Fixation Of Pilon Fractures Research Articles

Is it justifiable to perform tibio-talar arthrodesis rather than fixation as the treatment for severe pilon fractures?

Category: Trauma Introduction/Purpose: The purpose of this study was to compare functional outcome at minimum 2 years follow up post fixation of pilon fractures to that of patients undergoing elective procedure (in the form of TAR or ankle arthrodesis) for primary osteoarthritis of the ankle to assess whether pilon fracture patients would benefit from tibio-talar arthrodesis as a primary procedure rather than fixation to avoid significant functional disability between primary fixation and subsequent arthrodesis. Methods: This is a retrospective study of prospectively collected data of patients operated between April 2012 and December 2015. All patients with primary osteoarthritis undergoing elective TAR/arthrodesis (Group A) had pre-op functional scores recorded (MOX-FQ, EQ-5D and Foot and ankle outcome score FAOS). Patients with bilateral ankle arthritis, previous reconstructive surgery, inflammatory arthritis, hip and knee arthritis, spinal pathology and underlying neurological conditions were excluded from Group A. Patients in Group B (post Pilon fracture fixation with a minimum 2 year follow up) completed a postal questionnaire with the above scores. Outcomes between groups were compared using inferential statistical tests using SPSS. Results: Mean age of patients in Group A and Group B were (62.6 ± 10.9 years) and (46.4 ± 15 years) respectively; p<0.001. In group B, 9 patients (16.6%) had associated injuries and 45 patients (83.3%) had isolated injuries. 49 patients underwent an open reduction and internal fixation vs. 5 patients with hybrid fixator as a definitive management in Group B with 2 patients having significant infection (1 in each group). The results of functional scores comparing Group A to Group B (including sub-group analysis) are awaited and will be submitted subject to acceptance of this abstract. Conclusion: The outcomes of pilon fracture are well known to be poor with high rate of secondary osteoarthritis and significant functional disability associated with it in young individuals in active employment. The gold standard treatment for patients with significant osteoarthritis of the ankle is tibio-talar arthrodesis. However, a group of these patients continue to have high functional disability between initial injury and to the point of tibio-talar arthrodesis. The results of this study will highlight the justification to perform tibio-talar arthrodesis as a definitive treatment at the time of injury, rather than fixation.

Functional outcome of JESS fixation and bone grafting in distal tibial plafond-pilon fracture: a prospective study

<p class="abstract"><strong>Background:</strong> The Pilon fractures are one of the most difficult to treat. Fracture known as “orthopedicians nightmare”. The incidence of complications following ORIF of pilon ranges from 10-55% and other complication are infection, loss of reduction, secondary arthrosis. In these circumstances JESS and Bone grafting is cost effective and less hospitalization. Our aim was to evaluate in the functional outcome of JESS fixation and bone grafting in distal tibial plafond- pilon fracture using Olerud and Molander score.</p><p class="abstract"><strong>Methods:</strong> The JESS fixation and bone grafting was used for pilon fracture in 30 patients, 24 male and 6 female. Mean age 44 years range (18-60 years). Fractures caused by fall and RTA. All were treated with JESS fixation and bone grafting. the patients were assessed clinically and radiographically at regular interval of 1 month and later 2 months interval. Outcome was assessed using Olerud and Molander score. Complications were recorded.<strong></strong></p><p class="abstract"><strong>Results:</strong> 12 patients had Ruedi and Allgower type II fracture and 18 patients had type III fracture. After 9 month of follow up midterm OMAS score- 11.766 was achieved. Outcomes were good in 71.25% and fair results in 50.83% respectively. The complication seen was residual ankle pain in 6.66% patients and implant failure in 13.33%.</p><p><strong>Conclusions:</strong> Fixation of pilon fracture with JESS and bone grafting is associated with good functional outcome in type II and fair in type III pilon fracture. The incidence of complications high in type III pilon fracture. </p>

External fixation versus open reduction and internal fixation of pilon fractures: A systematic review and meta-analysis

Objectives: Pilon fractures are challenging to treat and associated with complications such as skin necrosis and superficial and deep infections that can potentially lead to amputation. This meta-analysis aimed to compare the postoperative outcomes following open reduction and internal fixation (ORIF) versus external fixation for pilon fractures. Methods: We searched several databases from January 1990 to July 2017, for any observational or experimental studies that evaluated the postoperative outcomes of pilon fractures. We pooled the effect sizes using fixed-effect models that compared the postoperative outcomes of ORIF versus external fixation. Descriptive and qualitative data were also extracted. Results: Of the 485 articles identified, 13 were eligible for the meta-analysis, with a total of 683 pilon fractures in 679 patients. The pooled estimate for major infection in external fixation of pilon fractures showed comparable events compared to those who underwent ORIF (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 0.56–1.96, I2= 42.2%). External fixation was also found to be associated with higher events for minor infection (OR = 2.83, 95% CI: 1.63; 4.93, I2= 0.00%), delayed union (OR = 2.42, 95% CI: 1.02; 5.72, I2= 0.00%), nonunion (OR = 1.58, 95% CI: 0.79; 3.18, I2= 0.00%), malunion (OR = 3.14, 95% CI: 1.65; 5.97, I2= 0.00%), and posttraumatic arthritis (OR = 2.55, 95% CI: 1.40; 4.63, I2= 0.00%). These results did not change even after doing sensitivity analysis comparing limited internal fixation with external fixation, uniplanar external fixation, and circular external fixator, to ORIF. Conclusions: External fixation was associated with the same chance of having adverse events that required additional procedure(s) or intravenous antibiotics compared to ORIF in pilon fractures, but the difference in bone healing complication was much more observed. ORIF allows accurate articular reduction with comparable infection rates and lower bone healing complications.

Evaluation of functional outcome of pilon fractures managed with limited internal fixation and external fixation: A prospective clinical study

IntroductionThe management of pilon fractures is controversial primarily due to the high rate of complications irrespective of the mode of treatment. Limited internal fixation with external fixation is associated with minimal soft tissue handling. This may reduce the chances of wound dehiscence and infection. This study was designed to evaluate the functional and clinical outcomes in patients treated with limited internal fixation combined with external fixation in pilon fractures. Material and methodsThis study was conducted as a prospective clinical study on 56 skeletally mature patients with closed fractures with poor skin condition, and with open grade 1 and grade 2 distal tibial intra-articular fractures. All patients were treated with combined limited internal fixation and ankle spanning external fixation. ResultsAll fractures in this series united with an average time period of union of 18.3weeks (ranging from 13 weeks to 30 weeks). There was no non-union in any case. There was malunion in 4 cases, varus malunion (>5 degree) in 2 cases and recurvatum in another 2 cases). Excellent to good functional results were observed in 88% cases based on the modified Ovadia and Beals score. The mean ankle dorsiflexion and planter flexion movements were 10.2±5.3 degrees and 27.4±7.2 degrees respectively. infections occurred in 6 patients which included 4 pin tract infections and 2 superficial wound infection, all 6 healed after removal of pin tract and with oral antibiotics. ConclusionThe technique of combined external fixation with internal fixation is safe and effective management option for intra-articular distal tibial fractures.

Effect of Lymphedema Treatment for Management of Acute Pilon Fractures.

Pilon fractures are high-energy injuries that often result in considerable edema and compromise of the soft tissue envelope of the ankle. These injuries are typically staged with an external fixator until the soft tissue is amenable for definitive fixation. This study was conducted to determine the effects of lymphedema treatment for the management of pilon fractures. Patients who underwent open reduction and internal fixation of pilon fractures between 2007 and 2014 at the authors' level II trauma center were identified by Current Procedural Terminology codes indicative of placement of an external fixator (20690) and open reduction and internal fixation of a pilon fracture (27826, 27827, or 27828). The primary efficacy endpoint to determine negative outcomes was 90 days after definitive fixation. Eighty-two patients with 84 pilon fractures met inclusion criteria. Forty-eight ankles (57%) received lymphedema treatment. There were no significant differences in population demographics between the control and treatment groups. Median times to internal fixation in the control and treatment groups were 20 days (inter-quartile range, 15.5-30 days) and 11 days (interquartile range, 6-18 days), respectively. This difference was statistically significant (P=.001). Additionally, there was no significant difference in the overall incidence of wound complications between the control and treatment groups (P=.246). Compression wrapping for posttraumatic edema was effective in reducing the time needed for soft tissues to be appropriate for definitive surgical fixation of pilon fractures without increasing the risk of wound complications. These promising results warrant future study. [Orthopedics. 2017; 40(4):e668-e674.].

Plating of pilon fractures based on the orientation of the fibular shaft component: A biomechanical study evaluating plate stiffness in a cadaveric fracture model

ObjectivesTo evaluate mechanically superior method of pilon fracture fixation by comparing axial stiffness between anterolateral and medial tibial locking plates in a cadaveric fracture model. MethodsEight matched pairs of fresh frozen cadaver specimens (lower limb after through-knee disarticulation) were used to eliminate confounder of bone quality. Simulated pilon fractures were created so that each pair represented either varus or valgus fracture pattern (AO 43-A2) with associated fibular fractures (transverse or comminuted). Specimens were plated with DePuy anterolateral or medial locking plate and axial load applied, measuring displacement at the fracture site. Each lower extremity was tested with a fracture wedge in place and removed to mimic comminution. Average force at which failure occurred was compared between the two fixation methods, for varus and valgus fracture pattern respectively, with the use of a Mann-Whitney U test. ResultsOn average, medial plate fixation of varus fractures resulted in 2.27 times (range of 1.6–3.9) greater load prior to failure as compared to anterolateral plate. Similarly, valgus simulated fractures tolerated 1.6 times (range 1.12–2.34) higher force prior to failure if anterolateral plate was applied versus medial plate. Analysis utilizing the Mann-Whitney U test for fracture patterns vs plate configuration approached statistical significance (p=0.081 varus failure and p=0.386 valgus failure). ConclusionsLateral plate fixation is biomechanically superior for pilon fractures resulting from valgus force as evident by comminuted fibular fracture. Similarly, medial plate location resulted in improved stiffness in compression for varus type fractures, evident by transverse fibular fracture. We approached statistical significance, however our lack of power regarding adequate sample size is an issue that is consistent with other biomechanical studies in this area.

Evaluation of Fibular Fracture Type vs Location of Tibial Fixation of Pilon Fractures.

Comminuted fibular fractures can occur with pilon fractures as a result of valgus stress. Transverse fibular fractures can occur with varus deformation. No definitive guide for determining the proper location of tibial fixation exists. The purpose of this study was to identify optimal plate location for fixation of pilon fractures based on the orientation of the fibular fracture. One hundred two patients with 103 pilon fractures were identified who were definitively treated at our institution from 2004 to 2013. Pilon fractures were classified using the AO/OTA classification and included 43-A through 43-C fractures. Inclusion criteria were age of at least 18 years, associated fibular fracture, and definitive tibial plating. Patients were grouped based on the fibular component fracture type (comminuted vs transverse), and the location of plate fixation (medial vs lateral) was noted. Radiographic outcomes were assessed for mechanical failures. Forty fractures were a result of varus force as evidenced by transverse fracture of the fibula and 63 were due to valgus force with a comminuted fibula. For the transverse fibula group, 14.3% mechanical complications were noted for medially placed plate vs 80% for lateral plating ( P = .006). For the comminuted fibular group, 36.4% of medially placed plates demonstrated mechanical complications vs 16.7% for laterally based plates ( P = .156). Time to weight bearing as tolerated was also noted to be significant between groups plated medially and laterally for the comminuted group ( P = .013). Correctly assessing the fibular component for pilon fractures provides valuable information regarding deforming forces. To limit mechanical complications, tibial plates should be applied in such a way as to resist the original deforming forces. Level of Evidence Level III, comparative study.

The management of tibial pilon fractures with the Ilizarov fixator: The role of ankle arthroscopy

BackgroundPilon fractures usually result from high energy trauma, and are commonly associated with extensive soft tissue damage which prevents the use of open reduction and internal fixation. PurposeThis study was designed to evaluate the use of the Ilizarov external fixator in the treatment of pilon fractures of the ankle, and to determine whether arthroscopy of the ankle could improve the outcome. MethodsFrom February 2011 to May 2013 a total of 23 patients with unilateral closed pilon fractures were divided into two groups treated with and without arthroscopy during fixation with the Ilizarov external fixator. The fractures were classified according to the AO Rüdi and Allgőwer classification. Follow up ranged from 10 to 37 months with a mean of 18 months. ResultsAll cases were evaluated at follow up by the AOFAS and the Bone et al. grading system. According to Bone et al. there were 3 cases excellent, 4 cases good, 2 cases fair, and 2 cases poor in Group A (without arthroscopy), whereas there were 4 cases excellent, 6 cases good, 2 cases fair in Group B (with arthroscopy). The AOFAS score for Group A was 77.8±5.8, and for Group B was 78.4±6.9. ConclusionWe concluded that the Ilizarov external fixator is an excellent method in treating pilon fractures as it minimizes the need for extensive surgery. We also conclude that the use of arthroscopy during pilon fracture fixation did not add statistically significant improvement to our results and it needs longer term investigation to assess its advantage – if any – to the final outcome.Level of evidence: level 2.

Strategies for surgical approaches in open reduction internal fixation of pilon fractures.

Pilon or tibial plafond fractures usually result from high-energy injuries with rotation and/or axial compression. They occur in an area of relatively poor soft tissue coverage and frequently present a surgical challenge in deciding which incisions will be best for performing open reduction internal fixation. A variety of anterior and posterior approaches have been described based on the ease of fracture reduction and internal fixation with plates. Some of the incisions are fracture specific, that is, planned for a limited approach to the pilon. But in more complex cases, a wider exposure is indicated and thus more extensile approaches, both anterior and posterior, can be valuable. This review article will describe the different surgical approaches, focusing on their indication and technique.

Early ORIF of Tibial Pilon Fractures is Safe

The complication rate with acute fixation of pilon fractures is comparable to that of delayed or staged fixation. This article discusses early and medium-term data from a prospective cohort study examining early open reduction and internal fixation of tibial pilon fractures.

Анализ напряженно-деформированного состояния дистального отдела голени и стопы при повреждениях pilon в условиях наружной фиксации при помощи стержневых аппаратов

Цель исследования — выявить возможности применения стержневых устройств для внеочагового остеосинтеза при повреждениях pilon и установить наиболее подходящие конструкции для данной локализации повреждений. Для этого в условиях лаборатории биомеханики ГУ «Институт патологии позвоночника и суставов им. проф. М.И. Ситенко АМН Украины» использован анализ напряженно-деформированного состояния дистального отдела голени и голеностопного сустава в норме и в условиях внеочаговой фиксации разными типами стержневых аппаратов при переломах pilon. Анализ проведен методом конечных элементов, который дает возможность в полной мере учитывать геометрические и физические особенности конструкций, а также предоставить полную картину нагрузки, провести объективное сравнение методов и устройств для фиксации переломов, оценить их преимущества и недостатки.Исследование проведено на объемной трехмерной модели дистального отдела голени и голеностопного сустава с применением трехмерной конечно-элементной модели. Расчеты проведены с применением расчетной программы BioCаd и программы визуализации расчетов Looker.В результате определены наиболее нагруженные участки исследуемой анатомической зоны в норме и распределение нагрузок в условиях внеочаговой фиксации при переломах pilon. Дказано, что применение стержневых односторонних устройств при переломах pilon в принципе возможно, так как обеспечивает разгрузку поврежденной анатомической зоны в условиях осевых нагрузок в границах половины массы тела человека, выделены конструкции фиксаторов, которым следует отдавать предпочтение.

Anterolateral approach to the distal tibia for fixation of pilon fractures

Background Pilon fractures continue to be a treatment challenge. The purpose of this study was to examine our rate of early (up to 6 weeks) complications associated with using the anterolateral approach to the distal tibia. Methods Thirty-six patients treated between September, 2005, and July, 2007, at a level I trauma center were reviewed. Patients were treated by two fellowship-trained orthopaedic trauma surgeons. Patients followed the standard staged protocol used for pilon fractures with early external fixation after injury and delayed definitive operative fixation through an anterolateral approach. Patients were examined clinically at 2–3 weeks and then 6 weeks for complications associated with the surgical approach. Results All fractures were AO/OTA type C fractures (72% C3, 19% C2, and 8% C1). Nine of the 36 patients (24.7%) had wound complications related to the anterolateral incision. Six patients (16.7%) had minor complications, and three (8%) had major complications. The three major complications were deep wound infections; the six minor complications were treated successfully with oral antibiotics and local wound care. Conclusions Open reduction and internal fixation of pilon fractures using an anterolateral approach provided an extensile approach to the distal tibia and ankle with a relatively low incidence of major early wound complications in a series of patients with highly complex pilon fractures.

Early open reduction and internal fixation of Pilon fractures

After some general considerations concerning the blood supply to the bone and skin, and the timing of the surgery, the different approaches to Pilon fractures are presented. These approaches have to be planned according to 3D CT reconstructions to provide the best visual control over the reduction manoeuvres without creating supplementary damage to the blood supply to the bone and skin. This article then reviews in detail the steps of reduction and internal fixation for different types of fractures. As a principle, it is recommended to begin with the fixation of the fibular fracture unless it is comminuted. In these cases a bridge plate osteosynthesis is made after tibial reconstruction.Tibial articular reconstruction can be achieved “from outside” in case of simple large fragments (AO types B1 and C1), or under direct visual control in case of comminution. There are different options for fixation, from isolated screws, eventually combined with intramedullary nailing in some simple fractures, to locking plates for complex fractures. There is no place anymore for conventional plating in pilon fractures. Pre-shaped locking plates are frequently used. In contrast, the AO LCP pilon plate can be placed at any position around the distal tibia depending on the fracture anatomy and the approaches. It has to be cut and adapted individually to each case. The extremities of the plate have to be glided below the soft tissues and screws inserted through stab incisions when necessary, to avoid additional soft tissue damage. In the postoperative care a plaster cast for 6 weeks is a reliable option to avoid equinus and secondary rehabilitation problems.In conclusion, open reduction and internal fixation of pilon fractures remains a challenge, but preoperative 3D CT reconstructions for planning, and fixation with locking plates changed dramatically the way of treating and the prognosis of these severe fractures.

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

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.

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.

Anterolateral and Medial Locking Plate Stiffness in Distal Tibial Fracture Model

The purpose of this study was to compare the axial and torsional stiffness between anterolateral and medial distal tibial locking plates in a pilon fracture model. The biomechanical stiffness of anterolateral or medial plated pilon fracture models was evaluated. Six Sawbones Composite Tibiae with a simulated pilon fracture representing varus or valgus comminution (OTA 43-A2.2) were plated with a Synthes 3.5-mm contoured LCP anterolateral or medial locking distal tibia plate. Load as a function of axial displacement and torque as a function of angular displacement were recorded. Each tibia was tested with a fracture wedge in place and removed with a medial and then anterolateral plate. Loading the tibial plateau medial to the central axis, no significant difference in mean stiffness between the anterolateral and medial plates was demonstrated with the fracture wedge in place. A significant difference was demonstrated with the wedge removed. Loading the plateau posterior to the central axis, no significant difference in mean stiffness between plates was demonstrated with the wedge in place or removed. With the wedge in place, there was a significant difference in mean torsional stiffness for clockwise rotation, but not counterclockwise rotation. With the wedge removed, no significant difference appeared in mean stiffness for clockwise and counterclockwise rotation. Distal tibia extra-articular fractures stabilized with anterolateral or medial locking plate constructs demonstrated no statistically significant difference in biomechanical stiffness in compression and torsion testing. We believe this study indicates the primary concern when treating a pilon fracture may be soft-tissue considerations. Further clinical studies are required before definitive changes can be recommended regarding pilon fracture fixation.

Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

A biomechanical study of different fixations for unstable pilon fractures

Objective To investigate the biomechanical properties of different fixations in the treatment of unstable pilon fracture of distal tibia. Methods Ruedi-Allgower type Ⅲ unstable pilon fractures were created on 7 fresh cadaveric ankle specimens and then fixed with 5 different methods: medial buttress plate(Group A), distal tibial anatomic plate plus medial cannulated screw (Group B), external fixator plus medial cannulated screw (Group C), external fixator plus medial plate (Group D), external fixator plus distal tibial anatomic plate (Group E) . Biomechanical properties such as strength, stiffness and failure load were tested respectively and comparisons among the different groups were conducted.Results In groups D and E, the compressive strengths (MPa) were 0.90±0.08 and 0.98±0.08, and the stiffnesses (N / mm) were 4800.00±490.61 and 4444.45±451.52, respectively. Fixation of pilon fractures with external fixator plus either medial tibial buttress plate or lateral anatomic plate had best biomechanical properties than the other devices. Conclusion Fixation of unstable distal tibial fracture with extemal fixator plus either medial tibial buttress plate or lateral anatomic plate is an effective option for complex un-stable pilon fracture. Key words: Tibial fractures; Fracture fixation; Biomechanics; External fixator

Percutaneous Contoured Locking Plate Fixation of the Pilon Fracture: Surgical Technique

Preservation of the soft tissue is of particular importance in the care of pilon fractures. Improper soft tissue management has been attributed to high rates of nonunion, nerve injury, and failures (1–12). Traditional open reduction internal fixation (ORIF) of pilon fractures allows for direct visualization of the fracture(s) but is criticized for the large exposure and periosteal stripping. As a result, this approach has been blamed for high nonunion rates as well as failure of the soft tissue to accommodate implants (1, 5, 8, 13). External fixation has also been used but has not demonstrated much advantage to internal fixation and requires significant postoperative care. Also, external fixation has a higher incidence of malunion (6, 14) and has inherent risks for pin-tract infections (14, 15). In an attempt to limit the iatrogenic soft tissue injury (5, 6, 7), some surgeons have used a limited ORIF concentrating on restoration of the articular surface combined with ring or hybrid external fixation. The “2-stage” technique combines the benefits of both external and internal fixation, and is thought to limit soft tissue related complications by allowing soft tissue recovery time before the introduction of internal fixation. Initial temporary external fixation combined with limited exposures for internal fixation (2-stage technique) at a later date allows for less disruption of the soft tissue envelope, leading to a decrease in complications associated with traditional open approaches. This may be achieved through relatively “small incisions” extending from the pole of the malleolus to the metaphyseal fracture(s), although these incisions can still be quite long, especially when significant articular reconstruction and/or bone grafting is required. Other descriptions include “limited approach” or “minimally invasive”; and this differs from a true percutaneous approach. With the advent of locking plate technology, surgeons have successfully managed a variety of fractures though smaller incisions to introduce the plate(s)—the percutaneous approach. Unlike traditional plating methods, locking plates do not rely on frictional forces between the plate/bone interface to achieve compression and stability. This allows for less damage to the periosteal blood supply, which may theoretically decrease the incidence of delayed or nonunion, soft tissue complications, and possibly secondary loss of fixation (16, 17). A recent study by Salton et al (18) demonstrated no major complications and only 4 minor soft tissue complications in a series of 19 patients treated with a limited incision and percutaneous medial plate fixation. More recently available contoured locking plates with multiple options for metaphyseal screw placement through the “percutaneous” incision allow for the surgeon to achieve stability through this access point. With percutaneous locking plates, the incision may be even smaller than used with the traditional 2-stage technique.

A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: Open reduction and internal fixation versus external Ilizarov fixation

Intra-articular fractures of the tibial plafond are complex injuries which continue to challenge orthopaedic surgeons in achieving anatomic reduction, while allowing early weight bearing and return to activity. Although a wide range of treatment options has been described for fixation of pilon fractures, the unique characteristic of each injury makes it difficult to advocate a general method of choice. We have attempted to compare a subset of AO/OTA type C pilon fractures treated either by a staged procedure of external fixation and conversion to open reduction and internal fixation (ORIF) versus definitive external Ilizarov fixation. Between 1998 and 2004, 42 patients admitted to our level 1 trauma centre underwent either procedure and were followed prospectively. Twenty-eight patients were treated with ORIF and 14 were treated by Ilizarov ring fixator. The outcome measures included time to union, as well as the rates of union, nonunion, malunion and infection. Although the ORIF group had a longer time to heal, the rates of nonunion, malunion and infection were lower compared to the Ilizarov group. However, these differences between the groups were not statistically significant. Thus, based on these results, no clinical recommendation can be made as to which procedure is better and safer for the patient. Future prospective randomised trials are required to determine with more scientific accuracy the optimal treatment strategy for these challenging injuries.