Fibula fixation in the treatment of tibial pilon fractures - Is it really necessary?

Fibula fixation is not associated with a higher rate of wound complications during pilon fracture open reduction internal fixation

Introduction

There is a lack of consensus regarding indications for fibula fixation in pilon fractures. Reduction of the fibula fracture can assist with restoring lateral column length and reduction of the tibial plafond during pilon ORIF. However, there are theoretical concerns with wound complications and soft tissue insult. The purpose of this study is to compare short-term outcome measures after tibial plafond ORIF with and without supplemental fibula fixation using a validated national database.

Materials and methods

The American College of Surgeons' NSQIP database was utilized to identify all patients undergoing tibial plafond ORIF with and without fibula fixation between January 1, 2015 and December 31, 2020 using Current Procedural Terminology (CPT) codes 27827 and 27828, respectively. Open fractures and cases with concurrent open procedures were excluded from analysis. Demographic data, medical comorbidities, surgical variables, and various 30-day outcome measures were compared between the two groups. Multivariate logistic regression was used to identify independent variables associated with various outcome measure of interest.

Results

A total of 3120 patients were included in the final cohort: 1530 patients underwent tibia fixation alone and 1590 patients underwent both tibia and fibula fixation. The supplemental fibula fixation group had a higher rate of reoperation (2.3 % vs. 1.1 %, p = 0.013) and non-home discharge (14.8 % vs. 11.2 %, p = 0.003). The rate of surgical site infection was comparable between groups. Supplemental fibula fixation was independently associated with unplanned reoperation (RR: 1.939 [1.081-3.477], p = 0.026).

Conclusions

Patients undergoing supplemental fibula fixation during tibial plafond ORIF had a higher rate of 30-day reoperation and non-home discharge. Supplemental fibula fixation during pilon fracture ORIF was independently associated with a higher rate of 30-day reoperation. There was no difference in the rates of surgical site infection or wound dehiscence between the two groups.

Level of evidence

3.

Current Strategies in Pilon Fracture Management and Looking to the Future

Historically high complication rates encouraged the evolution of pilon fracture management. This article reviews these complex fractures, offering insight into the evolution of treatment with a glimpse into future management techniques, while superimposing our experience with included retrospective analysis of 41 pilon fractures treated at our institution by a single surgeon (T.M.C.) spanning 60 months. With improved understanding and advancing technology, multiple literature-supported strategies are available for the management of these limb-threatening traumas. Intriguing strategies needing further investigation may one day shift the paradigm; as for now, the foundational principles of pilon fracture management continue to anchor the treatment strategy.

Should We Fix the Fibula in Tibial Plafond Fractures? A Meta-analysis Reviewing the Evidence Base for Fibula Open Reduction and Internal Fixation in Tibial Plafond Fractures

Open reduction and internal fixation are the standard of care to stabilize tibial plafond fractures. However, it remains uncertain as to whether fixation of the fibula affects the outcome. This study aimed to review the evidence base for comparable outcomes in tibial plafond fractures when undergoing open reduction and internal fixation of ipsilateral fibula fractures compared with open reduction and internal fixation of the tibia alone. A systematic review and meta-analysis of the literature was completed; 4 studies were included for analysis. This study demonstrated no statistically significant differences in the incidence of nonunion (p = .784) or mal-union (p = .416). There was a greater rate of removal of metalwork in the fibula operative group compared to the tibia alone group (p < .001). The current evidence demonstrates that open reduction and internal fixation of ipsilateral fibula fractures in tibial plafond fractures is not necessarily routinely indicated for all fractures.

Early posterior column internal fixation: A staged treatment of type C3 tibial pilon fracture

Pilon fractures represent a challenging subset of tibial fractures. The management of AO/OTA Type C3 fractures remains complex due to associated complications and lack of clear guidelines for surgical timing and methods. A prospective cohort study was conducted to evaluate two staged treatment strategies for AO/OTA Type C3 tibial pilon fractures. The study focused on assessing surgical difficulty, complications, and patient prognosis. One group of patients received early internal fixation of the fibula and tibial posterior column combined with external fixation, while the other group received external fixation alone in the first stage. Patients who received early internal fixation of the fibula and tibial posterior column combined with external fixation had better outcomes, including lower rate of allogeneic bone grafting (67.74 % versus 94.64 %), reduced incidence of wound delay and skin necrosis (3.23 % versus 21.43 %), shorter surgical time (133.06 ± 23.99 min versus 163.04 ± 26.83 min), shorter hospital stay (13.77 ± 2.53 days versus 18.25 ± 3.67 days), and higher AOFAS (83.05 ± 8.68 versus 79.36 ± 8.92). Additionally, avoiding fibular shortening was shown to be crucial in preventing prolonged surgery and improving patient function. The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. The findings support the use of this treatment to optimize outcomes in AO/OTA Type C3 pilon fractures.

Lower Limb Malrotation following Minimally Invasive Plating in Distal Tibia Fractures

Introduction

Minimally invasive percutaneousosteosynthesis (MIPO) plating techniques havedemonstrated good outcomes in the treatment of distal tibia fractures. Early arthritis and functional impairment mayoccur if length and rotation are not restored. This study aims to determine the incidence and severity of tibia malrotation following MIPO plating of isolated unilateral distal tibia fractures, defined as torsional difference of greater than 10° as compared to the contralateral limb and whether the degree of malrotation affects functional outcomes scores.

Materials and methods

This was a level 2 prospective cohort study. All patients with fractures of the distal tibia who underwent surgical fixation with the exclusion ofpatients with polytrauma, neurovascular injuries or pre-existing disabilities were recruited. Patients underwent MIPO plating followed by a post-operative ComputedTomography (CT) scan of bilateral lower limbs. AOFAS ankle-hindfoot score was recorded at six months and one year follow-up.

Results

A total of 24 patients (28 to 83 years old) were recruited. Nineteen patients obtained CT scans. Nine of the 19 patients (47.3%) had tibia malrotation. The mean tibia malrotation angle was 10.3° (0° - 45°). The average AOFAS scores was 82.4 and 84.3 at 6 months and 1 year follow-up. Degree of CT malrotation was not significantly associated with AOFAS scores at 6 month (spearman rho -0.386) and 1 year (spearman rho -0.343).

Conclusions

Tibia malrotation following MIPO plating of distal tibia fractures is common, with an incidence of 47.3% and an average malrotation angle of 10.3°. The degree of malrotation does not appear to have significant mid-term functional impact on the patient.

Matrix Rhythm Therapy (MRT) Along With Conventional Physiotherapy Proves to Be Beneficial in a Patient With Post-Operative Knee Stiffness in Case of Tibia-Fibula Fracture: A Case Report

Open fractures of the lower extremities are much more serious as compared to those of the upper extremities. Open fractures occur when the damaged bone is exposed to the external environment through injured soft tissue, increasing the risk of infection. The distal tibia can be fractured by a low-energy mechanism, such as rotational strain or perhaps a high-energy mechanism, such as motor vehicle accidents or falls from high altitudes. This case report is of a male individual who underwent an accident that led to a midshaft tibia and fibula fracture with lateral malleolus fracture. For that, he was operated on with open reduction and internal fixation (ORIF) with interlock nailing for a fracture of the tibia on the right side. A thorough physiotherapy protocol was set, which included matrix rhythm therapy (MRT), and improvements were seen in the outcome measures taken. The course of therapy improved the patient's state of well-being. Functional re-education increased the strength and endurance of the muscles. The patient also developed lower limb strength.

Management of High-Energy Tibial Pilon Fractures

➤ Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.➤ Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.➤ Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.➤ Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.➤ Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.➤ The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.

Early Reduction of the Posterior Column: A Surgical Technique in AO/OTA C3 Tibial Pilon Fractures

Staged treatment for pilon fractures is widely accepted. It remains to be discussed how to reduce and fix posterior column fractures while avoiding clinical complications. We provided a staged treatment protocol with detailed surgical techniques for closed AO Foundation/Orthopaedic Trauma Association (AO/OTA) C3 tibial pilon fractures with fibular fractures. In the first stage, the internal fixation of the fibula and distal tibial posterior column is accompanied by an external fixator. After swelling, the medial and anterior columns were fixed via the posteromedial approach in the second stage. We advocate early reduction and fixation of the posterior column and lateral column. The right timing of surgery can ensure well-reduced articular surface and alignment while minimizing soft tissue complications.

Team Approach: Perioperative Management of Pilon Fractures

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Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse.

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A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes.

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The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.

Morbidities and prognostic factors after tibial pilon fracture: impact on patients

INTRODUCTION

This study aims primarily to characterize the sequelae and morbidity associated with tibial pilon injuries from the patients' perspectives in terms of multiple surgical interventions, duration of hospital stay, downtime from work, loss of productivity and impact on patients' lives. The secondary aim is to review the associated risk factors for these morbidities.

MATERIALS AND METHODS

All patients with surgically treated tibial pilon fractures from 1st July 2007 to 30th June 2017 were included. The morbidities reviewed focused on delay to surgery, numbers of surgeries, limb amputation, length of stay (LOS), readmissions, duration of medical leave (ML), follow-up and number of outpatient visits.

RESULTS

There were 102 patients included in the review and up to 70% of them had an average 7 days delay to definitive surgery. They also required an average hospital LOS of at least 2 weeks extending up to 3 more weeks if soft tissue reconstruction was necessitated. Up to a third of patients were readmitted with 15% of them needing further treatment. These patients required a notable period of downtime from work as shown in the long ML (mean 152.6 days [S.D. = 110.7]). Multiple conditional regression models showed AO/OTA classification (B and C) and open fracture as independent predictors of delay to surgery. Predictors for increased LOS were high velocity mechanism of injury at 4 days longer and patients who needed soft tissue reconstruction at 21 days longer. In terms of downtime from work, only work injury has been identified as an independent predictor of ML at 88.5 days longer.

CONCLUSION

Tibial pilon fractures leads to significant morbidities with profound negative impact on patients' lives in terms of multiple surgical interventions required, prolonged hospital stay, need for readmissions and prolonged downtime from work. These morbidities from patients' perspective should be emphasized to patients and employers to manage their expectations and potential limitations.