful treatment method in the event of a severe open pilon fracture where there is a large osteochondral bone defect.
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Affiliation(s)
- Shota Harada
- Department of Traumatology, FUKUSHIMA Medical University, Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Tsukasa Teramoto
- Department of Traumatology, FUKUSHIMA Medical University, Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Motoyuki Takaki
- Department of Traumatology, FUKUSHIMA Medical University, Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Tomohiko Asahara
- Department of Traumatology, FUKUSHIMA Medical University, Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Narutaka Katoh
- Department of Traumatology, FUKUSHIMA Medical University, Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Nobuyuki Takenaka
- Department of Traumatology, FUKUSHIMA Medical University, Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Takashi Matsushita
- Department of Traumatology, FUKUSHIMA Medical University, Trauma & Reconstruction Center, Southern TOHOKU General Hospital, Fukushima, Japan
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Treatment of AO/OTA 43-C3 Pilon Fracture: Be Aware of Posterior Column Malreduction. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4265782. [PMID: 31111053 PMCID: PMC6487132 DOI: 10.1155/2019/4265782] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022]
Abstract
Treatment of pilon fractures remains challenging due to the difficulty of fracture reduction and associated soft tissue complications. The aim of this study was to evaluate the pitfalls and strategies of posterior column reduction in the treatment of complex tibial pilon fractures (AO/OTA 43-C3). Thirteen AO/OTA classification 43-C3 type pilon fractures treated between January 2013 and January 2016 were retrospectively analyzed. Nine cases were treated by external fixation within 26 hours (range, 6–56 hours) after injury. The definitive open reduction and internal fixation (ORIF) was performed after the wound was healed without infection and soft tissue swelling had subsided. During the delayed/second-stage operation, the articular surface of the distal tibial plafond was reduced through the posterolateral and anterior approaches. X-ray and CT scans were performed pre- or postoperatively. The reduction quality was evaluated using Burwell–Charnley's radiographic criteria. The follow-up was performed routinely and all complications were recorded. Ankle function was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. During the delayed/second-stage operation, primary reduction of the posterior column was performed entirely through posterolateral approaches. However, poor posterior column reduction was revealed by fluoroscopy in four cases, three of which were readjusted through the posterolateral and anterior approaches, and the fourth was adjusted directly through the anterior approach. Postoperative CT scan revealed that the step-off of the articular surface was less than 2 mm in 12 cases, and in only one case the step-off was greater than 2 mm but less than 5 mm. The satisfactory rate was 92.3% according to Burwell–Charnley's reduction criteria. Eleven patients were followed up regularly; superficial infections occurred in two cases but healed after wound care treatment in 3 and 5 weeks, respectively. All eleven fractures were healed within an average of 3.6 months (range, 2.6–5 months). The average range of ankle motion was 19° of dorsiflexion and 28° of plantar-flexion. The mean AOFAS ankle-hindfoot score was 82 (range, 61–92). In our opinion, we suggest that the reduction of the articular surface should be performed through combined posterolateral and anterior approaches in a delayed operation, with flexible fixation of the posterior column. If the posterior column is poorly reduced, the articular surface can easily be manipulated through anterior approaches. According to this strategy, satisfactory outcomes of AO/OTA C3 pilon fractures would be anticipated.
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