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

Management of Ipsilateral Pilon with Calcaneal Fractures: A Rare Case Report

Introduction

Ipsilateral pilon and calcaneal fractures are quite rare. Tibial pilon fractures are uncommon, <1% of all fractures to the lower extremity. Calcaneum is the most frequently fractured tarsal bone.

Case Report

This is a case report of a 33-year-old male presented on April 21, 2023 in Apollo Hospital, Navi Mumbai with ipsilateral pilon and calcaneal fracture with L2 burst fracture with cauda equina syndrome.

Result

The patient was treated D12-L4 Stabilization with dural repair on April 22, 2023 and was operated on April 28 with internal fixation with plates and screws for pilon and calcaneum .patient was followed up for a period of 1 year postoperatively.

Discussion

Open reduction and internal fixation of displaced calcaneal fractures and pilon fractures by locking plate to maintain the height and joint congruity. Surgery for pilon fractures fixation should be delayed, ideally till "wrinkling of the skin" occurs.

Conclusion

Based on our study, we conclude that a delayed single-stage open reduction and internal fixation with locking plate for calcaneum and pilon fracture with iliac crest bone graft is an excellent treatment option with good post-operative outcome and no significant complications. Axial loading due to a fall from height is the most common mode in these types of injuries.

Fibula fixation is not associated with a higher rate of wound complications during pilon fracture open reduction internal fixation

Introduction

There is a lack of consensus regarding indications for fibula fixation in pilon fractures. Reduction of the fibula fracture can assist with restoring lateral column length and reduction of the tibial plafond during pilon ORIF. However, there are theoretical concerns with wound complications and soft tissue insult. The purpose of this study is to compare short-term outcome measures after tibial plafond ORIF with and without supplemental fibula fixation using a validated national database.

Materials and methods

The American College of Surgeons' NSQIP database was utilized to identify all patients undergoing tibial plafond ORIF with and without fibula fixation between January 1, 2015 and December 31, 2020 using Current Procedural Terminology (CPT) codes 27827 and 27828, respectively. Open fractures and cases with concurrent open procedures were excluded from analysis. Demographic data, medical comorbidities, surgical variables, and various 30-day outcome measures were compared between the two groups. Multivariate logistic regression was used to identify independent variables associated with various outcome measure of interest.

Results

A total of 3120 patients were included in the final cohort: 1530 patients underwent tibia fixation alone and 1590 patients underwent both tibia and fibula fixation. The supplemental fibula fixation group had a higher rate of reoperation (2.3 % vs. 1.1 %, p = 0.013) and non-home discharge (14.8 % vs. 11.2 %, p = 0.003). The rate of surgical site infection was comparable between groups. Supplemental fibula fixation was independently associated with unplanned reoperation (RR: 1.939 [1.081-3.477], p = 0.026).

Conclusions

Patients undergoing supplemental fibula fixation during tibial plafond ORIF had a higher rate of 30-day reoperation and non-home discharge. Supplemental fibula fixation during pilon fracture ORIF was independently associated with a higher rate of 30-day reoperation. There was no difference in the rates of surgical site infection or wound dehiscence between the two groups.

Level of evidence

3.

Analysis of the Top Articles and Authors of the Journal of Orthopaedic Trauma and Bibliometric Comparison of Impact Factors of Orthopaedic Surgery Journals

OBJECTIVES

The objective of this study was to determine the top 100 cited authors and the top 20 articles in the Journal of Orthopaedic Trauma (JOT) and compare its impact factor (IF) with the orthopaedic and nonorthopaedic surgery literature.

METHODS

DESIGN

Retrospective.

SETTING

The Web of Science (WoS) and Journal Citation Reports (JCR) databases.

PATIENT SELECTION CRITERIA

Literature published in JOT from 1995 to present indexed in the WoS and JOT orthopaedic subspecialty and nonorthopaedic journals indexed in JCR with reported IF in 2023.

OUTCOME MEASURES AND COMPARISONS

WoS: Top 20 cited articles originating in JOT and top 100 cited author in the first, last, and any author position of JOT articles, author location of training and current place of work. JCR: Comparison of yearly IF and yearly IF percent growth of selected orthopaedic trauma, other orthopaedic subspecialty, and nonorthopaedic journals to JOT from 1997 to 2023.

RESULTS

The number of citations for the top 20 cited articles in JOT ranged from 302 to 787. Of the top 100 JOT first authors by the citation number, 93 were orthopaedic surgeons. In total, 65% of these completed a residency in the United States, 61% worked in the United States, and of the authors who work in the United States, 70.5% practice in an academic setting. From 1997 to 2023, JOT 's mean yearly IF was 1.6, and the mean yearly IF percent growth was 6.1%. The mean IF for included comparison orthopaedic subspecialty journals was 2.3, with 5.6% mean yearly IF percent growth. JOT's median IF was 1.8 and was second to Injury (IF 1.9) within orthopaedic trauma journals evaluated.

CONCLUSIONS

This bibliometric analysis shows that JOT's most cited authors are primarily US-trained orthopaedic surgeons in academic environments. JOT has consistently experienced annual growth in its IF throughout its almost 30-year history and has one of the highest impact factors of measured orthopaedic trauma journals.

The Direct Anterior Approach for AO/OTA43B and 43C Pilon Injuries

BACKGROUND

Pilon fractures carry high rates of early wound healing, infectious complications, and late posttraumatic arthrosis. When reconstructive procedures are indicated, these patients are at further risk for early complications. Perhaps using the same direct anterior (DA) approach for initial repair and later reconstruction might mitigate these risks, but the DA approach has not been explored for initial repair. This study aimed to evaluate the performance of the DA approach for internal fixation of pilon fractures. We hypothesized that the reoperation rate for fractures treated with the DA approach would not differ from other surgical approaches in our series.

METHODS

A retrospective chart and radiographic review of operative Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 43B and C fractures from 2013 to 2022 were undertaken. Using Kaplan-Meier estimations, the likelihood of reoperation within 1 year of index surgery was analyzed. Reoperation risk factors were determined using multivariable logistic regression analyses created using a backward stepwise process.

RESULTS

A total of 135 fractures in 130 patients were eligible for review. The overall reoperation rate was 40.7%. There was no significant difference between DA and all other approaches for rate of reoperation for infection (2.3% vs 10%, P = .21), nonunion (15.9% vs 16.5%, P > .99), posttraumatic osteoarthritis (PTOA) (9.1% vs 7.8%, P > .99), and removal of symptomatic hardware (25% vs 36.3%, P = .27). In multivariate regression analysis, DA approach was associated with a lower rate of reoperation within 1 year (odds ratio 0.25, 95% CI 0.07-0.71, P = .015).

CONCLUSION

The direct anterior approach can perform well for fixation of AO/OTA 43B and C fractures. Our retrospective series showed a favorable risk of reoperation at 1 year and a similar overall reoperation rate compared with all other combinations of approaches. Many factors determine the surgical approach to pilon fractures. This study has shown that the DA approach merits consideration as an option for open reduction and internal fixation.

The acute management of Pilon fractures (ENFORCE) study: a national evaluation of practice

INTRODUCTION

Pilon fractures are potentially limb-threating injuries. Staged soft tissue damage control is described, but actual practices are unknown. We report a national trainee collaborative evaluating how tibial Pilon fractures are acutely managed.

METHODS

ENFORCE was a multicentre retrospective observational study of the acute management of tibial Pilon fractures over a three-year period. Mechanism of injury, imaging, fracture classification, time to cast application, soft tissue damage control strategy and definitive management details were determined.

RESULTS

A total of 656 patients (670 fractures) across 27 centres were reported. AO fracture classifications were: partial articular (n=294) and complete articular (n=376). Initial diagnostic imaging mobilities were plain radiographs (n=602) and a trauma computed tomography (CT) scan (n=54). A total of 526 fractures had a cast applied in the emergency department (91 before radiological diagnosis), with the times taken to obtain postcast imaging being: mean 2.7 hours, median 2.3 hours and range 28 minutes-14 hours. 35% (102/294) of partial articular and 57% (216/376) of complete articular fractures had a spanning external fixator applied, all of which underwent a planning CT scan. Definitive management consisted of open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intramedullary nail (n=25) or other (n=18).

CONCLUSION

The management of tibial Pilon fractures is variable, with just over half of complete articular fractures managed with the gold standard 'span, scan, plan' staged soft tissue resuscitation. A national standard of care would increase the profile and standardise management of these potentially limb-threatening injuries, together with setting them apart from more straightforward ankle fractures.

Complications of Foot and Ankle Fractures in Diabetics

Patients with diabetes have an increased risk of both foot and ankle fractures. Patients with mild disease may be managed similarly to the population with no diabetes, although patients with advanced diabetes are likely to require more robust fixation with prolonged periods of non-weight-bearing. All patients with diabetes should be screened for peripheral neuropathy, as this is a marker for poor outcomes following both surgical and nonsurgical management. The overall goal of treatment is to achieve a stable, plantigrade foot that fits into normal footwear, supports functional ambulation, and avoids ulceration.

Are Drains Associated With Infection After Operative Fixation of High-Risk Tibial Plateau and Pilon Fractures?

OBJECTIVES

To determine the association between closed suction drainage and postoperative infection in patients with tibial plateau or pilon fractures. Secondarily, this study assessed whether intrawound vancomycin powder modified the association of closed surgical drains with infection.

METHODS

DESIGN

Secondary analysis of the Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial (VANCO).

SETTING

Thirty-six academic trauma centers.

PATIENT SELECTION CRITERIA

All patients with high-risk tibia fractures Orthopaedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO classification 41B/C or 43B/C) from the VANCO trial were considered. Closed suction drains were placed based on the treating surgeon's discretion. Patients were randomly assigned to receive 1-gram intrawound vancomycin powder in the surgical wound at definitive fixation or the standard infection prevention protocol at each center.

OUTCOME MEASURES AND COMPARISONS

Deep surgical site infection (SSI) within 6 months. Comparisons were made between patients treated with and without drains. Subgroup analysis also examined the effect of drains in patients with and without intrawound vancomycin powder.

RESULTS

Of the 978 study patients, 197 (20%) were treated with drains. Deep infection rates did not significantly differ between patients with or without surgical drains (8% vs. 8%, P = 0.88). However, intrawound vancomycin powder significantly modified the association of surgical drains on deep SSI (interaction P = 0.048). Specifically, patients with drains but no vancomycin powder had the highest deep infection rate (13%; 95% confidence interval, 6%-19%). When vancomycin powder was used in addition to a drain, deep SSI rates were reduced by 10% (95% confidence interval, 2%-17%, P = 0.01).

CONCLUSIONS

This study suggests that closed suction drains after operative fixation of high-risk tibia fractures may not be associated with deep infection in general. However, a secondary analysis raises the possibility that drains are associated with reduced deep infection rates if topical vancomycin powder is used but associated with increased infection rates if vancomycin powder is not used.

LEVEL OF EVIDENCE

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

Volumetric assessment of the soft tissue envelope in unilateral closed ankle fractures using a portable 3D scanner

Management of ankle fractures necessitating surgery is impacted by soft tissue swelling, often delaying open reduction and internal fixation (ORIF). Subjective evaluations are inconsistent, and traditional measurement methods are often inaccurate or impractical. This prospective observational study included 17 adults with unilateral closed ankle fractures requiring surgical fixation. A measurement protocol on regions of interest (ROI) was utilized, employing a handheld 3D scanner for daily volume scans of the fractured ankle, comparing these measurements with subjective assessments of swelling using a numerical scale. The 3D scanner detected significant soft tissue volume reductions of the ROI over 14 days, with reductions of 25 ± 25 % in the lower limb and 16 ± 9 % in the ankle. Significant swelling reduction was noted from day 8, preceding surgeons' assessments (days 11-14). The scanner exhibited high reproducibility, providing an objective tool for comparative studies on decongestive measures in perioperative soft tissue management.

The Impact of Fibular Fixation Method on Pilon Fracture Healing

Background: Pilon fractures are associated with high-energy injuries, and there is presently much debate as to optimal fixation strategies and timing of intervention. There is little evidence comparing the type of fibular fixation during pilon fracture fixation. The purpose of this study was to compare fibular fixation methods in complex pilon injuries as it relates to pilon union rates and development of post-traumatic arthritis. Methods: This was a retrospective review from an urban Level 1 trauma center from January 2009 to May 2019, including patients age ≥ 18 who sustained a pilon fracture with an associated fibula fracture. Patients were allocated into one of three groups based on fibular fracture treated with plating, intramedullary device, or no fixation. Radiographic analysis was performed postoperatively and at final follow up to evaluate for tibial or fibular nonunion, malunion, talocrural angle, and ankle Kellgren-Lawrence grade. Results: Of the 107 patients in this study, 42 underwent surgical fixation of their fibular fracture. There were no differences with respect to tibial or fibular union rates amongst the three groups. Furthermore, there were no differences in the presence of radiographic ankle arthritis at final follow up. However, Kellgren-Lawrence arthritis grading did appear to be a more severe grade in patients who did not undergo fibular fixation (p = 0.001). Conclusions: Fibular intramedullary fixation does not appear to influence tibial or fibular nonunion rates as compared to plating in complex pilon injuries.

Risk Factors and Complications in Tibiotalocalcaneal (TTC) Arthrodesis: A Nationwide Database Comparison Between Traumatic Ankle Fracture and Osteoarthritis

Background

Tibiotalocalcaneal (TTC) arthrodesis is an established treatment for osteoarthritis (OA), offering stabilization and earlier weightbearing. However, its role in managing traumatic fractures (TFs) remains controversial because of higher risks of complications. This study aimed to compare complication rates, readmissions, and predictors of adverse outcomes in TTC arthrodesis performed for OA vs TF using a national database.

Methods

A retrospective cohort study was conducted using the Nationwide Readmissions Database (2016-2021). Patients undergoing TTC arthrodesis were identified via International Classification of Diseases, Tenth Revision (ICD-10) codes and stratified by indication (OA or TF). Primary outcomes included complication rates, 30- and 90-day readmissions, and revision surgeries. Multivariable logistic regression identified independent predictors of complications. Propensity score matching (PSM) was performed to account for baseline differences.

Results

TF cases exhibited significantly higher complication rates (54.5% vs 16.0%, P < .001), including malunion (11% vs 2%, P < .001) and cellulitis (5% vs 1%, P < .001). Readmission rates were also elevated in TF patients at 30 days (17% vs 3%, P < .001) and 31-90 days (14% vs 4.8%, P < .001). Logistic regression identified chronic kidney disease, diabetes, and obesity as independent predictors of complications. PSM confirmed these findings, demonstrating significantly higher rates of complications and readmissions in TF patients.

Discussion

Findings indicate that TTC arthrodesis for TF is associated with higher risks of complications and readmissions compared with OA, attributable to acute injury characteristics and surgical complexity. Chronic comorbidities further exacerbate these risks. Optimizing perioperative management and timing of surgery in TF patients may mitigate complications. This study highlights the need for individualized care strategies to improve outcomes in TTC arthrodesis for trauma.

Level of Evidence

Level III, therapeutic: case-control study.

Predicting deep infection in pilon and tibial plateau fractures: a secondary analysis of the VANCO and OXYGEN trials

Objectives

To develop and validate a prediction model for a deep surgical site infection (SSI) after fixation of a tibial plateau or pilon fracture.

Design

Pooled data from 2 randomized trials (VANCO and OXYGEN).

Setting

Fifty-two US trauma centers.

Patients

In total, 1847 adult patients with operatively treated tibial plateau or pilon fractures who met criteria for a high risk of infection.

Intervention

We considered 13 baseline patient characteristics and developed and externally validated prediction models using 3 approaches (logistic regression, stepwise elimination, and machine learning).

Main Outcomes and Measures

The primary prediction model outcome was a deep SSI requiring operative debridement within 182 days of definitive fixation. Our primary prognostic performance metric for evaluating the models was area under the receiver operating characteristic curve (AUC) with clinical utility set at 0.7.

Results

Deep SSI occurred in 75 VANCO patients (8%) and in 56 OXYGEN patients (6%). The machine learning model for VANCO (AUC = 0.65) and stepwise elimination model for OXYGEN (AUC = 0.62) had the highest internal validation AUCs. However, none of the external validation AUCs exceeded 0.64 (range, 0.58 to 0.64).

Conclusions

The predictive models did not reach the prespecified clinical utility threshold. Our models' inability to distinguish high-risk from low-risk patients is likely due to strict eligibility criteria and, therefore, homogeneous patient populations.

A pilot prospective study of forward-looking infrared (FLIR) camera measurements to predict postoperative wound complications in high-energy lower extremity fractures

PURPOSE

To prospectively determine if forward-looking infrared (FLIR) camera temperature measurements can predict postoperative wound complications in high-energy lower extremity fractures.

METHODS

This is a prospective cohort study from a single level 1 trauma centre. Adult patients who sustained unilateral high-energy lower extremity fractures (tibial plateau, tibial plafond, trimalleolar ankle, midfoot, or calcaneus fractures) were included in the study. Preoperative and post-induction FLIR thermographic measurements were taken using the FLIRONE ® PRO camera system. The main outcome of interest was the development of any wound related postoperative complication.

RESULTS

Forty-eight patients were included in the study. A majority of the patients were male (58%) with a mean age of 44.2 years. FLIR imaging detected temperature differences between the operative extremity and the contralateral extremity, both in the preoperative area and following induction (Pre-op: 33.0 vs 30.8, p < 0.001; Post-induction: 29.6 vs 28.5, p = 0.046). Overall, 11 (23.9%) patients experienced a wound complication. Regression analysis did not demonstrate a significant association between preoperative or post-induction FLIR measurements and the development of wound complications.

CONCLUSION

While FLIR imaging could detect temperature changes related to traumatic injury, these differences did not correlate with postoperative outcomes. Further large-scale study may be warranted.

LEVEL OF EVIDENCE

III.

Timing of Fracture Fixation in Ankle Fracture-Dislocations

Ankle fracture-dislocations may require delayed internal fixation. Our aim was to compare acute open reduction and internal fixation (ORIF) with delayed ORIF, using external fixation or cast splint in ankle fracture-dislocations. Factors that affect the rates of re-operation and Surgical site infection (SSI) were identified. In this retrospective cohort study, patients were included with open and closed ankle fracture-dislocations treated with ORIF from two large peripheral hospitals and one academic center in the Netherlands. This study included 447 patients with an ankle fracture-dislocation. In the multivariate analysis, the difference between surgery <48 hours compared to bridging with cast or external fixation had no significant influence on unscheduled re-operation or SSI. Higher body mass index (BMI) and open fractures had a significant positive correlation with re-operation while diabetes mellitus (DM) and open fractures correlated with SSI. In patients with open fractures, there was also no significant difference in outcome between acute or delayed internal fixation. We suggest that it is safe to perform primary ORIF on all dislocated ankle fractures if the soft tissue injury allows surgery within 48 hours. When significant swelling is present, patients with well-reduced fractures and with no soft tissue injury could be treated safely with a cast until delayed ORIF is possible.Level of Evidence: Therapeutic level 2B (retrospective cohort study).

Temporary Circular External Fixation for Spanning the Traumatized Ankle Joint

Background

Temporary ankle-spanning circular fixation aims to provide osseous stability while (1) allowing access to and recovery of the traumatized soft-tissue envelope and (2) facilitating safe, comfortable, and clinically relevant cross-sectional imaging for surgical planning. It is most commonly utilized in a "span-scan-plan" treatment strategy in cases of peri-articular fractures around the ankle2. Conventional monolateral fixators are prone to morbidity at the half-pin sites in the foot and variation in construct stability. Temporary ankle-spanning circular external fixation of the traumatized ankle joint can mitigate these issues.

Description

A circular external fixator construct is assembled beginning with a single tibial ring that is fixed to the tibia by half-pins that are spread on either side of the ring and forming a "virtual ring block." A foot ring is attached via 2 crossed tensioned fine wires in the calcaneum and a single midfoot fine wire in order to prevent an equinus deformity. The tibial virtual ring block and the foot ring are interconnected by 3 polyaxial "rapid-adjust struts" that are evenly distributed around the limb. The fracture is then reduced, and the polyaxial rapid-adjust struts are locked1.

Alternatives

Numerous constructs have been proposed to optimally immobilize the ankle joint while also allowing limb elevation and access to the ankle for soft-tissue care3-6. A commonly utilized construct is the monolateral "bar-and-clamp" spanning external fixator, which relies on half-pin fixation in the foot that may induce bone lysis, result in pin-site infections, and prevent weight-bearing. Calcaneal half-pins are particularly troublesome and can lead to adjacent lysis, instability, and potential loss of initial reduction as a result of the cancellous bone quality.

Rationale

The principal objective of temporary joint-spanning external fixation is to realign the traumatized joint and to maintain this reduction until definitive surgery while facilitating soft-tissue treatment and surgical planning7-11. This strategy forms the first step in the "span-scan-plan" approach to pilon fractures described by Sirkin et al.2. Multiple subsequent studies have confirmed the superiority of external fixation over splinting for initial soft-tissue care following distal tibial and ankle trauma12,13.

Expected Outcomes

Temporary circular external fixation has been shown to outperform monolateral fixation in terms of both the adequacy of the initial reduction and the maintenance of this reduction1. Harrison et al. demonstrated that temporary circular fixation of the traumatized ankle yielded 100% good or excellent initial reduction compared with 91% for monolateral fixation. This initial reduction was also better maintained by circular fixator constructs compared with monolateral ones (96% versus 78%).

Important Tips

Placement and orientation of the rings should take into account the zone of injury, access for orthoplastic procedures, and the maximum length of adjustable struts.Orthogonal frame application allows the best biomechanical environment for stabilization of fracture and/or dislocation of the tibiotalar joint to facilitate soft-tissue care. Care should be taken in the operating room to ensure orthogonal mounting of both the proximal and the distal ring to their respective bone segments.Avoid transverse fine wires in the calcaneus to prevent translation while in the frame; consider the use of tensioned olive wires to further protect against translation.Place the midfoot wire through the base of the metatarsals or along the cuneiforms to maximize fixation.Take care to avoid placing the ankle or forefoot in equinus.

Acronyms and Abbreviations

CEF = circular external fixatorPAD = pronation adductionPER = pronation external rotationSAD = supination adductionSER = supination external rotation.

Management of Pilon Fractures

Pilon fractures are complex injuries that can be difficult to treat and lead to severe complications if not managed appropriately. A thorough examination for polytraumatic injuries, neurovascular status, and skin condition should be done. A variety of approaches can be chosen based on fracture pattern, including staging, incisional approach, and no-touch technique. This article discusses various ways to manage pilon fractures.

Severe Pilon Fractures: The Role of Quality of Reduction in Clinical and Functional Outcomes

Introduction The purpose of the current study is to present the outcome of closed reduction and stabilization using an Illizarov ring fixator in severe pilon fractures and to investigate the correlation between reduction quality and clinical and functional outcomes. Materials and methods Thirty-three type III tibial plafond fractures, which had been treated with this method, were retrospectively analysed. Quality of reduction was classified according to the Teeny & Wiss (TW) criteria. Clinical and functional assessment was carried out using the Ovadia & Beals (OB) and Olerud & Molander (OM) scores. Results All fractures were successfully united. The mean time in the fixator was 6.3 months, and the mean follow-up was 50 months after frame removal. There were no major infections. There was no significant relationship between TW and OM (r=-0.34, p=0.13), TW and OB (r=0.35, p=0.23), neither Delay (from injury until surgery) and OM (r=-0.03, p=0.28), and Delay and OB (r=0.30, p=0.31). Conclusions The present study demonstrates that the major problems of open reduction and internal fixation of pilon type III fractures can be avoided by a non-invasive approach to the treatment of these fractures. The articular surface can be reconstituted with olive-tip wires and small fragment washers, early ligamentotaxis and fracture stabilization with the Ilizarov ring fixator. These simple steps could lead safely to union and a good clinical and functional outcome.

Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures

BACKGROUND

This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours.

METHODS

Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion.

RESULTS

One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours.

CONCLUSION

Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner.

LEVEL OF EVIDENCE

Level IV.

Evaluation of Functional Outcome in Surgically Managed Tibial Pilon Fractures

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

Staged treatment of bicondylar tibial plateau fractures: influence of frame configuration and quality of reduction on outcomes

PURPOSE

Despite evolving treatment, the surgical management of high-energy tibial plateau fractures (TPF) remains challenging, associating high rates of complications. In recent decades, staged management has emerged as an encouraging option. The main goal of our study was to evaluate the influence of bridging external fixation (EF) frame configuration and the resultant quality of reduction (QOR) on outcomes after staged-treatment of bicondylar TPF.

METHODS

A retrospective review was conducted of patients with bicondylar TPF treated at our level-I trauma center using a staged-treatment protocol from January 2010 to January 2020. Data on baseline characteristics, injuries, treatments, and clinical/radiological results were collected. The QOR was evaluated on CT images after EF and on plain films after ORIF.

RESULTS

Sixty-eight patients were eligible for analysis. By our criteria, QOR was good in 57.4% and 70.6% after EF and ORIF, respectively. A squared EF configuration was associated with superior EF QOR (p = 0.032), while better EF QOR was linked to improved ORIF QOR (p = 0.016). No relationship between ORIF delay and ORIF QOR was identified. Postoperative complications were documented in 19 patients. Average ROM at one-year follow-up was 114.9 ± 12.6°, and non-influenced by anterior femoral pin placement.

CONCLUSIONS

Staged management of bicondylar TPF resulted in a reasonable rate of complications. A direct relationship between QORs obtained with EF and after ORIF was found. Squared frames were associated with faster and better reductions, regardless of the surgeon's background. Considering our results, we advocate for the wider use of squared EF configurations in these patients.

Should We Fix the Fibula in Tibial Plafond Fractures? A Meta-analysis Reviewing the Evidence Base for Fibula Open Reduction and Internal Fixation in Tibial Plafond Fractures

Open reduction and internal fixation are the standard of care to stabilize tibial plafond fractures. However, it remains uncertain as to whether fixation of the fibula affects the outcome. This study aimed to review the evidence base for comparable outcomes in tibial plafond fractures when undergoing open reduction and internal fixation of ipsilateral fibula fractures compared with open reduction and internal fixation of the tibia alone. A systematic review and meta-analysis of the literature was completed; 4 studies were included for analysis. This study demonstrated no statistically significant differences in the incidence of nonunion (p = .784) or mal-union (p = .416). There was a greater rate of removal of metalwork in the fibula operative group compared to the tibia alone group (p < .001). The current evidence demonstrates that open reduction and internal fixation of ipsilateral fibula fractures in tibial plafond fractures is not necessarily routinely indicated for all fractures.

The Use of the Ilizarov Fixator for the Treatment of Open and Closed Tibial Shaft and Distal Tibial Fractures in Patients with Complex Cases

INTRODUCTION

Open and closed fractures of the tibial shaft or distal tibia can be challenging for surgeons to treat if the fractures are accompanied by aggravating conditions, such as various accompanying diseases, pronounced soft tissue injuries, osteomyelitis, and/or noncompliance. The aim of this retrospective study was to present our approach and results with the Ilizarov fixator as a treatment option for such individually complex cases.

MATERIALS AND METHODS

Between 2005 and 2018, 20 patients were treated with the Ilizarov fixator for fractures of the tibial shaft/distal tibia. The indication for this was a 2nd- to 3rd-degree open fracture in 10 patients, a 1st-degree open fracture in one patient, and closed fractures in 9 patients. Aggravating conditions included soft tissue injuries, osteomyelitis, leg deformities, multiple traumas, smoking, alcohol/drug abuse, and obesity (BMI > 60). In addition to demographic data, the time of fixator treatment, complications, and the endpoint of consolidation were evaluated retrospectively.

RESULTS

The mean time of fixator treatment was 29 (range 15-65) weeks. Complete fracture consolidation was achieved in 13 patients (65%) with the Ilizarov fixator. The mean follow-up period after fixator removal was 36 (range 2-186) months in 14 patients. Five patients with complete consolidation were lost to further follow-up. One patient was amputated. In six patients without union, internal osteosynthesis was carried out.

CONCLUSION

The use of the Ilizarov fixator is a treatment option for individual high-risk patients with complicating courses but should be seen as a salvage procedure due to the high complication rate and long treatment process.

Early posterior column internal fixation: A staged treatment of type C3 tibial pilon fracture

Pilon fractures represent a challenging subset of tibial fractures. The management of AO/OTA Type C3 fractures remains complex due to associated complications and lack of clear guidelines for surgical timing and methods. A prospective cohort study was conducted to evaluate two staged treatment strategies for AO/OTA Type C3 tibial pilon fractures. The study focused on assessing surgical difficulty, complications, and patient prognosis. One group of patients received early internal fixation of the fibula and tibial posterior column combined with external fixation, while the other group received external fixation alone in the first stage. Patients who received early internal fixation of the fibula and tibial posterior column combined with external fixation had better outcomes, including lower rate of allogeneic bone grafting (67.74 % versus 94.64 %), reduced incidence of wound delay and skin necrosis (3.23 % versus 21.43 %), shorter surgical time (133.06 ± 23.99 min versus 163.04 ± 26.83 min), shorter hospital stay (13.77 ± 2.53 days versus 18.25 ± 3.67 days), and higher AOFAS (83.05 ± 8.68 versus 79.36 ± 8.92). Additionally, avoiding fibular shortening was shown to be crucial in preventing prolonged surgery and improving patient function. The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. The findings support the use of this treatment to optimize outcomes in AO/OTA Type C3 pilon fractures.

Primary Ankle Fusion Using an Antegrade Nail Into the Talus for Early Treatment of OTA Type C3 Distal Tibial Plafond Fractures: A Preliminary Report

BACKGROUND

Type C3 distal tibial plafond fractures consistently show poor outcomes with high complication rates and significant risk of posttraumatic arthritis. We describe a minimally invasive technique of performing a primary ankle fusion using an anterograde tibial nail and compare our early results to traditional methods of fixation.

METHODS

During the acute admission, the patient undergoes an arthroscopic preparation of the ankle joint and insertion of an anterograde nail into the talus. This technique is described in detail and presented alongside a retrospective 5-year review of all adult C3 distal tibial plafond fractures from our center.

RESULTS

Twenty-six patients (8 open fractures) had been fixed traditionally using open reduction internal fixation (24 patients) and circular frames (2 patients) with an average follow-up of 20 months. Those internally fixed had protected weightbearing for 3 months. Complications included deep infection (12%), nonunion (8%), malunion (4%), severe posttraumatic osteoarthritis (27%), and the secondary conversion to ankle replacement/fusion (12%) requiring an average of 3 reoperations.Six patients underwent primary fusion (3 open fractures) with an average follow-up of 18 months. Patients were allowed to immediately weightbear. There were no reported complications and the primary fusion group demonstrated shorter hospital stays, faster return to work, and higher mean self-reported foot and ankle score (SEFAS) compared to those treated with ORIF.

CONCLUSION

C3 distal tibial plafond fractures are difficult to manage and there has not been a satisfactory method of treating them that allows early return to work, has a low risk of complications, and reduces the risk of posttraumatic tibiotalar arthritis.We present our initial results with a method that uses traditional arthroscopic techniques to prepare the tibiotalar joint together with minimally invasive anterograde tibiotalar nailing. In this initial report of a small group of patients, we found that surgery can be performed once the swelling has subsided after injury and that allowing weightbearing as tolerated did not appear to have a negative effect on initial outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Role of Negative Suction Therapy and Platelet-Rich Plasma in the Management of Delayed Post-operative Wound Healing: A Case Report

Tibial Pilon fractures are rare yet devastating injuries. To classify these fractures, the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification system is the most commonly used method. Out of all the different types, type C fractures are the most difficult to manage because the enormous energy involved in creating this type of injury typically severely destroys the soft tissue surrounding the fracture zone. As a result, long-term outcomes are frequently poor, and proper initial primary care is critical. Pilon fractures are injuries that are difficult to manage, considering the poor soft tissue envelope. These injuries often are associated with delayed wound healing and require staged management. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. We share our experience in the management of AO type 43C3 grade I compound distal tibia fibular fracture with post-operative wound dehiscence, successfully managed with vacuum-assisted closure (VAC) and platelet-rich plasma (PRP) therapy.

Plating Versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis

OBJECTIVE

To compare rates of reduction loss, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (plate fixation [PF]).

METHODS

DESIGN

Retrospective review.

SETTING

Level-I academic trauma center.

PATIENT SELECTION CRITERIA

Patients age ≥ 18 with OTA/AO 43C1 and C2 IADTF treated with IMN or PF between 2013-2021.

OUTCOME MEASURES AND COMPARISONS

Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs) were compared for IMN versus PF treatments.

RESULTS

One hundred ten patients met the inclusion criteria (IMN 33 and PF 77). There was no loss of reduction found. Seventeen nonunions (15% overall; IMN 4/33 and PF 13/77) and 13 SSIs (12% overall; IMN 2/33 and PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (odds ratio 0.09 for closed fracture, 95% confidence interval, 0.02-0.56, P = 0.009) and SSI (odds ratio 0.07 for closed fracture, 95% confidence interval, 0.06-0.26, P = 0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients who received IMN versus PF ( P = 0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI ( P = 0.54 and P = 0.17, respectively). There was also no difference in PROs between IMN and PF (physical function: P = 0.25 and pain interference: P = 0.21).

CONCLUSIONS

Overall nonunion and SSI prevalence was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture was a significant risk factor for nonunion and SSI. Metaphyseal fixation through IMN or PF did not affect loss of reduction, nonunion, SSI, or PROs.

LEVEL OF EVIDENCE

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

Fracture blisters: predictors for time to definitive fixation in pilon fractures

PURPOSE

Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity.

METHODS

Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs.

RESULTS

314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2 days vs 7.9 days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007).

CONCLUSION

The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.

The VANCO Trial Findings Are Generalizable to a North American Trauma Registry

OBJECTIVES

To estimate the generalizability of treatment effects observed in the VANCO trial to a broader population of patients with tibial plateau or pilon fractures.

METHODS

Design and Setting: Clinical trial data from 36 United States trauma centers and Trauma Quality Programs registry data from more than 875 Level I-III trauma centers in the United States and Canada.Patient Selection Criteria: Patients enrolled in the VANCO trial treated with intrawound vancomycin powder from January 2015 to June 2017 and 31,924 VANCO-eligible TQP patients admitted in 2019 with tibial plateau and pilon fractures.Outcome Measure and Comparisons: Deep surgical site infection and gram-positive deep surgical site infection estimated in the TQP sample weighed by the inverse probability of trial participation.

RESULTS

The 980 patients in the VANCO trial were highly representative of 31,924 TQP VANCO-eligible patients (Tipton generalizability index 0.96). It was estimated that intrawound vancomycin powder reduced the odds of deep surgical infection by odds ratio (OR) = 0.46 (95% confidence interval [CI] 0.25-0.86) and gram-positive deep surgical infection by OR = 0.39 (95% CI, 0.18-0.84) within the TQP sample of VANCO-eligible patients. For reference, the trial average treatment effects for deep surgical infection and gram-positive deep surgical infection were OR = 0.60 (95% CI, 0.37-0.98) and OR = 0.44 (95% CI, 0.23-0.80), respectively.

CONCLUSIONS

This generalizability analysis found that the inferences of the VANCO trial generalize and might even underestimate the effects of intrawound vancomycin powder when observed in a wider population of patients with tibial plateau and pilon fractures.

LEVEL OF EVIDENCE

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

The effect of spanning external fixation on entrapped structures in tibial pilon fractures

PURPOSE

Pilon fractures are often complex injuries involving severe soft tissue injury. Studies have shown pilon fractures may entrap soft tissue structures between fracture fragments. Staged fixation of pilon fractures with spanning external fixation (SEF) is important for soft tissue rest and plays an important role in the management of these injuries. While SEF has been shown to promote soft tissue rest prior to definitive fixation, no studies have shown the effect SEF has on entrapped structures (ES). The purpose of this study was to evaluate how SEF effects ES in pilon fractures.

METHODS

A retrospective review of 212 pilon fractures treated at our institution between 2010 and 2022 was performed. Patients with a CT scan pre-SEF and post-SEF met inclusion criteria. CTs were reviewed to characterize ES in pre- and post-SEF imaging.

RESULTS

Of the 19 patients with ES identified on CT pre-SEF, seven (36.8%) had full release of ES post-SEF and 12 (63.2%) had no release of ES. The posterior tibial tendon was the most commonly ES and remained entrapped in 62.5% of cases. Only 25% of 43-C3 fractures had release of ES post-SEF, while 100% of 43-C1 and 43-C2 fractures demonstrated complete release of ES post-SEF.

CONCLUSION

Entrapped structures in pilon fractures are likely to remain entrapped post-SEF, with only one-third of our cohort demonstrating release. In 43-C3 patterns, if ES are identified on CT pre-SEF, surgeons should consider addressing these either through mini open versus open approaches at the time of SEF as they are likely to remain entrapped post-SEF.

Establishing regions of interest of the lower leg and ankle for perioperative volumetric assessment with a portable 3D scanner in orthopedic and trauma surgery - a pilot study

BACKGROUND

Soft tissue swelling assessment benefits from a reproducible and easy to use measurement method. Monitoring of the injured lower extremity is of clinical import during staged soft tissue management. Portable 3D scanners offer a novel and precise option to quantify and contrast the shapes and volumes of the injured and contralateral uninjured limbs. This study determined three regions of interest (ROI) within the lower extremity (lower leg, ankle and foot), that can be used to evaluate 3D volumetric assessment for staged soft tissue management in orthopedic and trauma surgery.

METHODS

Twelve healthy volunteers (24 legs) were included in this cohort study. Scans of all three ROI were recorded with a portable 3D scanner (Artec, 3D scanner EVA) and compared between the right and left leg using the software Artec Studio (Arctec Group, Luxemburg).

RESULTS

Mean volume of the right leg was 1926.64 ± 308.84 ml (mean ± SD). ROI: lower leg: 931.86 ± 236.15 ml; ankle: 201.56 ± 27.88 ml; foot: 793.21 ± 112.28 ml. Mean volume of the left leg was 1937.73 ± 329.51 ml. ROI: lower leg: 933.59 ± 251.12 ml; ankle: 201.53 ± 25.54 ml; foot: 802.62 ± 124.83 ml. There was no significant difference of the overall volume between right and left leg (p > 0.05; overall volume: △ difference: 29.5 ± 7.29 ml, p = 0.8; lower leg: △ difference: 21.5 ± 6.39 ml, p = 0.8; ankle: △ difference: 5.3 ± 2.11 ml, p = 0.4; △ difference: 16.33 ± 4.45 ml, p = 0.8.

CONCLUSION

This pilot study defines three regions of interest of the lower leg and demonstrates no difference between the right and left side. Based on these ROI, further studies are needed to evaluate the clinical applicability of the scanner.

Do superficial infections increase the risk of deep infections in tibial plateau and plafond fractures?

PURPOSE

Open reduction internal fixation of tibial plateau and pilon fractures may be complicated by deep surgical site infection requiring operative debridement and antibiotic therapy. The management of superficial surgical site infection is controversial. We sought to determine whether superficial infection is associated with an increased risk of deep infection requiring surgical debridement after fixation of tibial plateau and pilon fractures.

METHODS

This is a secondary analysis of data from the VANCO trial, which included 980 adult patients with a tibial plateau or pilon fracture at elevated risk of infection who underwent open reduction internal fixation with plates and screws with or without intrawound vancomycin powder. An association of superficial surgical site infection with deep surgical site infection requiring debridement surgery and antibiotics was explored after matching on risk factors for deep surgical site infection.

RESULTS

Of the 980 patients, we observed 30 superficial infections (3.1%) and 76 deep infections (7.8%). Among patients who developed a superficial infection, the unadjusted incidence of developing a deep infection within 90 days was 12.8% (95% confidence interval [CI] 1.3-24.2%). However, after a 3:1 match on infection risk factors, the 90-day marginal probability of a deep surgical site infection after sustaining a superficial infection was 6.0% (95% CI  - 6.5-18.5%, p = 0.35).

CONCLUSION

Deep infection after superficial infection is uncommon following operative fixation of tibial plateau and pilon fractures. Increased risk of subsequent deep infection attributable to superficial infection was inconclusive in these data.

LEVEL OF EVIDENCE

Prognostic Level II.

A case report of circular external fixator with low-profile mini-fragment plate fixation: A combination of two methods for a tibial pilon fracture

Tibial pilon fractures are difficult to treat. These fractures are associated with a high frequency of soft tissue complications. Therefore, two-stage surgery and less invasive surgical strategies using external fixation have been reported. The patient was a 79-year-old man. The right tibial pilon fracture was diagnosed as AO/OTA 43C3.1, Rüedi and Allgöwer type 2. He was treated with a low-profile mini-fragment plate and circular (Ilizarov type) external fixation. Herein, we report on a combination of these two methods: circular external fixator with low-profile mini-fragment plate fixation. At 18 months postoperatively, the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot score was a perfect score of 100. Radiographs taken in the loading position showed no narrowing of the joint fissure. There were no soft tissue infections, no plate breakage, no bone fusion, no symptoms of plate irritation, and no need for nail extraction.

Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters

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.

Acute Fixation Protocol for High-Energy Tibial Pilon Fractures Decreases Time to Fixation and Lowers Operative Costs Without Affecting Wound Complications and Reoperations

OBJECTIVES

To determine whether an acute fixation protocol for high-energy tibial pilon fractures increases the rate of wound complications.

DESIGN

Retrospective comparative study.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred forty-seven patients with OTA/AO 43B and 43C high-energy tibial pilon fractures treated with open reduction and internal fixation (ORIF).

INTERVENTION

Acute (<48 hours) versus delayed ORIF protocols.

MAIN OUTCOME MEASUREMENT

Wound complications, reoperations, time to fixation, operative costs, and hospital length of stay (LOS). Patients were compared by protocol, regardless of ORIF timing, for an intention-to-treat analysis.

RESULTS

Thirty-five and 112 high-energy pilon fractures were treated under the acute and delayed ORIF protocols, respectively. In the acute ORIF protocol group, 82.9% of patients received acute ORIF versus 15.2% of patients in the standard delayed protocol group. The 2 groups had no observed difference (OD) in the rate of wound complications (OD -5.7%, confidence interval (95% CI) -16.1% to 7.8%; P = 0.56) or reoperations (OD -3.9%, 95% CI, -14.1% to 9.4%; P = 0.76). The acute ORIF protocol group had a shorter LOS (OD -2.0, 95% CI, -4.0 to 0.0; P = 0.02) and lower operative costs (OD $-2709.27, 95% CI, -3582.02 to -1601.16; P < 0.01). On multivariate analysis, wound complications were associated with open fractures (odds ratio 3.36, 95% CI, 1.06-10.69; P = 0.04) and an American Society of Anesthesiologists score >2 (odds ratio 3.68, 95% CI, 1.07-12.67; P = 0.04).

CONCLUSION

This study suggests that an acute fixation protocol for high-energy pilon fractures decreases time to definitive fixation, lowers operative costs, and shortens hospital LOS without affecting wound complications or reoperations.

LEVEL OF EVIDENCE

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

Safety of Prepping the External Fixator In Situ During Staged Internal Fixation of Pilon Fractures: A Retrospective Comparative Cohort Study

OBJECTIVE

(1) To assess the rate of fracture-related infection (FRI) and unplanned reoperation of disinfecting and prepping in the external fixator (Ex-Fix) instrument during definitive open reduction and internal fixation (ORIF) of pilon fractures treated by a staged protocol and (2) to determine whether the amount of time from external fixation to ORIF influences the risk of FRI.

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS

One hundred thirty-three patients who underwent operative treatment for pilon fracture between 2010 and 2020.

INTERVENTION

External fixation and ORIF with or without the Ex-Fix prepped in situ during definitive fixation.

MAIN OUTCOME MEASUREMENTS

FRI and unplanned reoperation rates.

RESULTS

133 patients were enrolled, of which 47 (35.3%) had Ex-Fix elements prepped in situ. There was an overall infection rate of 23.3% and unplanned reoperation rate of 11.3%, and there was no significant difference in rates between the 2 cohorts. Patients with Ex-Fix elements prepped in situ who developed an FRI had a higher rate of MRSA and MSSA . Diabetes ( P = 0.0019), open fracture ( P = 0.0014), and longer (≥30 days) interval to ORIF ( P = 0.0001) were associated with postoperative FRI.

CONCLUSIONS

Prepping elements of the Ex-Fix in situ did not lead to an increase in rates of FRI or unplanned reoperation. Although diabetes and open fracture were associated with FRI risk, a stronger association was a longer interval of Ex-Fix utilization before definitive internal fixation, specifically 30 days or greater.

LEVEL OF EVIDENCE

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

Risk factors and nomogram predictive model of surgical site infection in closed pilon fractures

OBJECTIVES

In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model.

METHODS

From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration.

RESULTS

SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer-Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification.

CONCLUSION

Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture.

Pilon fractures: Consensus and controversy

Pilon fractures are complex injuries that require an individualized approach to treatment to avoid complications and achieve good outcomes. Staged open reduction internal fixation remains the gold standard for most cases to achieve anatomic articular reduction while minimizing soft tissue complications and infection. Careful preoperative planning based on computed tomography dictates the surgical approach for reduction. A subset of cases may be amenable to early definitive or provisional open reduction and internal fixation based on fracture pattern. In some cases of severe articular comminution where reconstruction is not possible, primary ankle arthrodesis may be a good alternative.

Medial malleolar window approach for varus-type tibial pilon fractures: a retrospective study

PURPOSE

Choosing a suitable surgical approach is crucial and challenging for type C pilon fractures. This article aims to explore the clinical efficacy of the medial malleolar window approach for varus-type tibial pilon fractures.

METHODS

A retrospective analysis was conducted on 38 patients with type C varus-type pilon fractures treated between May 2018 and June 2021. In total, 16 cases underwent surgical treatment through the medial malleolar window approach and 22 cases were treated with the traditional anteromedial approach combined with a posterior approach. The operation time, hospitalization time, fracture healing time, the American Orthopedic Foot and Ankle score, Visual Analogue Scale, and complications were recorded to comprehensively evaluate the clinical efficacy of the technique. Fracture reduction quality was evaluated using the criteria proposed by Burwell and Charnley.

RESULTS

All patients were followed up. No patients presented delayed union or nonunion. Compared with the conventional approach, the medial malleolar window approach had the advantage of better clinical effect recovery and better fracture reduction (P < 0.05). Meanwhile, the medial malleolar window approach had a shorter operation time, although the statistics suggest no significant difference with the control group. No implant exposure or infection occurred. There was good wound healing at two weeks after surgery in all but two cases. Local wound edge necrosis developed in one case in the medial malleolar window approach group, and the wound could not be closed at one stage in another case in the conventional group because of excessive tension, requiring secondary closure.

CONCLUSION

The medial malleolar window approach provides excellent exposure to type C pilon fractures, allowing for satisfactory fracture reduction and functional rehabilitation. The medial window approach is recommended for varus-type pilon fractures, which can effectively avoid a posterior incision and reduce the operation time.

Effects of multiwavelength photobiomodulation for the treatment of traumatic soft tissue injuries associated with bone fractures: A double-blind, randomized controlled clinical trial

This study evaluated the efficacy and safety of multiwavelength photobiomodulation (MPBM) in healing soft tissue injuries associated with tibial and/or ankle fractures. Participants were randomized into the MPBM or control group. Primary outcome was wound healing, measured by the Bates-Jensen scale. Assessments were performed daily. Twenty-seven hospitalized adults were included. MPBM showed an improvement in the daily mean Bates-Jensen scale (MPBM 32.1 vs. control 34.2; p = 0.029), daily mean pain score change (MPBM 0.5 vs. control 0.2; p = 0.04) and occurrence of infection at the site of the external fixator pins (MPBM 15.3% vs. control 57.1%; p = 0.02). MPBM group also showed faster-wound resolution (MPBM 13.1 vs. control 23.1 days). Subgroup analysis showed improvement in the MPBM group among less severe patients on the Bates-Jensen scale (MPBM 27.4 vs. control 34.7; p = 0.0081) and mean time for wound resolution (MPBM 7.0 vs. control 14.6 days; p = 0.03). MPBM appears safe and effective in reducing wound resolution time, infection in the surgical pin sites, reported pain and time before definitive surgery.

Early Reduction of the Posterior Column: A Surgical Technique in AO/OTA C3 Tibial Pilon Fractures

Staged treatment for pilon fractures is widely accepted. It remains to be discussed how to reduce and fix posterior column fractures while avoiding clinical complications. We provided a staged treatment protocol with detailed surgical techniques for closed AO Foundation/Orthopaedic Trauma Association (AO/OTA) C3 tibial pilon fractures with fibular fractures. In the first stage, the internal fixation of the fibula and distal tibial posterior column is accompanied by an external fixator. After swelling, the medial and anterior columns were fixed via the posteromedial approach in the second stage. We advocate early reduction and fixation of the posterior column and lateral column. The right timing of surgery can ensure well-reduced articular surface and alignment while minimizing soft tissue complications.

Percutaneous Reduction and Provisional Pinning of the Distal Fibula: A Novel Way to Maintain Fibular Length in Temporary Stabilization

Ankle fractures are commonly observed by orthopaedic trauma surgeons, foot and ankle surgeons, and general orthopaedists with more than 135,000 fractures surgically treated every year in the United States. 1 The soft tissue envelope surrounding the osseous anatomy of the ankle is limited and many injuries, including those that result from higher injury mechanisms and/or those occurring in hosts with vascular and metabolic comorbidities may benefit from a delay in definitive fixation; this may minimize risks of wound healing issues and fracture-related infection. 2,3 Open fractures may benefit from temporizing fixation after debridement and irrigation for the same reasons. 4-6 The benefits of temporizing external fixation in pilon fractures has been recognized for decades. 7 The use of ankle-spanning external fixation for ankle fractures and dislocations has become more frequently used to maintain coronal and sagittal alignment of the ankle mortise as a bridge to definitive fixation. 8-10 However, standard ankle-spanning external fixation techniques do not always directly restore fibular length and rotation, especially in fracture patterns with syndesmotic disruption and/or segmental fibular comminution. Some authors have advocated for limited internal fixation of fibula fractures at time of external fixation application to address this problem, 7 but this still necessitates a surgical approach through a traumatized soft tissue envelope and potentially compromises posterolateral and anterolateral approaches that could be used to address associated Volkman or Chaput fragments. Delayed distal fibular open reduction and internal fixation of shortened fractures has frustrated orthopaedic surgeons for decades and techniques such as "push-pull" screws 11 and extensive soft tissue dissection 12 are often necessary to restore anatomic fibular reduction of length and rotation. Given these challenges, the senior author began to use a technique of percutaneous reduction and buried provisional pinning of the distal fibula to the talus for fibula fractures with persistent shortening after ankle-spanning external fixation of injuries not deemed appropriate for immediate open reduction and internal fixation. We aim to report early results and describe this novel, low-cost surgical technique.

Minimally Invasive Technique in the Management of Tibial Pilon Fractures: New Approach and Promising Results

Background

Comminuted tibial pilon fractures are induced by high-energy mechanisms and are often associated with soft tissue injuries. Their surgical approach is problematic due to postoperative complications. Minimally invasive management of these fractures has a considerable advantage in preserving the soft tissue and the fracture hematoma.

Materials and Methods

We conducted a retrospective study of a series of 28 cases treated at the Orthopedic and Traumatological Surgery Department of the CHU Ibn Sina in Rabat over a period of 3 years and 9 months, from January 2018 to September 2022.

Results

After a mean follow-up of 16 months, 26 cases had good clinical results according to the Biga SOFCOT criteria and 24 cases had good radiological results according to the Ovadia and Beals criteria. No cases of osteoarthritis were observed. No skin complications were reported.

Conclusion

This study highlights a new approach that deserves to be considered for this type of fracture as long as no consensus has been given.

Outcomes of Tibiotalocalcaneal Hindfoot Fusion Nails Used for Acute Lower Extremity Trauma in a High-Risk Patient Population

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.

Presurgical Perspective and Postsurgical Evaluation of Tibial Pilon Fractures

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.

Does Time to Operative Intervention of Distal Radius Fractures Influence Outcomes?

BACKGROUND

No investigation has analyzed the time from injury to operative intervention and its effect on complications and functional outcomes in distal radius fractures. This investigation aimed to establish whether the time to surgical intervention from injury was associated with the observed rate of complications in distal radius fractures.

METHODS

A retrospective review of all orthopedic trauma patients who came to our center was conducted from 2008 through 2014. Patients who sustained closed distal radius fractures were included. A postoperative complication following distal radius fracture was defined as reoperation, superficial or deep infection, complex regional pain syndrome, new-onset carpal tunnel syndrome, tendon irritation, and symptomatic hardware.

RESULTS

In all, 190 patients were included in the study with a mean age of 48 years (SD ±14.7). According to the AO-Müller/Orthopaedic Trauma Association classification, radiographs revealed 80 A fractures, 15 B fractures, and 95 C fractures. Thirty distal radii were fixed within 0 to 3 days after injury, 91 patients within 4 to 10 days, and 69 patients after 10 days. Overall, 28 complications (14.7%) were identified. There was no statistical difference in the rate of complications between the time interval groups (P = .17).

CONCLUSIONS

Despite the increased popularity of surgical intervention for distal radius fractures, the optimal parameters to maximize patient outcomes have yet to be clearly defined. Time to intervention did not affect the rate of postoperative complication and range of motion.

Technique and Early Outcomes for High-Energy Calcaneus Fractures Treated With Staged External Fixation to Combined Open Reduction Internal Fixation and Subtalar Arthrodesis

OBJECTIVE

(1) To present an effective surgical technique for the treatment of open and high-energy calcaneal fractures with significant soft tissue injuries. (2) To present complications with this technique and to evaluate patient-reported outcomes of staged external fixation followed by delayed reconstruction with open reduction internal fixation (ORIF) and subtalar arthrodesis.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Twelve patients with 13 calcaneus fractures associated with open traumatic wounds (10 patients) or other severe soft tissue injury (ie, fracture blisters) between April 2013 and December 2019.

INTERVENTION

All patients were treated with staged ankle-spanning external fixation and delayed reconstruction with ORIF with subtalar arthrodesis.

MAIN OUTCOME MEASURES

Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes are presented via the domains of physical function (PF), pain interference (PI), and depression (D) in addition to visual analog score. Complications with the injury and surgical procedure were reported as well.

RESULTS

Patients underwent initial stabilization on average 1.3 days (range, 0-12 days) from injury with stage II occurring on average 31.1 days (range, 18-42 days) from external fixation. Mean time to radiographic union was 5.6 months (range, 4-10 months). One-year mean PROMIS outcomes were as follows: PF final average of 37.4 with an average improvement of 12.2 (P < 0.01), PI final average of 62.2 with average improvement of 5.6 (P = 0.01), and D final average of 52.1 with average improvement of 6 (P = 0.12). Mean final visual analog score pain score was 3.6 with an average improvement of 2.25 (P = 0.01).

CONCLUSION

Staged treatment with initial external fixation followed by ORIF and subtalar arthrodesis in the setting of highly comminuted calcaneus fractures with significant soft tissue compromise effectively addresses both bony and soft tissue concerns while providing for positive outcomes postoperatively with regards to pain and function. There were minimal complications noted for this complex injury.

LEVEL OF EVIDENCE

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

Should the location of distal tibial plating be influenced by the varus or valgus fracture pattern of tibial pilon fracture?

INTRODUCTION

Operative treatment of tibial pilon fracture is challenging. There is a lack of consensus and only one clinical study on the optimal location of distal tibial plating for fixation of pilon fractures based on varus or valgus fracture patterns. We hypothesize that complications rates, specifically mechanical complications, are not influenced by the location of the tibial plating in the fixation of pilon fractures with respect to varus or valgus fracture patterns.

MATERIALS AND METHODS

Sixty-nine patients who had single plating for tibial pilon from 2007 to 2017 were recruited. They were divided into two groups, transverse fibular fracture (varus fracture pattern) and comminuted fibular fracture (valgus fracture pattern). Our primary outcome measure was any mechanical complications as a result of the location of plating (medial vs lateral) on varus or valgus fracture patterns.

RESULTS

There were 38 (55.1%) patients with varus fracture pattern and 31 (44.9%) patients with valgus fracture pattern tibial pilon fractures. In the varus fracture pattern group, mechanical complications were not significantly different between the two plating locations (27.3 vs 33.3%, p > 0.05). Notably, there were more fibula fixations performed in patients with medial plating (74.1 vs 45.5%, p = 0.092) when compared those with lateral plating in the varus fracture pattern group. There were also no statistically significant differences found although 10 (40%) out of 25 patients had mechanical complications in the medial plating group compared to 1 (16.7%) out of 6 patients with lateral plating (p = 0.383) in the valgus fracture pattern group.

CONCLUSION

There were no differences in mechanical complications for medial vs lateral plating in tibial pilon fracture based on varus or valgus deforming forces. As much as we should consider the fracture patterns and deforming forces when deciding on plating location, other factors such as careful soft tissue management and fragment-specific fixation should be prioritized.

Approach to Complex Lower Extremity Reconstruction

Composite injuries to the lower extremity from etiologies including trauma and infection present a complex dilemma for the reconstructive surgeon, and require multidisciplinary collaboration amongst plastic, vascular, and orthopaedic surgical specialties. Here we present our algorithm for lower-extremity reconstructive management, refined over the last decades to provide an optimized outcome for our patients. Reconstruction is predicated on the establishment of a clean and living wound, where quality of the wound-bed is prioritized over timing to soft-tissue coverage. Once established, soft-tissues and fractures are provisionally stabilized; our preference for definitive coverage is for microvascular free-tissue, due to the paucity of healthy soft-tissue available at the injury, and ability to avoid the zone of injury for microvascular anastomosis. Finally, definitive bony reconstruction is dictated by the length and location of long-bone defect, with a preference to utilize bone transport for defects longer than 5 cm.

Bicondylar Tibial Plateau Fractures: What Predicts Infection?

OBJECTIVES

The purpose of this study was to identify the patient, injury, and treatment factors associated with infection of bicondylar plateau fractures and to evaluate whether center variation exists.

DESIGN

Retrospective review.

SETTING

Eighteen academic trauma centers.

PATIENTS/PARTICIPANTS

A total of 1,287 patients with 1,297 OTA type 41-C bicondylar tibia plateau fractures who underwent open reduction and internal fixation were included. Exclusion criteria were follow-up less than 120 days, insufficient documentation, and definitive treatment only with external fixation.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

Superficial and deep infection.

RESULTS

One hundred one patients (7.8%) developed an infection. In multivariate regression analysis, diabetes (DM) (OR [odds ratio] 3.24; P ≤ 0.001), alcohol abuse (EtOH) (OR 1.8; P = 0.040), dual plating (OR 1.8; P ≤ 0.001), and temporary external fixation (OR 2.07; P = 0.013) were associated with infection. In a risk-adjusted model, we found center variation in infection rates (P = 0.030).

DISCUSSION

In a large series of patients undergoing open reduction and internal fixation of bicondylar plateau fractures, the infection rate was 7.8%. Infection was associated with DM, EtOH, combined dual plating, and temporary external fixation. Center expertise may also play a role because one center had a statistically lower rate and two trended toward higher rates after adjusting for confounders.

LEVEL OF EVIDENCE

Level IV-Therapeutic retrospective cohort study.

Fibula fixation in the treatment of tibial pilon fractures - Is it really necessary?

BACKGROUND

There is a lack of consensus about the role of fibula fixation in these complex fractures, with only two clinical studies in the literature. We hypothesize that the fibula fracture need not be fixed in the tibial pilon fractures if primary stability can be achieved with tibial fixation alone.

METHODS

We reviewed 79 patients with operatively treated tibial pilon with associated fibula fractures from 2007 to 2017 and divided them into two groups; patients with fibula fracture fixation and those without fixation. The primary outcome measure was any mechanical complications. Secondary outcomes were wound complications and other morbidities.

RESULTS

There were 54 (68.4%) patients with fibula fixation and 25 (31.6%) patients without fixation. There were no statistically significant differences in mechanical complications between the two groups. However, patients without fibula fixation were noted to have more wound complications (44% vs 25.9%, p = 0.108) although this was not statistically significant. In terms of removal of implant (ROI), there were no differences noted in patients with or without fibula fixation (33.3% vs 28%, p = 0.796). There were also no significant differences in ROI for those fixed with plate and screws when compared to those fixed with Rush rod and K wire within the group with fibula fixation.

CONCLUSION

Fibula fixation in the treatment of tibial pilon fractures is not routinely necessary and does not result in decreased mechanical complications such as malunion, delayed union, nonunion and implant failure. Fibula fracture fixation should be reserved for cases where it may aid reduction or provide additional stability.