Staged procedure protocol based on the four-column concept in the treatment of AO/OTA type 43-C3.3 pilon fractures

Use of Three-dimensional Printing for Tibial Pilon Fracture Diagnosis and Treatment

Objective  To evaluate whether three-dimensional (3D) printing increases agreement in the classification of tibial pilon fractures. Methods  Orthopedists and traumatologists reviewed radiographs, computed tomography scans with 3D reconstruction, and prototyping 3D printing, and classified the fractures based on the Rüedi-Allgöwer and Arbeitsgemeinschaft für Osteosynthesefragen (AO, Association for the Study of Internal Fixation) Foundation/Orthopedic Trauma Association (AO/OTA) classification systems. Next, data evaluation used Kappa agreement coefficients. Results  The use of the 3D model did not improve agreement for tibial pilon fractures regarding the treatment proposed by the groups. Regarding the classification systems, the agreement only improved concerning the AO/OTA classification when the 3D model was used in the assessment by the foot and ankle specialists. Conclusion  Although 3D printing is statistically relevant for surgeons specializing in foot and ankle, its values remain lower than optimal.

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.

Preoperative temporary fixation for fractures around the ankle using a simple extensible external fixator significantly improves patient comfort

BACKGROUND

The authors developed a simple extensible external fixator, which has the advantages of easy application and inexpensiveness. The present study aimed to make a comparison between this external fixator and calcaneal traction in preoperative temporary fixation for malaligned ankle fractures and pilon fractures.

METHODS

From May 2020 to February 2022, patients with malaligned ankle fractures or Rüedi-Allgöwer type 2 or 3 pilon fractures with obvious soft tissue swelling were retrospectively reviewed and divided into the calcaneal traction group and the external fixation group. The two groups of patients were matched 1:1 before making comparisons.

RESULTS

A total of 38 patients were included. Higher General Comfort Questionnaire score and lower visual analog scale score were noticed in the external fixation group during hospitalization (p < 0.05), while the operation latency time, total cost, patient satisfaction, and functional outcomes one year after surgery were not significantly different between the two groups. No wound complications were observed.

CONCLUSION

Preoperative temporary fixation for fractures around the ankle using this simple extensible external fixator significantly improves patient comfort when compared to calcaneal traction.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Three-Dimensional Heat Map: The OTA/AO Type 43C Pilon Fracture Lines Distribution

Background

This study aimed to create three-dimensional heat map and study the characteristic of fracture lines and represented fragments of OTA/AO type 43C pilon fractures.

Methods

CT scan was performed in105 fractures diagnosed with OTA/AO type 43C pilon fractures between January 2017 and December 2022. Three-dimensional pilon fracture maps were created and converted into fracture heat maps. CT scan graphic parameters including the fracture line height, α angle, β angle, the ratio of the area and size of bone fragment represented by the fracture line to the total articular surface were measured.

Results

The study included 105 patients with 91 males and 14 females. The fractures included C1 (n=16), C2 (n=23), and C3 (n=66). There was no statistically different among the most parameters except in the fracture-line height of the anterior fracture line (p=0.03) and the sagittal fracture line (p=0.02) between C2 and C3 pilon fractures. The average size of the anterolateral fragment, occupied approximately 13.5% of the articular surface area, was (11.5±2.8) mm × (20.5±6.3) mm with the average height of 29.8 mm. The average size of the posterolateral fragment, occupied approximately 13.0% of the articular surface area, was (15.7±4.6) mm × (19.3±4.0) mm with the average height of 19.1 mm.

Conclusion

This study demonstrates that the articular surface fracture lines in the C type pilon fracture are formed by fixed main fracture lines. The understand of morphological and distribution characteristics of the fracture lines and size of fragments in OTA/AO type 43C pilon fractures would help the surgeons take suitable approach and fixation.

Management of complex pilon fractures: Is it necessary to fix all the columns in AO/OTA type 43-C fractures?

INTRODUCTION

Surgical treatment of AO/OTA 43-C pilon fractures has not yet taken a standard form. We aimed to evaluate whether patients that appeared to be labelled as unsupported columns according to the four-column theory would affect long-term clinical and radiological outcomes.

MATERIALS AND METHODS

Patients with AO/OTA 43-C type who were treated surgically between January 2010 and December 2019 were included in the study. 53 fractures in 52 patients who received osteosynthesis were categorized based on the fixed columns. These groups were formed as fully supported columns (FSC- Group A), partly supported columns (PSC-Group B), Ankle range of motions (ROM), Burwell Charnley's reduction evaluation criteria, Kellgren-Lawrence ankle osteoarthritis staging system, and American Orthopedic Foot and Ankle Society (AOFAS) Scoring System, Olerud-Molander Ankle Score, Visual Analog Scale were used for evaluating radiological and functional outcomes.

RESULTS

The mean follow-up period was 72.6 (12-131) months. Mean age was 42.6 (18-76). Two groups were homogenously distributed in terms of age (p = 0.785), sex (p = 0.376), laterality (p = 0.732), smoking status (p = 0.488) and reduction quality. There was no difference in AOFAS score (p = 0.452), Olerud-Molander score (p = 0.354) and VAS scores (p = 0.589). TAS, TLS and TT angle measurements suggested no difference between groups (p = 0.493, p = 0.834, p = 0.577). There was no difference between groups in terms of infection (p = 0.734), malunion (p = 0.688) and arthritis (p = 0.483) CONCLUSION: We presented findings that contradicted the hypothesis positing the existence of four distinct columns in pilon fractures, as well as the notion that each fractured column requires support from distinct implants.

LEVEL OF EVIDENCE

Level III.

Treatment strategies for complex ankle fractures-current developments summarized in a narrative review

Background and Objective

Ankle fractures occur frequently in patients throughout all ages. Due to the many pitfalls associated with their treatment, complex ankle and especially tibial pilon fractures remain a challenge for surgeons. As there is still need for improvement in treating complex ankle fractures and treatment options are steadily increasing this review aims to summarize current practice and aims to highlight current developments by reviewing the literature.

Methods

We conducted a thorough search of PubMed database in December 2022 to identify relevant articles on complex ankle and tibial pilon fractures. Articles in English and German were included in this study.

Key Contents and Findings

Complication rates, especially wound infection are still high, emphasizing the need for careful preoperative planning. Soft tissue management is crucial to reduce complication rates and will often dictate the treatment plan utilized. Open reduction and internal fixation (ORIF) remains the treatment of choice. Nevertheless, in select cases alternative methods such as external fixation, tibiotalocalcaneal nailing or conservative treatment need to be considered as well. Furthermore, additional treatment options such as arthroscopically assisted surgery might help to improve functional outcome after complex ankle fractures. The incidence of complex ankle fractures in geriatric patients keeps rising with our aging population. This group of patients demands particular care and further high-quality studies are needed to warrant best results.

Conclusions

However, more randomized controlled trials are need in order to enhance evidence of newly developed treatment options.

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.

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.

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.

Outcomes of tibial pilon fracture fixation based on four-column theory

OBJECTIVES

To assess the medium-term functional and radiological outcomes, as well as injury mechanisms, fracture patterns and demographics of typical pilon fractures and pilon variant fractures treated based on the four-column theory in adults.

METHODS

A retrospective comparative study was performed. Demographics of typical pilon and pilon variant fractures, injury mechanisms, OTA/AO classification, Rüedi-Allgöwer and the four-column classification were analyzed for the cohort. Radiographic ankle arthrosis (modified Kellgren-Lawrence 3/4), Burwell Charnley Score, and AOFAS score were also analyzed.

RESULTS

There were 142 pilon fractures met the inclusion and exclusion criteria for this study, of which 77(54.23%) were females and 65 (45.77%) were males, with an average of 48 (range, 18-86)years. One hundred twenty-five posterior columns fractured in 142 pilon fractures, and the posterior columns were most prone to fractures. Ninety cases of posterior pilon fractures in 142 pilon fractures were single posterior column fractures with or without medial or lateral malleolar fractures. The average age (51, range, 18-86 years) of low-energy pilon fractures was older than the average age (42, range, 19-66 years) of high-energy pilon fractures significantly. The average time (5, range, 0-17 days) from injury to definitive internal fixation of the low-energy group was shorter than the average time (9, range, 0-21 days) from injury to definitive internal fixation of the high-energy group significantly. The average of AOFAS (87, range, 56-100) of the low-energy group is higher than the average of AOFAS (82, range, 47-100) of the high-energy group significantly. There were more male patients and more die-punch or intercalary fractures in high energy groups significantly. There were more medial and lateral malleolar fractures in low-energy groups. Compared with the non-multiple column group, the multiple-column group had more Rüedi-Allgöwer type III cases, more modified Kellgren-Lawrence 3/4 cases and lower AOFAS score significantly. However, the numbers of Burwell Charnley Score type 1 and 2 cases were not significantly different between the two groups.

CONCLUSIONS

Kinds of pilon variants should be recognized. Outcomes of high-energy pilon fractures were worse than low-energy pilon fractures. The four-column theory can be applied to typical pilon fracture and pilon variants in adults.

Management of Pilon Fractures-Current Concepts

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.

Fusion versus fixation in complex comminuted C3-type tibial pilon fractures: a systematic review

BACKGROUND

Comminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes. This study reviewed [1] treatment, complications, and clinical outcomes in studies of complex comminuted tibial pilon fractures (type AO43-C3); and [2] primary ankle arthrodesis as a management option for these types of complex injuries.

METHODS

A systematic literature search was performed on PubMed from 1990 to 2020 to determine complications and outcomes after staged fracture fixation and primary ankle joint arthrodesis for comminuted C3-type tibial pilon fractures. The search was conducted in compliance with the PRISMA guidelines, using the following MeSH terms: "tibial pilon"/"pilon fracture"/"plafond fracture"/"distal tibial"/"43-C3"/"ankle fracture"/"ankle fusion"/"primary ankle arthrodesis"/"pilon fracture staged"/"pilon external fixation" and "pilon open reduction internal fixation." Inclusion criteria were restricted to original articles in English language on adult patients ≥18 years of age. Eligibility criteria for retrieved publications were determined using a "PICO" approach (population, intervention/exposure, comparison, outcomes). Weighted analysis was used to compare treatment groups on time to definitive treatment, follow-up time, range of motion, fracture classification, and complications.

RESULTS

The systematic literature review using the defined MeSH terms yielded 72 original articles. Of these, 13 articles met the eligibility criteria based on the PICO statements, of which 8 publications investigated the outcomes of a staged fixation approach in 308 cumulative patients, and 5 articles focused on primary ankle arthrodesis in 69 cumulative patients. For staged treatment, the mean wound complication rate was 14.6%, and the malunion/nonunion rate was 9.9%. For primary arthrodesis, the mean wound complication rate was 2.9%, and the malunion/nonunion rate was 2.9%. After risk stratification for fracture type and severity, the small cumulative cohort of patients included in the primary arthrodesis publications did not provide sufficient power to determine a clinically relevant difference in complications and long-term patient outcomes compared to the staged surgical fixation group.

CONCLUSIONS

At present, there is insufficient evidence in the published literature to provide guidance towards consideration of ankle arthrodesis for complex comminuted C3-type tibial pilon fractures, compared to the standard treatment by staged surgical fracture fixation.

Biomechanical comparison of fixation techniques for transverse acetabular fractures - Single-leg stance vs. sit-to-stand loading

OBJECTIVES

To biomechanically compare five different fixation techniques for transverse acetabular fractures using both the single-leg stance (SLS) and the sit-to-stand (STS) loading protocols and to directly compare fracture gap motion (FGM) and relative interfragmentary rotation (RIFR).

METHODS

Transtectal transverse acetabular fractures were created on fourth-generation composite hemipelves in a reproducible manner. Five different fixation techniques were biomechanically assessed using both an SLS and STS loading protocol: anterior plate (AP) only, posterior plate (PP) only, anterior plate plus posterior column screw (AP+PCS), posterior plate plus anterior column screw (PP+ACS) and anterior plus posterior plate (AP+PP). After preconditioning, the specimens were loaded from 50 to 750 N with a ramp of 100 N/s. FGM and RIFR under loads of 750 N were measured using an optical 3D measurement system.

RESULTS

In the three groups of fixation techniques addressing both columns, STS loading resulted in higher mean FGM and in RIFR than SLS loading. No construct failure was observed. In the single plate groups (AP only and PP only), STS loading resulted in failure of all specimens before reaching loads of 750 N, while no failure occurred after SLS loading. No significant differences in FGM and RIFR were found between the double plate (AP+PP) and the single plate plus column screw (AP+PCS and PP+ACS) techniques.

CONCLUSION

SLS loading appeared to overestimate the strength of acetabular fracture fixation constructs and STS loading may be more appropriate to provide clinically relevant biomechanical data. Internal fixation of a single column might not provide adequate stability for transverse fractures, while strength of single plate plus column screw fixation and double plate fixation was comparable.