Two-stage procedure protocol for minimally invasive plate osteosynthesis technique in the treatment of the complex pilon fracture

Abstract

Here we introduce a two-stage procedure protocol for minimally invasive plate osteosynthesis (MIPO) to treat complex pilon fractures and evaluate surgical wound healing and infection rates after this method was applied in clinical practice. This is a retrospective study design. The protocol consisted of immediate (within eight to 24 hours) open reduction and internal fixation of the fibula, using a fibular plate or one third tubular plate and application of an external fixator spanning the ankle joint. Patients were discharged after initial stabilisation and revaluated approximately ten to 14 days after discharge. Formal open reconstruction of the articular surface using MIPO depended on whether soft tissue swelling had lessened. Artificial bone was then injected into the defect rather than open surgery. Objective evaluation criteria were wound infection rates. Objective criteria (amount of post-traumatic arthritis, range of ankle movement, number of arthrodeses) and subjective criteria (pain, swelling, restriction of work or leisure activities) were identified via chart and radiograph reviews, patient interviews and physical examination. Twenty-nine patients, each with one pilon fracture were included. First-stage operations were performed from eight hours to seven days after injury, depending on whether the fracture was open or not. Average time from external fixation to open reduction and revision was one month (range 24-38 days); average time for the second-stage operation was 58 (range 45-110) minutes; average amount of haemorrhage was 400 (range 150-560) ml; average time of follow-up was 24 months and average time of healing was 6.7 (range five to 11.5) months after the second stage. There was no superficial or deep infection or wound-healing problem. All patients had normal functioning ankle joints. Application of the two-stage procedure protocol with MIPO seems to play a key role in reducing infection rates associated with open reduction and internal fixation of pilon fractures. Its effectiveness in closed and open fractures will be further tested by a late randomised controlled study.