Distal Tibial Pilon Fractures Research Articles

SURFACE AREA OF TALAR DOME INJURIES ASSOCIATED WITH TIBIAL PILON FRACTURES

This study investigated concurrent talar dome injuries associated with tibial pilon fractures, mapping their distribution across the proximal talar dome articular surface. It compared the two main mechanisms of injury (MOI), falling from a height and motor vehicle accident (MVA), and whether the fractures were open or closed.From a previously compiled database of acute distal tibial pilon fractures (AO/OTA 43B/C) in adults of 105 cases, 53 cases were identified with a concurrent injury to the talar dome with a known mechanism of injury and in 44 it was known if the fracture was open or closed. Case specific 2D injury maps were created using a 1×1mm grid, which were overlayed in an Excel document to allow for comparative analyses. A two-way ANOVA was conducted that examined the effect of both MOI and if the fracture was open or closed on what percentage of the talar dome surface was injured.There was a statistically-significant difference between the average percentage of injured squares on the talar dome by both whether the fracture was open or closed (f(1)=5.27, p= .027) and the mechanism of injury (f(1)=8.08, p= .007), though the interaction between these was not significant (p= .156). Open injuries and injuries that occurred during an MVA were more likely to increase the surface area of the talar dome injuries.We have identified both MOI and if the fracture was either open or closed impacts the size of the injury present on the talar dome. Future research will investigate the aetiology of the differences noted, highlighting the clinical implications.Surgeons treating tibial pilon fractures caused by either a MVA or an open fracture, should be aware of an increased risk of large injuries to the surface of the talar dome.

MACROSCOPIC OSTEOCHONDRAL INJURIES OF THE TALAR DOME ASSOCIATED WITH PILON FRACTURES

Tibial pilon fractures are typically the result of high-energy axial loads, with complex intra- articular fractures that are often difficult to reconstruct anatomically. Only nine simultaneous pilon and talus fractures have been published previously, but we hypothesised the chondral surface of the dome is affected more frequently.Data was acquired prospectively from 154 acute distal tibial pilon fractures (AO/OTA 43B/C) in adults. Radiographs, photographs, and intra-operative drawings of each case were utilised to document the presence of any macroscopic injuries of the talus. Detailed 1x1mm maps were created of the injuries in each case and transposed onto a statistical shape model of a talus; this enables the cumulative data to be analysed in Excel. Data was analysed using a Chi-squared test.From 154 cases, 104 were considered at risk and their talar domes were inspected; of these, macroscopic injuries were identified in 55 (52.4%). The prevalence of talar dome injury was greater with B-type fractures (53.5%) than C-type fractures (31.5%) (ρ = .01). Injuries were more common in men than women and presented with different distribution of injuries (ρ = .032). A significant difference in the distribution of injuries was also identified when comparing falls and motor vehicle accidents (ρ = .007).Concomitant injuries to the articular surface of the dome of the talus are relatively common, and this perhaps explains the discordance between the post-operative appearance following internal fixation and the clinical outcomes observed. These injuries were focused on the lateral third of the dome in men and MVAs, whereas women and fall mechanism were more evenly distributed.Surgeons who operatively manage high-energy pilon fractures should consider routine inspection of the talar dome to assess the possibility of associated macroscopic osteochondral injuries.

Is It Safe to Prep the External Fixator in Situ During Staged ORIF of Pilon Fractures? A Retrospective Comparative Cohort Study

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures usually result from high energy mechanisms and are associated with signifcant soft tissue injuries in addition to complex fracture patterns. Treatment typically involves staged management with initial placement of an external fixator and subsequent definitive internal fixation once soft tissues are amenable. The purpose of this study was to compare the risk of fracture-related infection (FRI) and unplanned re-operation after staged open reduction and internal fixation (ORIF) of pilon fractures between cases in which elements of the temporizing external fixator (ex-fix) were prepped into the surgical field and cases in which it was completely removed prior to definitive fixation. Methods: This was a multi-surgeon retrospective comparative cohort study on patients 18 years and older with pilon fractures who underwent operative treatment over a ten-year period between January 1, 2010 to January 1, 2020 at an academic-level 1 trauma center. Medical records and radiographic images were reviewed for each patient to assess demographics, clinical characteristics and surgical outcomes. The primary outcome measures were FRI and unplanned re-operation, including arthrodesis and amputation. All analyses were completed using JMP Software (Version 15.0, SAS Institute Inc., Cary, NC), and an alpha of 0.05 was used for statistical significance. Results: 133 patients underwent staged ORIF, 47 with retained elements of the ex-fix prepped in situ for definitive ORIF and 86 with the ex-fix entirely removed. The overall rate of FRI was 23.3% while the overall rate of unplanned re-operation was 11.3% (4.5% rate of arthrodesis and 6.8% rate of amputation). There was no difference in FRI between the group in which ex-fix was prepped in versus the group in which it was completely removed (23.4% vs 23.3%, p=0.985) and no difference in overall rate of unplanned re-operation (10.6% vs 11.6%, p=0.863). Assessing the subset of patients with FRI, those with ex-fix prepped in had a higher prevalence of infection with MRSA and MSSA (81.8% vs 40%, p=0.021). Using alpha=0.05, and power=0.8, a sample size of 42 patients with FRI post-ORIF (27 with ex-fix prepped in, and 15 with ex-fix removed) would be needed to detect a difference in MRSA/MSSA bacteriology. Conclusion: Although there were relatively high complication rates in this cohort of pilon fractures treated with staged ORIF, prepping in elements of the external fixator did not lead to a significant increase in rates of fracture-related infection nor unplanned re-operation, including arthrodesis and amputation. This study offers clinical support regarding a common practice used to assist in reduction and definitive fixation of distal tibial pilon fractures.

Retrograde Intramedullary Kirschner Wire Fixation as an Alternative for Treating Distal Fibular Shaft Fractures Combined with Distal Tibial Pilon Fractures.

Treatment or management techniques for pilon fractures are associated with high complication rates and poor outcomes. No consensus exists regarding the optimal surgical option for pilon fractures, especially for pilon fractures combined with distal fibular fractures. Accordingly, we explored the use of fibular fixation for treating pilon fractures involving distal fibular shaft fractures. We hypothesized that retrograde intramedullary Kirschner wire (K-wire) fixation is a suitable alternative technique for distal fibular fixation. We retrospectively reviewed the data of 156 patients who underwent surgery for pilon fractures at our hospital from May 2013 to May 2021. The radiographic and functional outcomes were comparable between the fibular intramedullary nailing (Group A; n = 80) and the fibular plating (Group B; n = 76) groups. Groups A and B differed significantly in total hospitalization time (11.4 vs. 18.2 days, p = 0.024), length of postoperative admission (6.8 vs. 11.4 days, p = 0.012), and total admission cost (USD 3624 vs. USD 6145, p = 0.004). We also noted that poor Olerud and Molander ankle scores were significantly associated with age (p = 0.008), smoking (p = 0.012), and preoperative admission length (p = 0.018). Retrograde intramedullary K-wire fixation produced a comparable 12-month functional outcome to plate fixation for distal fibular shaft fractures, rendering it a viable alternative method based on soft tissue condition.

Does Surgical Approach Influence the Risk of Postoperative Infection After Surgical Treatment of Tibial Pilon Fractures?

To determine whether a particular surgical approach or combination of approaches is a risk factor for infection. Retrospective review. Two Level-1 trauma centers. Five hundred ninety pilon fractures in 581 patients (66% male) with a median age of 45 years were identified. Open reduction internal fixation of pilon fractures. Postoperative deep surgical site infection and risk factors for postoperative deep infection. The most common primary surgical approach was medial (54%), followed by anterolateral (25%), anteromedial (11%), posterolateral (8%), and posteromedial (2%). A dual approach to the distal tibia was used in 18% of the cases. The overall deep infection rate was 19%. There was no association between primary surgical approach and development of infection (P = 0.19-0.78). Independent risk factors for infection were smoking (hazard ratio, 2.1; P < 0.001) and need for soft tissue coverage (hazard ratio, 6.9; P < 0.001). Surgical approach does not appear to be a significant risk factor for postoperative infection after open reduction internal fixation of distal tibial pilon fractures. When treating tibial plafond fractures, surgeons should select the approach they feel best addresses the specific fracture pattern. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

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

Circular External Fixation for Pilon Fractures

Introduction: The use of small-tensioned wire external fixation techniques is utilized for the treatment of distal tibial pilon fractures. There are many specific indications for their use over contemporary staged internal fixation methodologies. These include highly comminuted articular surfaces, fractures with proximal diametaphyseal extension, and skeletal injuries associated with severe open injuries, or in those closed injuries with severe soft tissue compromise. Technique: Joint evaluation using distraction computed tomographic (CT) scans is mandatory for developing a preoperative plan for achieving reductions of impacted articular surfaces. Limited open fixation combined with multiple-tensioned wires stabilize the distal tibial ring block. Two or 3-ring frames are utilized to provide shaft stabilization. Foot frames spanning the ankle joint can be used in cases of severe articular fragmentation. Standard connecting rods, Quick connect rods, or Spatial Struts are options for connecting the articular ring to the shaft rings. Each strut type has variable properties to achieve rapid dynamization or adjust the mechanical axis during the treatment phase and are chosen based on the particular indication being treated. Management: With this noninvasive method of articular and shaft reduction, rapid articular consolidation occurs. Foot frames are removed at 4 to 6 weeks and active range of motion is initiated. Diametaphyseal healing is more prolonged and protected weight-bearing is modulated based on x-ray evidence of fracture healing. Frames are dynamized as weight-bearing progresses. The patient should be fully weight-bearing with the frame connections between the distal articular ring and the shaft fully dynamized. At this time the frame can be removed. Conclusions: Meticulous preoperative planning and the correct application of a tensioned-wire fixator is crucial in applying a frame that can modulate its biomechanical properties as fracture healing progresses. Successful application results in clinical results comparable with internal fixation techniques without the risks of having the severe complications often related to open procedures.

Open distal tibial pilon fractures treated with "one-stage" external fixation method

Introdiction: Open distal tibial pilon fractures are considered as hard injuries, caused by high-energy axial load. Different treatment methods of these injuries are described in the literature. Authors of this paper are presenting own experience and results in the method of ?one-stage? external fixation with or without limited internal fixation of the fracture. Material and methods: All the patients had emergent surgical treatment in 4 to 8 hours after the hospitalisation. Surgical protocol included wound irrigation, debridement, fracture reduction and external fixation in type A fractures. Type B and type C fractures were treated by ?bridging? external fixation with limited internal fixation. In the cases where wound had not been possible to close primarily additional surgical procedures (soft tissue defects coverage) were performed. Results: Final functional outcome was excelent in 5(31,25%) patients, good in 6 (37,5%) patients, moderate in 3(18,75%) patients and bad in 2 (12,5%) patients (according Karlsson Score). Final anatomical and functional results were in correlation with the type of primary injury. One case of septic pseudoarthrosis and three cases of late ankle arthrosis were found as a major complication. Conclusion High-energy open distal tibial pilon fractures are still considered as a challange and significant surgical problem. The method of external fixation with or without limited internal fixation, as ?one-stage? method, was approved in clinical practice to give excelent and good final functional and anatomical results. Though final functional results were in correlation with degree of the injury, described method gives good outcome results and further clinical application will surely approve its clinical significance.

Short-term results for the management of distal tibial fractures by minimally invasive locked plating

BackgroundFractures of the distal tibia can be challenging to treat because of the limited soft tissue, the subcutaneous location, and poor vascularity. Minimally invasive locked plate aims to reduce surgical soft-tissue trauma and to help preserve periosteal blood supply and fracture hematoma and is useful in treating these challenging fractures.Patients and methodsThis study included 26 patients between 20 and 53 years of age (mean 34 years), with both open and closed distal tibial pilon fractures that were intra-articular or extra-articular. All fractures were fixed using minimally invasive plate osteosynthesis under image control using a precontoured locking compression plate-distal tibial plate.ResultsThere were 11 AO 43 A, seven AO 43 B, and eight AO 43 C fractures including 18 closed and eight open fractures. Fracture union was achieved in 23 patients (88%), whereas three cases (12%) showed delayed union. Four cases suffered from late infection, and plate removal was necessary, whereas six cases had minor wound problems and responded to conservative treatment. Twenty-two patients (85%) returned to their work within 1 year of operation; however, 17 patients (65%) had not returned to their preinjury sporting or leisure activities. Seven patients (27%) had angular deformities, all less than 7°. The final ankle-hindfoot score was 84.8 points.ConclusionShort-term results for treating distal tibial pilon fractures using minimally invasive locked plate (locking compression plate-distal tibial plate) to reduce surgical soft-tissue trauma and to help preserve periosteal blood supply and fracture hematoma appears encouraging, with union rates similar to that of open reduction internal fixation (ORIF) techniques, but avoiding the usual associated drawbacks.

Distal tibial pilon fractures (AO/OTA type B, and C) treated with the external skeletal and minimal internal fixation method

Distal tibial pilon fractures include extra-articular fractures of the tibial metaphysis and the more severe intra-articular tibial pilon fractures. There is no universal method for treating distal tibial pilon fractures. These fractures are treated by means of open reduction, internal fixation (ORIF) and external skeletal fixation. The high rate of soft-tissue complications associated with primary ORIF of pilon fractures led to the use of external skeletal fixation, with limited internal fixation as an alternative technique for definitive management. The aim of this study was to estimate efficacy of distal tibial pilon fratures treatment using the external skeletal and minimal internal fixation method. We presented a series of 31 operated patients with tibial pilon fractures. The patients were operated on using the method of external skeletal fixation with a minimal internal fixation. According to the AO/OTA classification, 17 patients had type B fracture and 14 patients type C fractures. The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. This retrospective study involved 31 patients with tibial pilon fractures, average age 41.81 (from 21 to 60) years. The average follow-up was 21.86 (from 12 to 48) months. The percentage of union was 90.32%, nonunion 3.22% and malunion 6.45%. The mean to fracture union was 14 (range 12-20) weeks. There were 4 (12.19%) infections around the pins of the external skeletal fixator and one (3.22%) deep infections. The ankle joint arthrosis as a late complication appeared in 4 (12.90%) patients. All arthroses appeared in patients who had type C fractures. The final functional results based on the AOFAS score were excellent in 51.61%, good in 32.25%, average in 12.90% and bad in 3.22% of the patients. External skeletal fixation and minimal internal fixation of distal tibial pilon fractures is a good method for treating all types of inta-articular pilon fractures. In fractures types B and C dynamic external skeletal fixation allows early mobility in the ankle joint.

The different operative curative effect comparison of distal tibial pilon fractures

Objective To investigate the effects of different operation methods for the treatment of distal tibial pilon fractures.Methods 40 cases of distal tibial pilon fractures were randomly divided into study group and control group,each of 20 cases.The research group used percutaneous insertion of the distal tibia locking plate internal fixation,the control group used the traditional open reduction and anatomical locking plate fixation.The average healing time,the incidence of complications and high rate of fracture healing were compared between the two group.Results The average healing time of the fracture study group(3.0±0.2)months was significantly shorter than that in the control group(4.0±0.3)months.Complication rate in the study group 5.0％ was significantly lower than that in the control group 35.0％.Fracture healing rate of study group 95.0％ was significantly higher than that of control group 65.0％.There was significant difference(P＜0.05).Conclusion The insertion of percutaneous locking plate fixation in the treatment of distal tibia has less trauma,simple operation,ankle joint function recovery,and the complication rate is low. Key words: Tibial fracture; Fracture fixation,internal

Early internal fixation and soft tissue cover of severe open tibial pilon fractures.

We studied 32 consecutive patients with open distal tibial pilon fractures. All patients had radical debridement with immediate skeletal stabilisation and early soft-tissue cover with a vascularized muscle flap. The minimum follow-up was 1 (range 1-8) year. There were four superficial infections, two deep infections and two amputations. There were no long-term problems with union and no patient required an ankle fusion. Patients were assessed using the SF-36 questionnaire. There were significant differences from the US norm in physical function score ( p<0.01), role physical score ( p<0.05) and physical component score ( p<0.01). Physical component score of 38.5 was significantly better ( p<0.01) when compared with amputees from severe lower-extremity trauma. Our protocol for management resulted in a good functional outcome with low infection and amputation rates.

The small pin circular fixator for distal tibial pilon fractures with soft tissue compromise.

A Monticelli-Spinelli small pin circular external fixator was used in combination with closed reduction or a limited open reduction internal fixation in five cases in an attempt to salvage a satisfactory result in distal tibia pilon fractures when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin fixator enhances the ability to perform a closed reduction through a technique that uses distraction with pins in the tibia and calcaneus, combined with correction of angulation by tensioning wires with a stop nut. Small pin stabilization of these comminuted fractures allows early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this technique as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.