Fixation Of Fibular Fractures Research Articles

Consequences in plating of fibula of distal metaphyseal tibial and fibular fractures: A teaching hospital based study in North India

The tibia is exposed to frequent injury. Distal tibial metaphyseal fractures are often the result of high-energy trauma, usually associated with distal fibular fractures. The presence of the ankle joint allows rotatory deformity after fracture, and care should be taken during reduction to correct such deformity. Fixation of fibular fractures in distal tibial metaphyseal fractures is controversial, although fixation of the fibular fracture by a plate and screws partially stabilizes comminuted fractures of the distal tibial shaft or metaphysis and considered in distal tibial fractures treated with intramedullary fixation to prevent valgus deformity even there is increased potential for delaying the tibial fracture healing. Objectives: The purpose of this study was to compare the functional and radiological outcome of fractures of distal third tibia and fibula treated by interlocking nail of tibia with fibular plating and without fibular plating. Material and Methods: A total of 24 patients who had fractures of lower third tibia and fibula are included in this study. 24 patients were divided into two groups A and B (12 patients in each group) based on fibular fixation. Results: Functional results were evaluated based on classification system for result of treatment by Johner and Wruhs criteria. Functional Outcome according to Johner and Wruhs criteria based on clinical rotational alignment, radiological valgus angulation and ankle range of movements, in group A 7 patients (58%) had good results and 5 patients (42%) had fair results. In group B 8 patients (67%) had good results and 4 patients (33%) had fair results (p=1.00 statistically not significant).Conclusion: Based on the results of the study, it was confirmed that fixation of fibula first, along with interlocking nailing of the tibia maintains limb length and decreases the malalignment and malrotation of the tibia in distal third fractures of tibia and fibula as compared with only interlocking nailing of tibia in distal third fractures of tibia and fibula.

Twisted Plating - A Method of Distal Fibula Fixation.

Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1 st January 2012 to 31 st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8–14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86–100) at a mean follow-up of 31.5 months (14–61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.

Clinical, radiographic and pedobarographic analysis of skeletally immature patients with surgically treated distal metaphyseal fractures of the tibia: is concomitant fixation of the fibula necessary?

This study evaluated the outcomes of distal tibia metaphyseal fractures (DTMFs) managed surgically and compared the outcomes of patients with and without associated fibula fracture fixation. Thirty-two consecutive patients (14 males; mean age at the time of injury: 7.8 years) with closed displaced DTMFs, with (22 patients; group A) or without associated fibula fractures fixation (10 patients; group B), were included. Besides standard radiographic measurements, the following static and dynamic pedobarographic parameters were evaluated: foot total static plantar pressure percentage (PP%), static plantar pressure percentage of the forefoot (PP%) and of the rear foot (PP%), landing sequence of the metatarsals during contact with the ground (MT), and impulse percentage of the metatarsal heads (MT%) and the medial and lateral heel (MH% and LH%). All patients were followed for at least 2 years (range: 2-4.5 years). Functional outcomes were excellent to good in all but two patients (93.8%) at the last follow-up visit using the Johner-Wruths criteria'. Radiographic measurements, PP%, PP%, PP%, MT%, MH% and LH% were not significantly different between two groups as well as between injured and uninjured side of patients within the same group (P > 0.05). Abnormal MT sequence was found in 40.9% of group A (9/22) and in 40% of group B patients (4/10) (P > 0.05). Stabilization of associated fibula fractures did not significantly impact the clinical, radiographic and pedobarographic outcomes of the children with displaced DTMFs who were surgically treated. Level of evidence: Level III.

Safety and efficacy of surgical fixation of fibula fractures using an intramedullary nail: a retrospective observational cohort study in 30 patients

BackgroundOpen reduction and internal fixation remains the standard treatment for displaced unstable ankle fractures. Plate fixation represents the most frequently used instrumentation option in fibula fractures and favourable outcomes have been reported. Recently, intramedullary nailing techniques have been suggested as a viable alternative resulting in less soft tissue disruption. The objectives of this study are to describe the surgical technique and to evaluate the safety and efficacy of using an intramedullary nail in patients undergoing surgical fixation of their fibula fracture.MethodsA total of 30 skeletally mature patients with unstable ankle fracture who underwent intramedullary fixation of their fibula fractures from February 2016 to July 2017 were included in this retrospective study. Patients were evaluated using the Short Form-36 (SF-36) and the American Orthopaedic Foot and Ankle Society (AOFAS) at 18 months after surgery.ResultsAll patients went on to fracture union. Two patients required a secondary surgical procedure. No patient included in this series developed any wound complications. The mean Physical Component Summary (PCS) of the SF-36 was 53.90 ± 13.3 and the mean Mental Component Summary Score (MCS) was 52.63 ± 11.12. The AOFAS subscale scores were 34.67 ± 1.03 for pain, 42.40 ± 0.2997 for function and 9.50 ± 0.2785 for alignment.ConclusionsOur study demonstrates promising outcomes associated with intramedullary nail fixation of unstable fibula fractures. We recommend intramedullary nail fixation of fibula fractures to be a safe procedure with a low complication rate.Level of evidenceLevel 4 retrospective case series.

Fibular Nail Fixation: Topical Review.

Intramedullary implants have been used historically in long bone fractures with success. In recent years, a variety of intramedullary implants for the treatment of fibular fractures have been investigated. These various implants have not been assessed together in a cohesive manner. In this review, we assess implants used for intramedullary fixation of fibular fractures with respect to implant design and clinical results. A comprehensive systematic literature review for intramedullary implants in fibular fractures was performed. All publications that assessed intramedullary fibular implants were reviewed. In total, 11 different intramedullary nails were found. Clinical results obtained from these studies were reviewed. The intramedullary implants used for fibular fracture fixation generally fell into one of 3 categories: an unlocked longitudinal strut, an implant roughly equivalent to a large screw, or a more traditionally locked intramedullary nail. Reported clinical results were generally good, although inconsistent outcome reporting greatly limited comparison between studies. Complication rates varied with the implants but were generally low. Intramedullary implants for fibular fracture stabilization have changed over the years to improve stability. Although clinical results are limited, data suggest that these implants are safe and can potentially approximate more traditional implants. Level II, systematic review.

Evaluation of Results of Combined Blocking Screw and Interlocking Intramedullary Nail in the Treatment of Diaphyseo-Metaphyseal Tibial Fractures

AbstractBackground: Diaphyseo-metaphyseal tibial fractures tend to malalign while treatment by interlocking intramedullary nail. Multiple techniques are used to avoid malalignment as provisional unicortical plate, percutaneous clamping, universal distractor, fibular plating in distal tibia and blocking screw.Aim of Study: Was to evaluate the results of combined blocking screw and interlocking intramedullary nail in the treatment of diaphyseo-metaphyseal tibial fractures.Patients and Methods: This study was done on 21 patients with closed proximal or distal diaphyseo-metaphyseal tibial fractures, admitted at Tanta University Hospital. The distri-bution of patients was according to age, sex, and side, mode of trauma, and AO type of fracture, medical history, smoking, fracture level, time lag, fibular fixation and design of inter-locking nail. Fixation was done by interlocking intramedullary nail and the reduction was assisted by blocking screw in the coronal plane for varus or valgus malalignment and in the sagittal plane for recurvatum or procurvatum malalignment. Clinical evaluation was according to Hospital of Special Surgery Knee Rating Scale.Results: There were significant statistical correlation between the final clinical result and interlocking nail design either conventional or expert tibial nail or the time for union. There were significant statistical correlation between the time of union and sex of patients, mode of trauma, type of fracture, fibular fracture fixation and smoking.Conclusion: Blocking screw is a simple technique that assist in the reduction of diaphyseo-metaphyseal tibial fractures while fixation by interlocking nail, maintenance of the reduc-tion and stability of the fracture.

Does fixation of fibular fractures accompanying distal tibial fractures affect the ankle stability?

Does fixation of fibular fractures accompanying distal tibial fractures affect the ankle stability?

Non-locking buttress plate in distal tibial metaphyseal fractures

Background: Treatment of distal tibial metaphyseal fractures is often challenging and no single technique has been unanimously advocated. Open reduction and internal fixation with plates and screws allows better restoration of anatomical alignment but with more soft tissue complication. Simultaneous fixation of the fibula is not universally carried out. This study aims at evaluation of the outcome of plating technique and the effect of fixation of fibula fracture in treatment of distal tibial metaphyseal fractures.
 Material and methods: Thirty-one cases (14 cases in Group A with concomitant distal fibula fracture and 17 cases in Group B without distal fibula fracture) were analyzed retrospectively for the mean duration of full weight bearing, mean union time and complications, and compared.
 Results: The mean time for full weight bearing and radiological union in our study was 14.2 weeks (15.9 in Group A and 13.1 in Group B) and 23.8 weeks (26.6 in Group A and 21.5 in Group B) respectively. 16.1% of cases had post-operative complications including one case of deep infection and malalignment of 6 degree varus (following delayed union) was seen in one case of Group A. Range of motion (ROM) at ankle was not problem in any of the cases except the one delayed union which had 5 degrees of dorsiflexion and 15 degrees of plantiflexion.
 Conclusion: Open reduction and internal fixation with plate and screws in distal tibial metaphyseal fracture is more economic means of treatment modality with comparable incidence of post-union malalignment and union time,though more soft tissue complications compared to other modalities. Fixation of fibula fracture aids in reducing the incidence of malalignment.

Interlocking nail for management of distal tibia fracture: our experience at tertiary center of Bihar

Introduction: Tibia is the most commonly fractured bone amongst all long bones of the body due to its position and lack of soft tissue protection. Treating tibia distal 1/3rd fracture is still a greater challenge because Most of the distal third tibia is subcutaneous and has precarious blood supply. Fractures of the distal third tibia have comminution at the fracture site and have associated significant soft tissue injury. Generally, associated with ecchymosis, blebs, swellings, wounds, etc. All these factors contribute to delayed union, non-union, and malunion. The present study is about the ability to maintain a mechanically stable reduction in the distal third tibia with intramedullary nail, when lower 4cm of tibia not fractured. If associated with fibula fracture (in lower 10 cm), it fixed to give stability to syndesmosis and stability to same-level tibia fracture. Materials and methods: all patients of distal tibia fracture fulfilling the inclusion criteria from July 2011 to July 2017, were operated and followed up at every 4 weeks, till sign of union seen. Results: 72 patients (male 40, female 32) with Mean age of was 35.2 years (20–50 yrs), Fracture union was seen radiologically within 12 to 20 weeks, depending on fracture geometry. Conclusion: We found that results of fractures of distal third tibia not extending into lower 4 cm of tibia treated with interlock nailing were found satisfactory. Careful planning and placement of nail at the center of a wide metaphysis in the anteroposterior and lateral is necessary to avoid varus, valgus, and antero-posterior tilt. Polar screw or temporary K-wire during surgery was found to be helpful. Same-level fibula fracture fixation with a plate or k-wire is effective for stability of reduction.

Clinical comparison of two plate systems for distal fibular fracture fixation

The treatment of 3 and 4 part proximal humeral fractures in elderly patients is still controversial. The frequent co-existence of poor quality bone and rotator cuff abnormalities in patients with multiple clinical conditions and with difficulties for physical rehabilitation leads to disappointing clinical results, even when the radiological images are acceptable.To evaluate the clinical, radiological, and functional results in patients over 65 years old with complex proximal humerus fractures treated with reverse shoulder arthroplasty.A prospective review was carried out on 30 patients (26 women and 4 men) with proximal humeral fractures treated with reverse shoulder arthroplasty in our department. The mean age was 74.9 years (SD = 6.3), and the mean follow-up was 34.5 months (SD = 19.3).Clinical and functional results were acceptable, with a mean forward flexion of 124° and a mean external rotation of 13°. The mean abbreviated Constant abbreviated score was 49.1 (SD = 14.1), 27 (SD = 6.3) in the UCLA scale, and 32.2 (SD = 19.2) in the QuickDASH questionnaire. The large majority (80%) of the patients are pain free, and they do not need medication to do daily activities. The complication rate was 13.3%.We consider that reverse shoulder arthroplasty is a valid option to treat 3 and 4 part proximal humeral fractures in elderly patients. The surgical goals should include the anatomical reconstruction of the tuberosities, avoiding enlargement of the operated arm greater than 2 cm.El tratamiento de las fracturas en 3 y 4 fragmentos de húmero proximal en el paciente anciano resulta controvertido. La frecuente coexistencia de un hueso de mala calidad y la afección del manguito rotador con dificultades para el tratamiento rehabilitador en pacientes pluripatológicos conlleva, en muchas ocasiones, resultados clínicos decepcionantes, aun cuando el resultado radiológico sea aceptable.Evaluar los resultados clínicos, radiológicos y funcionales obtenidos en el tratamiento de las fracturas de húmero proximal complejas con prótesis inversa en pacientes mayores de 65 años de nuestro servicio.Revisión prospectiva en la que incluimos a 30 pacientes con fractura de húmero proximal intervenidos en nuestro servicio con prótesis total inversa de hombro. De ellos, 26 eran mujeres y 4 hombres. La edad media fue de 74,9 años (DE = 6,6). El seguimiento medio fue de 34,5 meses (DE = 19,3).El resultado clínico y funcional ha sido aceptable, con una antepulsión activa media de 124° y una rotación externa media de 13°. La puntuación media en la escala abreviada de Constant fue de 49,1 puntos (DE = 14,1), en la escala UCLA fue de 27 puntos (SD = 6,3) y en el cuestionario QuickDASH de 32,2 puntos (DE = 19,2). El 80% de los pacientes están libres de dolor sin precisar analgesia para la realización de sus actividades habituales. El 95% de los pacientes estaban satisfechos o muy satisfechos tras la intervención. La tasa de complicaciones fue del 13,3%.Consideramos la artroplastia total inversa como una opción válida en el tratamiento de las fracturas en 3 y 4 fragmentos de húmero proximal en pacientes mayores de 65 años. Los objetivos de la cirugía deben incluir la reconstrucción anatómica de las tuberosidades, evitando incrementos de la longitud del miembro intervenido superiores a 2 cm.

A prospective randomized comparative study on fractures of lower third of both bones of the leg treated by interlock nailing of tibia with or without fixation of fibula

<p class="abstract"><strong>Background:</strong> In the treatment of fractures of the distal third of tibia and fibula treated by interlocking nail of tibia, the role of fixing the fibular fracture is not clearly defined. This study was conducted to assess the benefits of fixation of fibular fracture in distal third leg bones fractures<span lang="EN-IN">.</span></p><p class="abstract"><strong>Methods:</strong> 95 patients were enrolled into study and divided randomly into two groups based on whether fibula fixed or not with interlock intramedullary nailing tibia. Patients were followed for an average period of 11 months both radiologically and clinically.<strong></strong></p><p class="abstract"><strong>Results:</strong> We observed that the average valgus angulation was significantly less<strong> </strong>(P =0.001) in the group where fibula was fixed. The outcome of the two groups for clinical ankle score, time of union and complication showed no difference (P ≥0.05)<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> We concluded that fixation of fibula decrease the malalignment of tibia in distal third fractures of tibia and fibula treated with interlocking nail of tibia<span lang="EN-IN">.</span></p><p class="abstract"> </p>

Fixation of distal fibular fractures: A biomechanical study of plate fixation techniques.

Ankle fractures are complex injuries with variable prognoses that depend upon many factors. The aim of the treatment is to restore the ankle joint biomechanical stability with maximum range of motion. Most ankle fractures are fibular fractures, which have a typical oblique fracture line in the distal fibula located in the area of the tibiofibular syndesmosis. The aim of this study was to simulate numerically several fixation techniques of the distal fibular fractures, evaluate their stability, determine their impact on surrounding tissue load, and correlate the results to clinical treatment experience. The following three models of fibular fracture fixation were used: (a) plate fixation with three screws attached above/below and lag screws, (b) plate fixation with two screws attached above/below and lag screws, and (c) three lag screws only. All three fracture fixation models were analyzed according to their use in both healthy physiological bone and osteoporotic bone tissue. Based on the results of Finite Element Analysis for these simulations, we found that the most appropriate fixation method for Weber-B1 fibular fractures was an unlocked plate fixation using six screws and lag screws, both in patients with physiological and osteoporotic bone tissue. Conversely, the least appropriate fixation method was an unlocked plate fixation with four screws and lag screws. Although this fixation method reduces the stress on patients during surgery, it greatly increased loading on the bone and, thus, the risk of fixation failure. The final fixation model with three lag screws only was found to be appropriate only for very limited indications.

Distal fibula fracture fixation: Biomechanical evaluation of three different fixation implants.

The goal of this study was to evaluate the biomechanical performance of three distal fibula fracture fixation implants in a matched pair cadaveric fibula model: (1) a 5-hole compression plate with lag screw, (2) a 5-hole locking plate with lag screw, and (3) the 6-hole tabbed-plate with locking screws. Three-dimensional motions between the proximal and distal fibular segments were measured under cyclic valgus bending, cyclic compressive axial loading, and cyclic torsional external-rotation loading. During loading, strains were measured on the surfaces of each fibula near the simulated fracture site, and on the plate, to assess load transfer. Bone quality was quantified globally for each donor using bone mineral density (BMD) measured using Dual X-ray absorptiometry (DEXA) and locally at the fracture site using bone mineral content (BMC) measured using peripheral quantitative computed tomography (pQCT). Mean failure loads were below 0.2Nm of valgus bending and below 4Nm of external-rotational torque. Mean failure angulation was below 1degree for valgus bending, and failure rotation was below 7degrees for external-rotation. In the compression plate group, significant correlations were observed between bone quality (global BMD and local BMC) and strain in every one of the five locations (Pearson correlation coefficients >0.95, p<0.05). In contrast, in the locking and tabbed-plate groups, BMD and BMC correlated with far fewer strain locations. Overall, the tabbed-plate had similar construct stability and strength to the compression and locking plates. However, the distribution of load with the locking and tabbed-plates was not as heavily dependent on bone quality.

The Role of Fibular Fixation in Distal Tibial Fractures.

Lower tibial extra-articular fractures of lower tibial extra-articular bone, treated with Minimally Invasive Percutaneous plate osteosynthesis (MIPPO) may have certain advantages, though the modiality is technically demanding. To assess the results of distal tibial fractures treated with minimally invasive plate osteosynthesis utilizing precontoured dital medial tibial locking plates without fibular fracture fixation. The study was conducted during the period from june 2009 to june 2011. A series of 30 patients (22 men and 8 women) with concurrent distal tibia and fibula fractures who underwent minimally plate osteosynthesis utilizing precontoured distal tibial medial locking plates without fibular fracture fixation have been reviewed after surgery. 14 fractures were type A1, 6 type A2, and 4 type A3. Open Grade II fracture were 4 and Open Grade IIIA fracture is2. The mean follow-up duration was 2 years. The mean time to bone union was 20 weeks. No patient had shortening, hardware breakdown, or deep-seated infection. Out of 30 patients, 24 had excellent results, 6 had good results. Four patients had palpable screws, two patient had blisters which subsidized with conservative treatment. This minimally invasive technique for treatment of distal tibial fractures proved to be a feasible and worthwhile method of stabilization. It appears from our study that fibula fixation is not required in non-syndesmotic distal metaphyseal extra articular fractures when fixed by locking plate using minimal invasive techniques.

Pilon kırıklarında fibula tespitinin önemi

Tibial pilon fractures constitude 1% of lower extremity frac- tures and approximately 7-10% of all tibial fractures. These fractures are often occurs after a high-energy injury and 85% of pilon fractures are accompanied by fibula fracture. Good results after surgical treatment of pilon fractures depends on the quality of articular reduction, providence of methaphysodiaphyseal alignment and stable fixation that could provide early mobilization. Although detection of accompanying fibula fractures is important in terms of lengthening, rotation and alignment, ensuring stable fixation provides additional stability to the tibia fixation. Although screw-plaque is the conventional method in the fixation of fibula fractures accompanying pilon fractures, intramedullary implants can also be used in the fixation and both techniques have advantages and disadvantages when compared. Fixation of fibula fractures accompanying pilon fractures is recommended in order to get better functional outcomes after surgical treatment of pilon fractures, and experience to a lesser extent tibial malunion and post-trau- matic ankle arthritis.

Management of Fractures of Distal third Tibia by Interlock Nailing

ABSTRACT Introduction Most of the distal third tibia is subcutaneous and has precarious blood supply. Fractures of the distal third tibia have comminution at the fracture site, as it is metaphyseal cancellous bone with a thin shell of cortex, and have associated significant soft tissue injury. Generally, skin condition is not satisfactory due to ecchymosis, blebs, swellings, wounds, etc. All these factors contribute to delayed union, nonunion, and malunion. The present study is about the ability to maintain a mechanically stable reduction in the distal third tibia with intramedullary nail, when lower 4 cm of tibia not fractured. If associated with fibula fracture (in lower 10 cm), it is always fixed as a rule to give stability to syndesmosis and stability to same-level tibia fracture. Materials and methods From January 2013 to March 2015, 60 patients of distal tibia fracture admitted to Government Medical College and Hospital, Latur, were operated and followed up prospectively. Results Mean age of patients was 35 years (25–50). Fracture union was seen radiologically within 3 to 4 months, depending on fracture geometry. Conclusion We conclude that results of fractures of distal third tibia not extending into lower 4 cm of tibia treated with interlock nailing were found satisfactory. Meticulous planning and placement of nail at the center of a wide metaphysis in the anteroposterior and lateral is mandatory to avoid varus, valgus, and posterior tilt. Polar screw or temporary K-wire during surgery is very helpful. Same-level fibula fracture fixation with a plate or square nail is very effective for stability of reduction. How to cite this article Gawali SR, Kukale SB, Nirvane PV, Toshniwal RO. Management of Fractures of Distal third Tibia by Interlock Nailing. J Foot Ankle Surg (Asia-Pacific) 2016;3(1):15-22.

Anesthetic Management for Lower Limb Fracture in Severe Aortic Valve Stenosis and Fat Embolism: A Case Report and Review of Literature

Introduction:Anesthesia in severe aortic stenosis, which describes a valve surface area less than 1 cm2, can result in rapid clinical deterioration and patient mortality. These patients may require treatment for aortic stenosis before any surgical intervention. In suitable patients percutaneous balloon aortic valvutomy appears to carry lower risk, but in emergency situations, it is important to determine which kind of anesthesia technique has the lowest risk for these patients, without any cardiac intervention.Case Presentation:In this case report, we present a patient who had tibia and fibula fractures and a symptomatic severe critical aortic stenosis which was diagnosed during a preoperative visit. The patient had exertional dyspnea, palpitations and fainting history, but he had not received any medical therapy before the present admission. During hospitalization and preoperative evaluation, a fat embolism occurred and the patient was admitted to the intensive care unit. Immediately after his recovery, we successfully managed the tibia and fibula fracture fixation without any cardiac intervention.Conclusions:Our anesthesia method was sciatic and femoral nerve block under double ultrasonic and nerve stimulator guidance.

Biomechanical Evaluation of Mini-Fragment Hardware for Supination External Rotation Fractures of the Distal Fibula

Supination external rotation distal fibula fractures are common, requiring fixation when associated with talar displacement. Subcutaneous distal fibula hardware may become painful, necessitating operative removal. We hypothesize that mini-fragment and small-fragment constructs will demonstrate similar biomechanical stability. A biomechanical comparison was performed in synthetic osteoporotic sawbones. The first arm compared two 2.4-mm lag screws with one 3.5-mm lag screw for fixation of a simulated supination external rotation distal fibula fracture. The second arm compared a 2.4-mm plate-screw construct with a 3.5-mm lag screw and one-third tubular neutralization plate. During torsional testing, torque and displacement were recorded, and stiffness and peak torque were determined. Differences in mean stiffness and mean load at failure were not statistically significant with lag screw-only fixation. The 3.5-mm plate-screw construct outperformed the 2.4-mm plate-screw construct, but neither mean stiffness nor mean load at failure were statistically significantly different. Dynamic testing also demonstrated similar results. Our data suggest that isolated 2.4-mm screws function similarly to one 3.5-mm screw. Although the 3.5-mm plate-screw construct was stiffer, mean load at failure was equivalent for the 2 constructs. These data provide biomechanical evidence to support further investigation in the use of mini-fragment hardware for distal fibula fracture fixation. Therapeutic, Level V.

The results of two-staged operative management of pilon fractures–a review of 25 cases

Abstract To evaluate the two-staged operative fixation of Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) type C pilon fractures. Retrospective review of prospectively collected data. Twenty-five consecutive patients with AO/OTA type C pilon fractures. All the patients underwent immediate application of external fixator spanning the ankle joint and internal fixation of fibular fracture. After a mean duration of 12 days, the external fixator was removed and internal fixation of pilon fracture was performed. At average follow-up of 18 months, all patients were evaluated by using subjective, objective, and radiographic measurements as described by Burwell and Charnley. Range of motion and postoperative complications were also recorded. Twenty-three of the 25 fractures healed within an average of 4 months. Average range of motion was 7° of dorsiflexion, 31° of plantar flexion, 11° of eversion, and 13° of inversion. Subjective and objective measurements showed 80% good results, 12% fair results, and 8% poor results. Radiographs showed anatomic reduction in 84% cases and fair reduction in another 16% cases. There were no infections or soft tissue complications. The arthrodesis rate was 4%. A two-staged approach offers good outcome for the treatment of AO/OTA type C pilon fractures.

Comment 2

The authors describe an alternative method for assessment of the integrity of the distal tibiofibular syndesmosis. In their description of the technique, they highlight the importance of fixation of the fibular fracture prior to performing the test. However, they neglect to mention the importance of fixation of any associated medial malleolar fracture prior to testing syndesmotic stability. Indeed, the images accompanying the note show their test being performed on a bimalleolar fracture with the medial malleolar fracture untouched, but the final image shows medial malleolar fracture fixation and syndesmosis screws present. This is in contrast to conventional teaching. In the majority of bimalleolar fractures, rigid fixation of both medial malleolar and fibular fractures should stabilise the syndesmosis and abolish the need for a syndesmosis screw.1,2 The exception to this is if there is co-existing ligamentous disruption medially or laterally, in which case syndesmotic widening would be observed on testing the syndesmosis after fixation of both medial malleolar and fibular fractures.