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

Preliminary results of stabilization of far distal tibia fractures with the distal tibial nail: A prospective, multicenter case series study

INTRODUCTION

The distal tibial nail (DTN) is a novel retrograde intramedullary nail used for distal tibial fracture stabilization. We investigated the clinical results of DTN use for distal tibial fractures and compared them with those reported in the literature on locking plates and antegrade intramedullary nails.

MATERIALS AND METHODS

This multicenter, prospective, observational cohort study examined distal tibial fractures with AO/OTA classification 43 types: A1, A2, A3 or C1. The primary outcomes included bone union rate, soft tissue problems, and surgical complications. Secondary outcomes were EuroQol-5 Dimension-5 Level (EQ-5D-5L), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot clinical scores 1 year postoperatively. Incidence of varus or valgus/anterior-posterior flexion deformity with a difference of ≥5° and postoperative reduction loss rate were evaluated.

RESULTS

Five men and five women were enrolled (mean age, 69 years [range, 30-77 years]), including one open-fracture-type Gustilo type IIIB case. Bone union was observed in all patients at 6 months postoperatively. Delayed union, leg edema, and guide pin breakage were observed in three, one, and one cases, respectively. No soft tissue or surgical complications were observed. During the final follow-up, the EQ-5D-5L, SAFE-Q, and AOFAS hindfoot scores were 0.876 (0.665-1.0), 83-92, and AOFAS 92.6 (76-100), respectively. Varus and retroflexion deformities were observed in one case each.

DISCUSSION

DTN has been reported to have biomechanically equivalent or stronger fixation strength than locking plates or antegrade intramedullary nails. In addition, while DTN was thought to be less invasive for soft tissue and can avoid injury to the knee, it was thought that care should be taken to avoid medial malleolus fractures and posterior tibialis tendon injuries. Comparisons with literature treatment results for locking plates and antegrade intramedullary nails showed comparable to advantageous results.

CONCLUSIONS

DTN treatment results for distal tibial fractures were as good as those for locking plates and antegrade intramedullary nails. DTN is useful for stabilization and does not compromise the surrounding soft tissues.

Analysis of risk factors, pathogenic bacteria characteristics, and drug resistance of postoperative surgical site infection in adults with limb fractures

PURPOSE

We carried out the study aiming to explore and analyze the risk factors, the distribution of pathogenic bacteria, and their antibiotic-resistance characteristics influencing the occurrence of surgical site infection (SSI), to provide valuable assistance for reducing the incidence of SSI after traumatic fracture surgery.

METHODS

A retrospective case-control study enrolling 3978 participants from January 2015 to December 2019 receiving surgical treatment for traumatic fractures was conducted at Tangdu Hospital of Air Force Medical University. Baseline data, demographic characteristics, lifestyles, variables related to surgical treatment, and pathogen culture were harvested and analyzed. Univariate analyses and multivariate logistic regression analyses were used to reveal the independent risk factors of SSI. A bacterial distribution histogram and drug-sensitive heat map were drawn to describe the pathogenic characteristics.

RESULTS

Included 3978 patients 138 of them developed SSI with an incidence rate of 3.47% postoperatively. By logistic regression analysis, we found that variables such as gender (males) (odds ratio (OR) = 2.012, 95% confidence interval (CI): 1.235 - 3.278, p = 0.005), diabetes mellitus (OR = 5.848, 95% CI: 3.513 - 9.736, p < 0.001), hypoproteinemia (OR = 3.400, 95% CI: 1.280 - 9.031, p = 0.014), underlying disease (OR = 5.398, 95% CI: 2.343 - 12.438, p < 0.001), hormonotherapy (OR = 11.718, 95% CI: 6.269 - 21.903, p < 0.001), open fracture (OR = 29.377, 95% CI: 9.944 - 86.784, p < 0.001), and intraoperative transfusion (OR = 2.664, 95% CI: 1.572 - 4.515, p < 0.001) were independent risk factors for SSI, while, aged over 59 years (OR = 0.132, 95% CI: 0.059 - 0.296, p < 0.001), prophylactic antibiotics use (OR = 0.082, 95% CI: 0.042 - 0.164, p < 0.001) and vacuum sealing drainage use (OR = 0.036, 95% CI: 0.010 - 0.129, p < 0.001) were protective factors. Pathogens results showed that 301 strains of 38 species of bacteria were harvested, among which 178 (59.1%) strains were Gram-positive bacteria, and 123 (40.9%) strains were Gram-negative bacteria. Staphylococcus aureus (108, 60.7%) and Enterobacter cloacae (38, 30.9%) accounted for the largest proportion. The susceptibility of Gram-positive bacteria to Vancomycin and Linezolid was almost 100%. The susceptibility of Gram-negative bacteria to Imipenem, Amikacin, and Meropenem exceeded 73%.

CONCLUSION

Orthopedic surgeons need to develop appropriate surgical plans based on the risk factors and protective factors associated with postoperative SSI to reduce its occurrence. Meanwhile, it is recommended to strengthen blood glucose control in the early stage of admission and for surgeons to be cautious and scientific when choosing antibiotic therapy in clinical practice.

Risk factors for tibial infections following osteosynthesis - a systematic review and meta-analysis

Aim

This study aimed to quantitatively summarise risk factors associated with surgical site infection (SSI) following surgically managed tibial fractures.

Method

We searched the Embase/Medline, Cochrane Library, and Scopus databases for relevant studies in October 2023. We included original studies investigating risk factors for SSI following surgically managed traumatic tibial fractures that included ≥10 adult patients with SSIs. Meta-analysis was performed when >5 studies investigated the same risk factor. The risk of bias was assessed using the critical appraisal checklist from Joanna Briggs Institute for cohort studies.

Results

This study included 42 studies comprising 24,610 patients with surgically managed tibial fractures and 2,418 SSI cases. The following were identified as significant risk factors for SSI (p < 0.05): compartment syndrome (odds ratio [OR] = 3.8, 95% confidence interval [CI]: 2.4-6.0), blood transfusion (OR = 3.8, 95% CI: 2.1-6.6), open fracture (OR = 3.6, 95% CI: 2.5-5.1), Gustilo-Anderson classification >2 (OR = 3.1, 95% CI: 2.1-4.6), external fixation (OR = 2.9, 95% CI: 2.3-3.8), American Society of Anesthesiologists classification >2 (OR = 2.5, 95% CI: 1.5-4.1), polytrauma (OR = 2.4, 95% CI: 1.5-4.0), dual incision approach (OR = 2.1, 95% CI: 1.5-3.0), smoking (OR = 1.8, 95% CI: 1.5-2.1), male sex (OR = 1.6, 95% CI: 1.3-1.8), high energy trauma (OR = 1.5, 95% CI: 1.1-2.1), and prolonged surgery time (OR = 0.62, 0.43-0.82). Other factors, including diabetes, hypertension, and time to surgery, were not identified as risk factors for SSI. However, the included studies were generally of poor quality and at risk of bias.

Conclusions

The review provides a basis for preoperatively assessing a patient's risk of developing an SSI, which could be used to initiate adjusted antibiotic regimes and more frequent postoperative controls. Furthermore, it indicates the risk factors future research should include when adjusting for confounding factors.

Management of High-Energy Tibial Pilon Fractures

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

Incidence and Risk Factors for Fracture-Related Infection After Peri-Prosthetic Femoral Fractures: A Multicenter Retrospective Study (TRON Group Study)

Background: Fracture-related infection (FRI) sometimes occurs with peri-prosthetic femoral fracture (PPF) treatment. Fracture-related infection often leads to multiple re-operations, possible non-union, a decreased clinical function, and long-term antibiotic treatment. In this multicenter study, we aimed to clarify the incidence of FRI, the causative organisms of wound infection, and the risk factors associated with post-operative infection for PPF. Patients and Methods: Among 197 patients diagnosed with peri-prosthetic femoral fracture who received surgical treatment in 11 institutions (named the TRON group) from 2010 to 2019, 163 patients were included as subjects. Thirty-four patients were excluded because of insufficient follow-up (less than six months) or data loss. We extracted the following risk factors for FRI: gender, body mass index, smoking history, diabetes mellitus, chronic hepatitis, rheumatoid arthritis, dialysis, history of osteoporosis treatment, injury mechanism (high- or low-energy), Vancouver type, and operative information (waiting period for surgery, operation time, amount of blood loss, and surgical procedure). We conducted a logistic regression analysis to investigate the risk factors for FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable. Results: Fracture-related infection occurred after surgery for PPF in 12 of 163 patients (7.3%). The most common causative organism was Staphylococcus aureus (n = 7). The univariable analysis showed differences for dialysis (p = 0.001), Vancouver type (p = 0.036), blood loss during surgery (p = 0.001), and operative time (p = 0.001). The multivariable logistic-regression analysis revealed that the patient background factor of dialysis (odds ratio [OR], 22.9; p = 0.0005), and the operative factor of Vancouver type A fracture (OR, 0.039-1.18; p = 0.018-0.19) were risk factors for FRI. Conclusions: The rate of post-operative wound infection in patients with a PPF was 7.3%. Staphylococcus was the most frequent causative organism. The surgeon should pay attention to infection after surgery for patients with Vancouver type A fractures and those undergoing dialysis.

Silver-coated versus uncoated locking plates in subjects with fractures of the distal tibia: a randomized, subject and observer-blinded, multi-center non-inferiority study

BACKGROUND

Antimicrobial coatings of implants are of interest to reduce infection rate in orthopedic surgery. Demonstration of clinical effectiveness of such coated implants to obtain market approval is challenging. The objective of this article is to define a design for a randomized controlled trial to evaluate the clinical performance of a silver-coating for locking plates for fracture treatment.

METHODS

The study design has to respect different criteria, such as feasibility, focus on overall complications, such as functional impairment, fracture healing, and particularly on infection rates. Distal tibia fractures were chosen due to the high prevalence of infections in this type of injuries, which warrants a particular benefit of antimicrobial prophylaxis and thus might allow to see a statistical trend in favor of the coated product. The study design was defined as a randomized, controlled, subject and observer-blinded, multi-center study in subjects with fractures of the distal tibia with a total of 226 patients. A number of 113 patients are planned for each of the two treatment arms with treatment of the fracture with a silver-coated device (first arm) or with an uncoated device (second arm). Inclusion criteria are closed fractures of the distal tibia according to the Tscherne-Oestern classification or open fractures of the distal tibia according to the Gustilo-Anderson classification in subjects older than 18 years. Primary outcome parameter is the Anticipated Adverse Device Effects (AADE) including all typical complications of this type of injury, such as functional impairment of the affected limb, non-union, and infections based on a non-inferiority study design. Also, silver-typical complications, such as argyria, are included. Secondary parameters are infection rates and fracture healing. Follow-up of patients includes five visits with clinical and X-ray evaluations with a follow-up time of 12 months.

DISCUSSION

Demonstration of clinical effectiveness of antimicrobial coatings of fracture fixation devices remains a challenge. Definition of a prospective randomized pre-market trial design and recruitment of clinical sites for such a study is possible. A confirmative proof of the expected clinical benefit in terms of reduction of device-related infections will be addressed with a prospective post-market clinical follow-up study in a second step due to the large sample size required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05260463. Registered on 02 March 2022.

Definitive Taylor Spatial Frame management for the treatment of high-energy open tibial fractures: Clinical and patient-reported outcomes

BACKGROUND

High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided.  We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided.

METHOD

A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant.

RESULTS

Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work.

CONCLUSION

Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures.  We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.

Tibial pilon fractures treated with a periarticular external fixator: Retrospective study of 47 cases

INTRODUCTION

Tibial pilon fractures are a treatment challenge, since there is no true gold standard treatment, and because of potential skin complications. Periarticular external fixation (PAEF) appears to produce good results, but the outcomes with the TL-HEX Trauma™ (Orthofix®, Verona, Italy) have not yet been evaluated. We performed a study with the following objectives: 1) evaluate time to union and union rate; 2) determine clinical and radiological results; 3) detect complications.

HYPOTHESIS

PAEF will produce comparable fracture union to other external fixator techniques for tibial pilon fractures.

METHODS

A single center, retrospective study, was done between June 2016 and December 2018. Patients who had a tibial pilon fracture operated with a PAEF were included if they had a minimum of 12 months' follow-up. Forty-seven patients were included; the mean follow-up was 2.45 years (1.2-3.7). The primary endpoint was the time to union and union rate at the final assessment. The secondary endpoints were the joint range of motion, residual pain (VAS), functional scores (AOFAS and SF12) and complication rate.

RESULTS

The union rate was 70% (33/47) and the mean time to union was 201±79 days (89-369). The range of motion was significantly reduced relative to the contralateral side. Twenty patients had residual pain that averaged 2.9 (1-6) on the VAS. The mean AOFAS score was 74 points (51-95). Twenty patients (43%) suffered at least one complication.

DISCUSSION

While a PAEF helps to avoid skin complications, in our study, it was associated with a lower union rate and longer time to union than in other published studies. This difference is likely due to a higher rate of open fractures and high-energy trauma in our study, different protocol for return to weightbearing and a different external fixator than other studies. This is the first study reporting the results of the TL-HEX Trauma in this indication.

LEVEL OF EVIDENCE

IV, retrospective study.

Morbidities and prognostic factors after tibial pilon fracture: impact on patients

INTRODUCTION

This study aims primarily to characterize the sequelae and morbidity associated with tibial pilon injuries from the patients' perspectives in terms of multiple surgical interventions, duration of hospital stay, downtime from work, loss of productivity and impact on patients' lives. The secondary aim is to review the associated risk factors for these morbidities.

MATERIALS AND METHODS

All patients with surgically treated tibial pilon fractures from 1st July 2007 to 30th June 2017 were included. The morbidities reviewed focused on delay to surgery, numbers of surgeries, limb amputation, length of stay (LOS), readmissions, duration of medical leave (ML), follow-up and number of outpatient visits.

RESULTS

There were 102 patients included in the review and up to 70% of them had an average 7 days delay to definitive surgery. They also required an average hospital LOS of at least 2 weeks extending up to 3 more weeks if soft tissue reconstruction was necessitated. Up to a third of patients were readmitted with 15% of them needing further treatment. These patients required a notable period of downtime from work as shown in the long ML (mean 152.6 days [S.D. = 110.7]). Multiple conditional regression models showed AO/OTA classification (B and C) and open fracture as independent predictors of delay to surgery. Predictors for increased LOS were high velocity mechanism of injury at 4 days longer and patients who needed soft tissue reconstruction at 21 days longer. In terms of downtime from work, only work injury has been identified as an independent predictor of ML at 88.5 days longer.

CONCLUSION

Tibial pilon fractures leads to significant morbidities with profound negative impact on patients' lives in terms of multiple surgical interventions required, prolonged hospital stay, need for readmissions and prolonged downtime from work. These morbidities from patients' perspective should be emphasized to patients and employers to manage their expectations and potential limitations.

Comparison of EQ-5D-3L and 5L versions following operative fixation of closed ankle fractures

Purpose

To undertake the first testing and comparison of measurement properties for the EuroQol EQ-5D-3L and 5L in patients with ankle problems.

Methods

The cross-sectional postal survey of 959 patients aged ≥ 18 years, who underwent surgical treatment (ORIF) for unstable and closed ankle fractures in Eastern Norway. Both the EQ-5D-3L and 5L were included in a postal questionnaire in 2015, 3–6 years post surgery. Missing data, floor and ceiling effects, and response consistency were assessed. Tests of validity included comparisons with scores for the SF-36 and widely used ankle-specific instruments. The 5L version was assessed for test–retest reliability.

Results

There were 567 (59%) respondents; 501 completed both versions and 182 (61%) the 5L retest questionnaire. The 5L outperformed the 3L in tests of data quality and classification efficiency. Correlations with scores for other instruments largely met expectations, those for the 5L being slightly higher. All 5L scores had acceptable levels of reliability. For the 5L index, the smallest detectable differences for group and individual comparisons were 0.02 and 0.20, respectively.

Conclusion

The 5L outperformed the 3L in terms of data quality, number of health states assessed and tests of validity. The 5L is recommended in research and other applications following surgery for ankle fracture but further testing including responsiveness to change is recommended at clinically relevant follow-up periods.

Risk factors for infection in fixation of distal tibia fractures

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Posterolateral Plating of Distal Tibia Fractures: Extending the Use of a Familiar Approach

BACKGROUND

Distal tibia fractures present challenges in surgical management and when nailing is not an option, plate osteosynthesis is performed. This is usually done with a minimally invasive approach to reduce the risk of wound complications in an already fragile soft-tissue envelope. We propose that a posterolateral open approach can lead to stable fixation construct and comes with advantages of approaching fibula fractures via same approach and has a thicker soft tissue envelope over the fixation. We report a series of distal tibia fractures with posterolateral plate fixation and present the outcomes.

METHODS

This is a retrospective review conducted at a single institution, where 13 patients underwent posterolateral approach for distal tibia fracture fixation. Where required, medial plating and fibular fixation was additionally performed. Patients were followed-up with primary endpoint of successful clinical and radiological union or complications required re-intervention. Operative and long-term clinical outcomes were recorded.

RESULTS

Long term follow-up was available for 12 patients. There was 1 non-union requiring revision (8.3%). For the other patients, clinical union occurred by 14.5 weeks and radiological union by 20 weeks on average. There was no malunion and 2 patients (16.6%) underwent removal of implants for symptoms of hardware irritation.

CONCLUSION

We found that outcomes in our cohort demonstrate posterolateral plating is safe as a primary or adjunctive method of fixation, and does not compromise other outcomes when compared with traditional fixation methods.

Is Definitive Plate Fixation Overlap With External Fixator Pin Sites a Risk Factor for Infection in Pilon Fractures?

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.

Efficacy of Pie-Crusting Technique on Soft Tissues in Distal Tibia and Fibula Fractures

Distal tibia and fibula fractures are challenging injuries to treat as evidenced by the high rates of wound complications because of vulnerable soft tissue coverage. The aim of this study was to examine the effect on soft tissue complications of the pie-crusting technique when applied between 2 incisions in distal tibia and fibula fractures treated with open reduction and internal fixation. We reviewed 34 patients with distal tibia and fibula fractures treated between September 2014 and March 2017. The pie-crusting technique was performed during wound closure in 16 (47.06%) fractures (group 1) and classic wound closure was done in 18 (52.94%) fractures (group 2). The primary outcome was evaluated as the presence or absence of soft tissue complications such as superficial skin necrosis, deep skin necrosis, and deep infection. The mean age was 50.44 ± 13.51 (range 23 to 65) years in group 1 and 51.67 ± 14.49 (range 18 to 68) years in group 2. The mean follow-up time was 27.35 ± 9.02 (range 16 to 46) months. The mean surgery time after injury was 5.88 ± 3.5 (range 1 to 14) days in group 1 and 7.32 ± 4.25 (range 1 to 16) days in group 2. No soft tissue complications were seen in any patient in group 1. Five (27.77%) occurrences of superficial skin necrosis were observed in group 2. In 2 (11.11%) patients in group 2, deep necrosis and wound dehiscence occurred, and subsequent deep infection developed in 1 (5.55%) of these patients. The overall complication rate was higher in group 2 (p = .005). We believe that the pie-crusting technique is beneficial for wound closure in distal tibia and fibula fractures, because it reduces the tension of the skin and allows leakage of subcutaneous fluids.

Successful Limb Salvage Using Bone Transport for Complete Loss of Distal Tibia and Talus: A Case Report

Complex comminuted fractures involving the distal tibia, ankle joint, and talus are often accompanied by bone loss and are highly prone to complications such as soft tissue infection, fixation failure, and posttraumatic arthrosis, with joint reconstruction being difficult in cases with severe joint destruction or bone loss. In this case, bone transport and fusion procedures were performed to treat a patient with an open fracture involving total talar dislocation, talar bone loss, and distal tibial bone loss. Just as in this case, where the surrounding soft tissues remain healthy, limb salvage via segmental bone transport may be a reasonable option in fractures with massive bone loss that include joints.

Soft tissue complications in distal tibial fractures managed with medial locking plates: A myth or reality?

BACKGROUND

Distal tibial fractures are common injuries that are prone to complications and require careful management. The use of medial periarticular locking plates is an established modality in the treatment if these fractures. These plates are inserted using the minimally invasive plate osteosynthesis (MIPO) or open technique. Our study looks at the soft tissue complications associated with the use of medial locking plates in the management of these fractures.

METHODS

This was a retrospective study carried out at a tertiary care university hospital in an urban setting. Forty four patients with distal tibia fractures treated with periarticular locking plates during a three year period were included in the study. Both closed and open fractures were included while those with an established non-union were excluded. Patient data related to inpatient stay, outpatient visits as well as readmissions was extracted from hospital records and analysed. Spanning external fixation was done if necessary and definitive fixation was done using medial locking plates with either MIPO technique or open reduction and internal fixation (ORIF) with biological technique. The sub cohort of patients with soft tissue complications was compared to the parent group.

RESULTS

The study group included 44 patients (28M:16F) with 45 fractures with a median age of 42.6 years (range 18-65 years) followed up for a mean of 9.2 months (range 5-20 months). Domestic falls were the cause of injury in 61.4% (n = 27) of the fractures. The average time to union was 26.2 weeks (range 12-66 weeks). Out of these 45 fractures, soft tissue complications were seen in 22.2% of cases (n = 10) with road side accidents seen in 60% (n = 6) of cases. In four patients, there was difficulty in achieving primary wound closure and in five other cases wound dehiscence with exposure of implant was seen within 12 to 30 days of surgery. One patient required secondary suturing after readjustment for malreduction. No statistically significant difference was found in the parent cohort and the sub cohort with soft tissue complications with respect to the use of spanning external fixator, MIPO/ORIF technique or fibular fixation.

CONCLUSION

The incidence of soft tissue complications with the use of medial locking plates in distal tibial fractures may be more than what is currently reported in literature and further studies are required to shed more light on this subject.

[Tibial pilon fractures : Advoidance and therapy of complications]

Because of the complex fracture morphology and vulnerable soft tissue coverage, fractures of the tibial pilon are difficult to treat. Complications are more common than in bi- or trimalleolar fractures. The surgeon has to know about the special risks of these injuries to avoid complications. Early complications are soft tissue necrosis, persisting fragment dislocations after surgery, loss of reposition and deep wound infection. The surgeon has to be aware of early signs of compartment-syndrome and chronic regional pain syndrome (CRPS). In late complications such as bony necrosis with or without deviation, non-union and osteoarthrosis of the ankle joint give the surgeon more time for planning the therapy. Intensive monitoring until bone healing is necessary in tibial pilon fractures to detect complications early and start the therapy immediately. This kind of therapy results in the best outcome for these patients.

Comparison of intramedullary nailing and minimal invasive plate osteosynthesis in the treatment of simple intra-articular fractures of the distal tibia (AO-OTA type 43 C1-C2)

OBJECTIVE

The aim of this study was to compare midterm functional and radiographic results of minimal invasive plate osteosynthesis (MIPO) with intramedullary nailing (IMN) of simple intra-articular distal tibial fractures (AO-OTA type 43 C1-C2).

METHODS

Seventy-three simple intra-articular distal tibial fracture patients were evaluated retrospectively. All were treated between 2009 and 2014. The average age of the patients was 40.3 years. Thirty-seven patients were treated with IMN and 36 patients were treated with MIPO. Fibular plate osteosynthesis was applied in 5 cases (13.5%) in the IMN group and in 23 patients (63.9%) in the MIPO group.

RESULTS

Functional results and complications of IMN and MIPO methods were assessed in 73 patients. The average union time was 16.4 ± 2.7 weeks in the IMN group and 15.2 ± 1.8 weeks in the MIPO group (p = 0.079). The average Olerud-Molander Ankle Score was 87.8 ± 8.1 in the IMN group and 81.5 ± 11.8 in the MIPO group (p = 0.013). Four patients in the IMN group experienced valgus malunion, while it was not observed in any patients in the MIPO group (p = 0.042). Recurvatum malunion was detected in 10 patients in the MIPO group and not seen in the IMN group (p = 0.001). Ankle dorsiflexion angle was 25.8 ± 4.5° in the IMN group and 33.3 ± 8.9° in the MIPO group (p = 0.000).

CONCLUSION

Simple intra-articular distal tibial fractures are successfully treated with IMN and MIPO. Prevalence of valgus malunion was higher in the IMN group and recurvatum was more prevalent in the MIPO group. MIPO is the first preference according to the literature; however, successful results have been obtained with IMN in this fracture pattern.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.