Preoperative full reset combined with minimally invasive treatment of extreme distal pilon fractures

Abstract

Objective To investigate the clinical efficacy of preoperative full reset combined with minimally invasive treatment of extreme distal pilon fractures. Methods A retrospective analysis was made on 34 patients (35 ankles) with tibial fractures extremely close to the distal articular surface treated surgically between January 2011 and January 2015. There were 21 males and 13 females, aged 20-71 years (mean, 36.2 years). Injury resulted from traffic accidents in 32 patients and high falls in two. Using the AO/OTA fracture classification system, type 43-B3 was noted in three patients, 43-C1 in five patients, 43-C2 in 18 patients and 43-C3 in eight patients. Calcaneal traction combined with manipulative reduction was used to correct fracture displacement preoperatively. All fractures were stabilized by minimally invasive percutaneous plate osteosynthesis (MIPPO) through single or combined medial, anteromedial and anterolateral approaches while minimizing damage to bone attachment and continuity of soft tissue, after soft tissue swelling subsided. For the patients with articular surface collapsing with severe comminution, a series of procedures were done under direct vision including using the talus articular surface as a mold, stable fixation with fine Kirschner (1-1.5 mm) and thin screws (2.1-2.7 mm series) and impaction bone grafting below subchondral bone. Thereafter, distal tibia anatomical short multi-directional locking plate fixation, distal nail support and early ankle joint functional exercise were done. Burwell-Charnley radiological evaluation system was used for radiological assessment, and Teeny-Wiss scoring system for ankle clinical symptoms and function. Postoperative complications were recorded. Results Follow-up lasted for 11-38 months (mean, 16.6 months). No infection, wound disunion, or plate exposure occurred. Burwell-Charnley radiological evaluation system showed anatomic reduction in 32 patients, unsatisfactory reduction in one, and poor reduction in one. According to the Teeny-Wiss scoring system, the results were excellent in 31 patients, good in two and poor in one, with the excellent-good rate of 97%. Three patients suffered traumatic arthritis after operation and alleviated after oral administration of painkiller. Conclusion With use of full reset combined with manipulative reduction to correct fracture displacement, minimally invasive locking plate, distal row of nails, impaction bone grafting and limited fixation, the patients with extremely distal tibial pilon fractures achieve satisfactory reduction, stable fixation, and early functional exercise. Key words: Tibial fractures; Traction; External fixators; Fracture fixation, internal; Pilon fractures