Treatment Of Tibial Plafond Fractures Research Articles

Influence of reduction quality on functional outcome and quality of life in treatment of tibial plafond fractures: a retrospective cohort study

BackgroundThe aim of the study was to evaluate the impact of reduction quality, using intraoperative 3D imaging, on quality of life and functional outcome in the operative treatment of tibial plafond fractures.MethodsA group of patients with tibial plafond fractures was re-examined. The operative treatment was performed between September 2001 and October 2011. The follow-up examination was at least 2 years after the final surgical procedure. Final reduction result was assessed intraoperatively using a mobile 3D C-arm. A categorization with regard to descriptive parameters as well as type and size of joint surface irregularities was performed. Follow-up results were evaluated using: Olerud and Molander (O & M) score, Short-Form-36 (SF-36) score, movement deficit, Kellgren and Lawrence grade of osteoarthritis, and pain intensity.Results34 patients with operatively treated tibial plafond fracture could be re-examined. Reduction quality had the greatest influence on functional result measured by the O & M score (p = 0.001) and the PCS domain of the SF-36 score (p = 0.018).Significant differences with regard to O & M score (p = 0.000), SF-36 score (p = 0.001 to p = 0.02; without MCS domain), movement deficit (p = 0.001), grade of osteoarthritis (p = 0.005) and pain (p = 0.001) could be verified under consideration of the reduction quality. The group with the anatomically more accurate reduction also showed a better result for clinical follow-up and quality of life. Furthermore, it is not the type of joint surface irregularity that is always decisive, but rather the size.ConclusionsDespite other relevant factors, it appears that reduction quality –which can be analyzed with intraoperative 3D imaging– plays the most important role in postoperative quality of life and functional outcome. Corrections should therefore be performed on joint surface irregularities with a size above 2 mm.

Impact of Intraoperative Cone Beam Computed Tomography on Reduction Quality and Implant Position in Treatment of Tibial Plafond Fractures.

The intraoperative assessment of the articular surface in displaced intra-articular distal tibia fractures can be challenging using conventional fluoroscopy. The aim of the study was to determine the frequency and the method of intraoperative corrections of fracture reductions or implant placements during open reduction, internal fixation by using cone beam computed tomography (CT) after conventional fluoroscopy. Displaced intra-articular distal tibia fractures were retrospectively analyzed from August 2001 until December 2011. The fractures were classified according to the standards of the AO/OTA as type B or C and treated with open reduction and internal plate fixation. After primary reduction using conventional fluoroscopy, an additional cone beam CT scan was used to determine the alignment of the joint line and the implant position. The number of intraoperative revisions of the primary reduction due to the use of cone beam CT was analyzed. A total of 143 patients with an intra-articular tibial plafond fracture were included in the analysis. In 43 patients (30%), an intraoperative correction was performed after the cone beam CT scan. In 34 (24%) of these cases, intraoperative correction was required because of inadequate joint line reduction. Nine (6%) corrections were required as a result of a malposition of the implant. The revision rate did not differ by fracture classification. Despite its acceptance as the standard method of imaging, intraoperative conventional fluoroscopy for the assessment of implant positioning and fracture reduction of tibial plafond fractures is limited. The intraoperative utilization of cone beam CT provided additional information for the surgeon to detect insufficient reduction or implant malposition. Level III, retrospective comparative series.

Management of distal tibial intra-articular fractures with circular external fixation

The treatment of tibial plafond fractures requires careful management of the soft tissue envelope, reconstruction of the articular surface and stable fixation with minimal additional damage. Thirty cases of AO type 43 C tibial fractures were treated by transosseous osteosynthesis (Ilizarov technique). The external fixator constructs used were Ilizarov (Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth of tissue, Springer, Berlin, 1992) and Sheffield (Classification AO des fractures, Springer, Berlin, 1987) circular fixator systems. All tibial plafond fractures healed. Using radiological criteria for assessment of reduction of the articular fragments and the clinical scoring system described by Teeny and Wiss, there were excellent and good restoration of articular structure in 27 cases and good clinical results in 14. This treatment method compares well with previous published series and is to be recommended for this group of difficult fractures.

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.

The Use of Medial and Lateral Surgical Approaches for the Treatment of Tibial Plafond Fractures

There has been a sharp reduction in complications associated with tibial pilon fractures with the introduction of the two-step approach to treatment. However, there has yet to be any real reevaluation of the standard anterior approach used to expose and reduce these fractures. Now, with the ability to obtain computed tomographic (CT) scans after initial reduction, the fracture pattern of the tibia can be seen more clearly, suggesting that perhaps other surgical approaches may be better suited to visualize, reduce, and stabilize these injuries. At our institution, a two-incision approach using standard medial and lateral incisions, when appropriate to the fracture pattern, was found to allow improved visualization of the tibial articular surface and talus, ease of fixation placement with the new plate designs, and a low complication rate regarding soft-tissue issues when compared with published methods.

Results and Outcomes After Operative Treatment of High-Energy Tibial Plafond Fractures

The purposes of this study were to evaluate the clinical and radiographic results and the functional outcomes after operative treatment of tibial plafond fractures treated with internal or external fixation. A retrospective review identified 76 patients with 79 fractures (OTA 43-B or 43-C) of the tibial plafond. Their average age was 45 years. Twenty-one fractures (27%) were open, and 43 (54%) were type 43-C3. Five were type 43-B1, four were 43-B2, two were 43-B3, 15 were 43-C1, and 10 were 43-C2. Patients were treated with open reduction and internal fixation (ORIF) (n = 63) or limited open articular reduction and wire ring external fixation (EF) (n = 16). Tibial fixation was performed at a mean of 7.6 days after injury, with staged reconstruction in 56 fractures (71%). Bone graft was used initially in 32 fractures (41%). Early and late complications, secondary procedures, and radiographic evidence of post-traumatic arthritis were evaluated. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered. Seventy-nine fractures were followed clinically and radiographically for a mean of 26 (range 24 to 38) months, and 33 patients completed outcomes questionnaires at a mean of 98 months after surgery. Early complications included two superficial wound problems and three deep infections. Late complications included two nonunions and four malunions. Thirty-one fractures (39%) developed post-traumatic arthritis. Complications occurred after six of 21 open fractures and after 11 of 43 type C3 fractures (p = 0.007). Patients treated with EF more frequently had type C3 fractures (88% versus 46%, p = 0.004) compared with patients treated with ORIF. The EF patients developed more complications (six of 16, p = 0.007) and post-traumatic arthritis (11 of 16, p = 0.01) when compared with ORIF. Patients treated with EF (88% were type C3 fractures) had lower FFI and MFA scores. The greatest impairment in outcome was noted after type C3 fractures, regardless of the method of treatment. Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.

Posterior Blade Plate Fusion: A Salvage Procedure in Severe Posttraumatic Osteoarthritis of the Tibiotalar Joint

The treatment of tibial plafond fractures is challenging and often is complicated by the compromise of the anterior ankle soft-tissue envelope and a high degree of fracture comminution. Many of these injuries are nonreconstructable and posttraumatic osteoarthritis of the tibiotalar joint is unavoidable. These patients may benefit from a salvage procedure using a posterior blade plate fusion of the tibiotalar joint. This procedure avoids the compromised anterior ankle soft-tissue envelope and allows simultaneous reconstruction of the metaphyseal defect as well as fusion of the tibiotalar joint. Indications include the acute treatment of severely comminuted tibial plafond fractures that appear nonreconstructable, management of posttraumatic tibiotalar osteoarthritis that is associated with significant compromise of the anterior ankle soft tissue envelope, and salvage of distal metaphyseal nonunions or delayed unions that are associated with posttraumatic tibiotalar osteoarthritis. We suggest posterior blade plate fusion as a standard procedure for these patient populations. Further clinical trials are required to investigate the clinical long-term outcomes in these patients.

Extracapsular placement of distal tibial transfixation wires.

Treatment of tibial plafond fractures with external fixation may involve use of transfixation wires within the periarticular region. Pin track infections that develop along wires placed intracapsularly may lead to joint infection. To our knowledge, there have been no previous investigations assessing the circumferential reflection of the ankle capsule or the potential for communication between the distal tibiofibular joint and the tibiotalar joint. The purpose of this study was to define these anatomic entities to provide guidelines for safe extracapsular placement of distal tibial wires. Twelve fresh-frozen cadaveric ankles and three ankles of living human volunteers were utilized for this study. High-resolution magnetic resonance imaging was performed on each ankle after pressurized distention of the joint capsule with gadolinium solution. The perpendicular distance from the subchondral bone at the joint line to the capsular synovial reflection was measured with use of a verified technique. The cadaveric ankles were sectioned, the capsular synovial reflections were measured by investigators who were blinded to the imaging results, and the corresponding measurements were compared. The anterolateral capsular synovial region displayed the most proximal reflection in all specimens (mean, 9.3 mm; maximum, 12.2 mm). The anteromedial region displayed less reflection (mean, 3.3 mm; maximum, 5.5 mm). All posteromedial and posterolateral synovial reflections were <or=2 mm. Capsular synovial reflections proximal to the medial and lateral malleoli were negligible. In all ankles, the distal tibiofibular joint communicated with the tibiotalar joint and had a maximum proximal extension of 20.6 mm. Placement of distal tibial transfixation wires >12.2 mm from the subchondral surface of the plafond avoids penetration of the capsule. The distal tibiofibular joint communicates with the tibiotalar joint and thus should not be penetrated, to ensure extracapsular placement of the wires.

The treatment of tibial plafond fractures with external fixation: closed or limited open reduction technique

Objectives: To evaluate the results of treatment for tibial plafond fractures with the use of external fixation with closed or limited open reduction. Methods: Twenty-two fractures of 21 patients (14 males, 7 females; mean age 28.2 years; range 19 to 52 years) were evaluated. According to the Ruedi and Allgower classification, the types of fractures were I, II, and III in four, four, and 14 patients, respectively. Four patients had grade I, four had grade II, and five had grade III open fractures. The tibial joint surface restoration was made by limited open reduction and minimal osteosynthesis (n=7); and fibular restoration with tubular plates (n=4), and Rush pins (n=6). The fixators were circular (n=8), monolateral (n=10), and hybrid (n=4). Primary otogeneous bone grafting was performed in four cases with metaphyseal bone defect, and skin grafting for soft tissue coverage in two cases. The results were evaluated according to the Teeny criteria. The mean duration for external fixation was nine weeks (6 to 15 weeks); the mean follow-up was 27 months (6 to 48 months). Results: The results were excellent in five cases, good in five, fair in seven, and poor in five cases. Bone and soft tissue infections were not encountered. Complications included skin slought (n=3), malunion having more than 5° tilt on the tibial joint surface (n=4), and post-traumatic osteoarthrosis that required ankle arthrodesis (n=1). Conclusion: Treatment with external fixators with limited open reduction or closed reduction is safe and effective in high energy fractures that may present an increased risk for wound healing problems when treated by the traditional method.

Stabilization of the fractured tibial plafond

Historically, open treatment of tibial plafond fractures has produced an unacceptable complication rate. The use ofmodern fracture treatment principles, such as indirect reduction and biological fixation, along with careful timing of surgery and handling of surrounding soft tissues, can minimize the complications for which these fractures are so well known. The surgical goals include restoration of extremity length and alignment, precise articular reconstruction, rigid fracture fixation, and early joint motion. Such goals are typically accomplished through formal open reduction with internal fixation or by limited internal fixation of the articular surface combined with an external fixation device. This article focuses on the operative management of distal tibial articular fractures with emphasis on avoiding potential complications.

Results of Surgical Treatment of Tibial Plafond Fractures

To clarify which factors influence the final result of surgical management of plafond or pilon fractures, 66 patients with 67 pilon fractures treated at the Orthopaedic Department of the University of Athens between 1978 and 1993 were reviewed. There were eight (11.95%) Type I, 33 (49.25%) Type II, and 26 (38.8%) Type III fractures according to the Ruedi-Allgower classification. Eleven (16.4%) were open injuries. Fifty of the 67 fractures were treated by internal fixation following the AO principles, whereas minimal osteosynthesis was performed in nine cases, and the remaining eight cases were managed by external fixation. The final outcome of the treatment was evaluated after 2 to 17 years followup (mean, 8.1 years) and was based on the subjective, objective, and radiographic results of each case, using the method of Burwell and Charnley. The findings indicate that three parameters significantly influenced the outcome of plafond fracture management. Specifically, the results of surgical management were affected by the clinical type of the fracture, the quality of reduction achieved at surgery, and the specific surgical procedure by which the fracture was managed.