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Liu P, Mei X, Wang Z, Xu F, Cai X, Shou K, Wei S. Optimal biomechanical choice of implant placement in various pilon fracture types: a finite element study. BMC Musculoskelet Disord 2024; 25:950. [PMID: 39587566 PMCID: PMC11587616 DOI: 10.1186/s12891-024-08076-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 11/14/2024] [Indexed: 11/27/2024] Open
Abstract
BACKGROUND The research on the biomechanical characteristics of individual implant placement for pilon fractures based on the different initial direction of fracture displacement is still insufficient. This study's aim is to compare the stress distribution in bones and implants with various pilon fracture types. METHODS Varus, valgus, dorsiflexion, and plantarflexion type fractures were categorized as type I, II, III, and IV, respectively. The buttress plate was placed medially in subtypes IA and IIB, whereas it was placed anterolaterally in subtypes IB and IIA; The anterior or posterior buttress plate was utilized in subtypes IIIA and IVA, the lag screws were applied in subtypes IIIB and IVB. The maximum equivalent stress of tibia (TI-Smax) and implants (IF-Smax), stress of fracture fragments (Sfe), and axial displacement values of the fracture fragments (ADfe) in each subtype were analyzed when the ankle was in a neutral position, 15° of varus and valgus in types I and II, 15° of dorsiflexion and plantarflexion in types III and IV. RESULTS Under the same axial stress loading conditions, TI-Smax, Sfe, ADfe of subtypes IA and IIA were significantly lower than subtypes IB and IIB, while IF-Smax of subtypes IA and IIA were obviously larger than subtypes IB and IIB. Additionally, TI-Smax, Sfe, ADfe of subtypes IIIA and IVA were considerably lower as IF-Smax met expectations compared to subtypes IIIB and IVB. CONCLUSION Based on these results, when making decisions for open reduction and internal fixation in various pilon fractures, the choice and placement of the implant can be recommended as follows: the medial buttress plate for varus types; the anterolateral plate for valgus types; the anterior plate for dorsiflexion types; the posterior plate for plantarflexion types.
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Affiliation(s)
- Peizhao Liu
- Department of Orthopedics, General Hospital of Central Theater Command of PLA, (Wuhan General Hospital of Guangzhou Command, Previously), Hubei Province, NO. 627, Wuluo Road, Wuhan, 430030, P.R. China
| | - Xianzhong Mei
- Department of Orthopedics, Shenzhen Pingle Orthopedic Hospital, Shenzhen, Guangdong, P.R. China
| | - Zhixiang Wang
- Department of Orthopedics, Wuhan No.1 Hospital, Wuhan, Hubei, P.R. China
| | - Feng Xu
- Department of Orthopedics, General Hospital of Central Theater Command of PLA, (Wuhan General Hospital of Guangzhou Command, Previously), Hubei Province, NO. 627, Wuluo Road, Wuhan, 430030, P.R. China
| | - Xianhua Cai
- Department of Orthopedics, South China Hospital, Medical School, Shenzhen University, Shenzhen, Guangdong Province, 518116, P.R. China.
| | - Kangquan Shou
- Department of Orthopedics, The First College of Clinical Medical School, China Three Gorges University and Yichang Central People's Hospital, Yichang, Hubei, P.R. China
| | - Shijun Wei
- Department of Orthopedics, General Hospital of Central Theater Command of PLA, (Wuhan General Hospital of Guangzhou Command, Previously), Hubei Province, NO. 627, Wuluo Road, Wuhan, 430030, P.R. China.
- The First Clinical Medical School of Southern Medical University, Guangzhou, Guangdong, P.R. China.
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Wang BH, Zhang BB, Gong ZL, Mei J, Luo CF, Zhu Y. Biomechanical evaluation of different medial column fixation patterns for valgus pilon fractures. BMC Musculoskelet Disord 2024; 25:533. [PMID: 38992608 PMCID: PMC11238518 DOI: 10.1186/s12891-024-07660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 07/04/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND The purpose of this study was to perform a biomechanical analysis to compare different medial column fixation patterns for valgus pilon fractures in a case-based model. METHODS Based on the fracture mapping, 48 valgus pilon fracture models were produced and assigned into four groups with different medial column fixation patterns: no fixation (NF), K-wires (KW), intramedullary screws (IS), and locking compression plate (LCP). Each group contained wedge-in and wedge-out subgroups. After fixing each specimen on the machine, gradually increased axial compressive loads were applied with a load speed of one millimeter per minute. The maximum peak force was set at 1500 N. Load-displacement curves were generated and the axial stiffness was calculated. Five different loads of 200 N, 400 N, 600 N, 800 N, 1000 N were selected for analysis. The specimen failure was defined as resultant loading displacement over 3 mm. RESULTS For the wedge-out models, Group-IS showed less displacement (p < 0.001), higher axial stiffness (p < 0.01), and higher load to failure (p < 0.001) than Group-NF. Group-KW showed comparable displacement under loads of 200 N, 400 N and 600 N with both Group-IS and Group-LCP. For the wedge-in models, no statistical differences in displacement, axial stiffness, or load to failure were observed among the four groups. Overall, wedge-out models exhibited less axial stiffness than wedge-in models (all p < 0.01). CONCLUSIONS Functional reduction with stable fixation of the medial column is essential for the biomechanical stability of valgus pilon fractures and medial column fixation provides the enough biomechanical stability for this kind of fracture in the combination of anterolateral fixation. In detail, the K-wires can provide a provisional stability at an early stage. Intramedullary screws are strong enough to provide the medial column stability as a definitive fixation. In future, this technique can be recommended for medial column fixation as a complement for holistic stability in high-energy valgus pilon fractures.
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Affiliation(s)
- Bing-Hao Wang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Bin-Bin Zhang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Zi-Ling Gong
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Jiong Mei
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Cong-Feng Luo
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
| | - Yi Zhu
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
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3
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Kugach KA, Leong WM, Clements JR. Management of Pilon Fractures. Clin Podiatr Med Surg 2024; 41:503-518. [PMID: 38789167 DOI: 10.1016/j.cpm.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Pilon fractures are complex injuries that can be difficult to treat and lead to severe complications if not managed appropriately. A thorough examination for polytraumatic injuries, neurovascular status, and skin condition should be done. A variety of approaches can be chosen based on fracture pattern, including staging, incisional approach, and no-touch technique. This article discusses various ways to manage pilon fractures.
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Affiliation(s)
- Kelly A Kugach
- Carilion Clinic Institute for Orthopaedics and Neuroscience, 3 Riverside Circle, Roanoke, VA 24014, USA.
| | - Wesley Maurice Leong
- Monument Health Orthopedics and Specialty Hospital, 1635 Caregiver Way, Rapid City, SD 57702, USA
| | - John Randolph Clements
- Department of Surgery, Section of Orthopaedics, Carilion Clinic Institute for Orthopaedics and Neuroscience, 3 Riverside Circle, Roanoke, VA 24014, USA
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Yang K, Shen G, Zheng Q, Yang H, Zhang H, Li X, Tan Y, Zhu Y. Medial malleolar window approach for varus-type tibial pilon fractures: a retrospective study. BMC Musculoskelet Disord 2023; 24:358. [PMID: 37149577 PMCID: PMC10163773 DOI: 10.1186/s12891-023-06444-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/19/2023] [Indexed: 05/08/2023] Open
Abstract
PURPOSE Choosing a suitable surgical approach is crucial and challenging for type C pilon fractures. This article aims to explore the clinical efficacy of the medial malleolar window approach for varus-type tibial pilon fractures. METHODS A retrospective analysis was conducted on 38 patients with type C varus-type pilon fractures treated between May 2018 and June 2021. In total, 16 cases underwent surgical treatment through the medial malleolar window approach and 22 cases were treated with the traditional anteromedial approach combined with a posterior approach. The operation time, hospitalization time, fracture healing time, the American Orthopedic Foot and Ankle score, Visual Analogue Scale, and complications were recorded to comprehensively evaluate the clinical efficacy of the technique. Fracture reduction quality was evaluated using the criteria proposed by Burwell and Charnley. RESULTS All patients were followed up. No patients presented delayed union or nonunion. Compared with the conventional approach, the medial malleolar window approach had the advantage of better clinical effect recovery and better fracture reduction (P < 0.05). Meanwhile, the medial malleolar window approach had a shorter operation time, although the statistics suggest no significant difference with the control group. No implant exposure or infection occurred. There was good wound healing at two weeks after surgery in all but two cases. Local wound edge necrosis developed in one case in the medial malleolar window approach group, and the wound could not be closed at one stage in another case in the conventional group because of excessive tension, requiring secondary closure. CONCLUSION The medial malleolar window approach provides excellent exposure to type C pilon fractures, allowing for satisfactory fracture reduction and functional rehabilitation. The medial window approach is recommended for varus-type pilon fractures, which can effectively avoid a posterior incision and reduce the operation time.
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Affiliation(s)
- Kangyong Yang
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China
| | - Guodong Shen
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China
| | - Qian Zheng
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China
| | - Haiyun Yang
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China
| | - Hongning Zhang
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China
| | - Xue Li
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China
| | - Yanqing Tan
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China
| | - Yongzhan Zhu
- The Eighth School of Clinical Medicine, Guangzhou University of Chinese Medicine, Foshan, Guangdong, China.
- Department of Foot and Ankle Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, 528000, China.
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Stamatos NJ, Ostrowski TJ, Mori BV, Fiscella K, Anoushiravani AA, Rosenbaum A. Team Approach: Perioperative Management of Pilon Fractures. JBJS Rev 2023; 11:01874474-202303000-00002. [PMID: 36913508 DOI: 10.2106/jbjs.rvw.22.00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
» Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse. » A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes. » 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.
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Affiliation(s)
| | - Tyler J Ostrowski
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | | | - Kimberly Fiscella
- Department of Surgery, Division of Plastic Surgery, Albany Medical Center, Albany, New York
| | | | - Andrew Rosenbaum
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
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Abdelgaid SM, Hatata DMZ, Elshafey AE, Alsharkawy WM. Minimally Invasive Reduction and Fixation Techniques of Pilon Fractures Based on the Preoperative CT Findings. J Foot Ankle Surg 2022; 61:590-603. [PMID: 34810084 DOI: 10.1053/j.jfas.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 05/25/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
Tibial plafond fractures are often associated with significant articular cartilage and soft tissue damage. The presence of co-morbidities has been associated with an increased risk of surgical site complications. With improved in surgical techniques and implants, complication rates have declined; however, the overall prognosis often remains poor. The aims of this study were to evaluate the results of innovative minimally invasive reduction and fixation techniques in tibial plafond fractures based on a CT classification and to compare the difference between short and long-term outcomes. Based on preoperative CT findings, fractures were classified into varus, valgus, anterior, posterior, and neutral types. The minimally invasive reduction and fixation techniques depend on type of fracture, size and location of the intraarticular fragments, and degree of comminution of the extra-articular component. Ninety-one pilon fractures (90 patients) underwent minimally invasive reduction and fixation, of which 7 fractures (7.69%), required open reduction because of intraoperative failure to achieve anatomic reduction. Of the 84 fractures that underwent successful minimally invasive reduction and fixation reported, 35 fractures (41.7%) with excellent outcomes, 40 fractures (47.6%) with good outcomes, 6 fractures (7,1%) with fair outcomes, and 3 fractures (3.6%) had poor outcomes for the long-term American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score (follow-up ≥ 60 months). These results prove that minimally invasive treatment is an effective and durable treatment option for intra-articular pilon fractures. We encourage future clinical studies to further refine minimally invasive techniques for pilon fractures to improve outcomes.
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7
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Surgical approach strategies for open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans. J Orthop Surg Res 2020; 15:283. [PMID: 32718324 PMCID: PMC7385877 DOI: 10.1186/s13018-020-01770-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To explore the application and clinical efficacy of surgical approach strategies in open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans. METHODS This retrospective cohort study included data of 25 patients with closed complex tibial Pilon fractures treated from October 2011 to March 2014, including 19 males and 6 females aged 18-54 years (average 39.5 years). According to classification criteria of the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), 4 patients were type 43C1, 10 type 43C2, and 11 type 43C3. Surgical approaches were selected based on fracture line distribution and bone displacement revealed by axial CT scans, and an open reduction method was adopted for internal fixation of the bone plates. Postoperatively, Burwell-Charnley radiographic criteria were used to determine fracture reduction quality. Functional evaluation was performed using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Complications, fracture union time, and the AOFAS scores at last follow-up were recorded. RESULTS The 25 included patients were followed for 22-60 months postoperatively (average follow-up 33.9 months). Of these, 19 patients achieved anatomical reduction of the articular surface, 5 achieved good reduction, and one achieved fair reduction. Two patients developed superficial infection on the anteromedial incision and delayed union but recovered well after local dressing change and oral administration of antibiotics. Another patient developed deep infection on the anterolateral incision, which was controlled by debridement, catheter irrigation, and intravenous antibiotic injection. All fractures healed well and average union time was 2.8 months (range, 2-3 months). No fracture malunion or internal fixation failures were found at last follow-up. All 25 patients had AOFAS scores ranging from 80 to 100 at last follow-up (average 88.4). Overall, 15 patients were excellent, 10 good, and 0 fair or poor, with excellent and good rates of 100%. CONCLUSIONS Surgical approach strategies for complex tibial Pilon fractures based on axial CT scans accurately reconstruct the articular surface and achieve solid internal fixation of assembled locking plates, while early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications.
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8
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Abstract
Malunion of ankle and pilon fractures has significant detrimental effect on function and development of post-trauma osteoarthritis. Unfortunately, the incidence of malunion has been reported to be increasing. It is important to assess the ankle for congruency, because this determines the level where correction will occur. A plethora of techniques are available, with low-level evidence supporting each, and therefore it is important that the treating surgeon is fully prepared and comfortable in the techniques they are to use. Supplementary procedures are common and should be expected. This article provides a review of current methods of treatment and their outcomes.
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Gulbrandsen TR, Hulick RM, Polk AJ, Weldy JM, Howell KL, Spitler CA, Crist BD. Does surgical approach affect sagittal plane alignment and pilon fracture outcomes? Injury 2020; 51:750-758. [PMID: 32008815 DOI: 10.1016/j.injury.2020.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/07/2020] [Accepted: 01/19/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Sagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement. PATIENTS AND METHODS A retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs. RESULTS 580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02). CONCLUSIONS The sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.
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Affiliation(s)
- Trevor R Gulbrandsen
- University of Iowa Hospitals and Clinics, Department of Orthopedic Surgery, Iowa City, IA, United States
| | - Robert M Hulick
- University of Mississippi Medical Center, Department of Orthopaedic Surgery, Jackson, MS, United States
| | - Andrew J Polk
- University of Missouri School of Medicine, Columbia, MO, United States
| | - John M Weldy
- University of Mississippi Medical Center, Department of Orthopaedic Surgery, Jackson, MS, United States
| | - Kathryn L Howell
- Tulane University, Department of Orthopaedic Surgery, New Orleans, LA, United States
| | - Clay A Spitler
- University of Mississippi Medical Center, Department of Internal Medicine, Jackson, MS, United States; University of Alabama-Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States
| | - Brett D Crist
- University of Missouri, Department of Orthopaedic Surgery, Columbia, MO, United States.
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Tosun B, Selek O. Lateral Transfibular Approach to Tibial Pilon Fractures: A Case Report. J Am Podiatr Med Assoc 2019; 109:459-462. [PMID: 31755769 DOI: 10.7547/17-212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We present a case of tibial pilon fracture where only the lateral part of the distal tibia was affected. The transfibular approach to the ankle was used for the surgical treatment of the fracture. After an initial nonweightbearing period of 3 weeks, full weightbearing was allowed 8 weeks after surgery. The second-year follow-up showed no evidence of degenerative signs, with full ankle range of motion.
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Affiliation(s)
- Bilgehan Tosun
- Department of Orthopaedics and Traumatology, Kocaeli University, School of Medicine, Izmit, Kocaeli, Turkey
| | - Ozgur Selek
- Department of Orthopaedics and Traumatology, Kocaeli University, School of Medicine, Izmit, Kocaeli, Turkey
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11
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Zhang J, Wang H, Pen C, Qu WC, Duan L, Ren J, Li L, Liu Z, Sun T. Characteristics and proposed classification system of posterior pilon fractures. Medicine (Baltimore) 2019; 98:e14133. [PMID: 30653144 PMCID: PMC6370166 DOI: 10.1097/md.0000000000014133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Posterior pilon fractures involve the medial malleolus (MM). Our purpose was to define the characteristics of posterior pilon fractures, and propose a classification system based on fracture morphology and type of management.The records of patients with posterior pilon fractures treated from 2011 to 2015 were retrospectively reviewed. The injury mechanism, fracture morphology, surgical approach, and follow-up results were reviewed and analyzed. This study was approved by the Institutional Review Board of PLA Army General Hospital.Thirty-six patients, 18 males and 18 females (mean age: 48.9 years) were included in the study. Four characteristics were used to define posterior pilon fractures. A simple posterolateral approach or a combined posterolateral and posteromedial approach was used for reduction and fixation in all patients. The mean follow-up time was 28.2 months, and at the end of follow-up, the mean American Orthopedic Foot and Ankle Society Score (AOFAS) was 82.5 points (range: 35-100 points). Based on injury mechanism and fracture morphology, we classified posterior pilon fractures into 3 types that suggest the optimal surgical approach: type I, a single complete fracture fragment; type II, a posterior malleolus fracture with 2 subtypes; type III, a posterior malleolus fracture associated with complete MM fracture with 2 subtypes.The proposed classification system based on injury mechanism and fracture morphology can guide the surgical approach to maximize outcomes.
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Affiliation(s)
- Jianzheng Zhang
- Department of Orthopedic Surgery, PLA Army General Hospital, No. 5 Nanmencang, Dongcheng District, Beijing, China
| | - Hao Wang
- Department of Orthopedic Surgery, PLA Army General Hospital, No. 5 Nanmencang, Dongcheng District, Beijing, China
| | - Cheng Pen
- Department of Orthopedic Surgery, PLA Army General Hospital, No. 5 Nanmencang, Dongcheng District, Beijing, China
| | - Wen-Chun Qu
- Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lida Duan
- Department of Orthopedic Surgery, PLA No. 66029 Army Hospital, Sonid Right Banner, Neimenggu, China
| | - Jixin Ren
- Department of Orthopedic Surgery, PLA Army General Hospital, No. 5 Nanmencang, Dongcheng District, Beijing, China
| | - Lianhua Li
- Department of Orthopedic Surgery, PLA Army General Hospital, No. 5 Nanmencang, Dongcheng District, Beijing, China
| | - Zhi Liu
- Department of Orthopedic Surgery, PLA Army General Hospital, No. 5 Nanmencang, Dongcheng District, Beijing, China
| | - Tiansheng Sun
- Department of Orthopedic Surgery, PLA Army General Hospital, No. 5 Nanmencang, Dongcheng District, Beijing, China
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Bennett A, Ramaskandhan J, Siddique M. Total Ankle Replacement for Osteoarthritis Following Pilon Fracture of the Tibia. Foot Ankle Int 2018; 39:1008-1018. [PMID: 30110559 DOI: 10.1177/1071100718793091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Outcomes for total ankle replacement (TAR) performed for osteoarthritis following pilon fracture are underreported. We compared the outcomes between different indications for TAR. METHODS Patient-reported outcome measures (PROMs) for TAR performed from 2006 to 2014 by a single surgeon were reviewed. Foot and Ankle Outcome Score (FAOS), SF-36, comorbidities, self-reported body mass index (BMI), and patient satisfaction scores were reviewed. Data were collected preoperatively and at 1 and 2 years postoperatively. Clinical notes and radiographs highlighted the indication for TAR. The following subgroups were created: osteoarthritis (OA), rheumatoid arthritis (RA), pilon fracture (PF), ankle fracture (AF), and posttraumatic arthritis without previous fracture (PTOA). PROMs were available for 173 TARs: 89 (51.4%) for OA, 36 (20.8%) for AF, 21 (12.1%) for RA, 15 (8.7%) for PF, and 12 (6.9%) for PTOA. The pilon fracture group were the youngest and had the highest BMI (mean, 56.5 years; mean BMI, 31.6 kg/m2). No difference was found in number of reported comorbidities ( P > .05). RESULTS Significant improvement in FAOS scores was seen in all subgroups from preoperatively to 1 year ( P = .01, .05, and .03). SF-36 had similar results for all subgroups with improvement in all parameters by 2 years. Significant improvement in role physical and role emotional domains was seen by 1 year following TAR ( P = .018 and P = .042). Patient satisfaction scores were similar in each group. There was no major difference in any of the reported outcomes between subgroups by 2 years postoperatively. CONCLUSION We found similar outcomes for patients who underwent TAR after pilon fracture compared to other indications. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Adam Bennett
- 1 Trauma and Orthopaedics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Jayasree Ramaskandhan
- 1 Trauma and Orthopaedics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Malik Siddique
- 1 Trauma and Orthopaedics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Abstract
OBJECTIVES To evaluate the outcomes of neglected pilon fractures treated by the Ilizarov fixator and to determine whether this technique was successful in avoiding an ankle arthrodesis. DESIGN Retrospective case series. SETTING Level I university trauma center. PATIENTS Between January 2003 and March 2015, 18 patients (mean age of 42.17 years) with an untreated pilon fracture with late presentation (>1 month) were evaluated. Six patients were women and 12 were men. The mean duration from trauma to management was 11.17 weeks (range: 7-15). All fractures were OTA/AO 43 type C. Four cases were open fractures. INTERVENTION Closed fracture reduction, correction of deformity, and restoration of alignment by the Ilizarov fixator. MAIN OUTCOME MEASUREMENTS The radiographs were evaluated for tibial alignment, quality of reduction, and development of arthrosis. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale was used for functional assessment. RESULTS The follow-up period ranged from 18 to 168 months (mean; 38.00). The quality of reduction was excellent in 2 cases, satisfactory in 13 cases, and poor in 3 cases. The external fixator period averaged 29.06 weeks (range: 6.1-7.5 months). All fractures healed without deep infection. Ankle dorsiflexion and plantar flexion averaged 8.67 and 25.67 degrees, respectively, in 15 cases. Arthrodesis was performed for the remaining 3 cases. The mean AOFAS Ankle-Hindfoot score was 82.67. One case had mild anterior translation, and another 1 had a procurvatum of 5 degrees. Arthrosis developed in 6 ankles. CONCLUSIONS A satisfactory outcome was achieved after management by the Ilizarov fixator while avoiding arthrodesis in most cases of this series of neglected pilon fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Sohn HS, Oh JK, Yang HS, Kim HR. Anatomically Precontoured Locked Plates in Pilon Fractures: A Computed Tomography Based and Cadaveric Study. Indian J Orthop 2018; 52:665-671. [PMID: 30532309 PMCID: PMC6241063 DOI: 10.4103/ortho.ijortho_602_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of comminuted tibia plafond fractures remains clinically challenging due to the complexity of the articular fracture pattern despite using the anatomically precontoured locked plates. This study describes the morphologic characteristics of the anterolateral fragment and to evaluate the fixability of the anterolateral fragment with the anatomically precontoured locked plate in the pilon fracture. MATERIALS AND METHODS One hundred and twenty five cases of AO 43-B and C fracture were evaluated using the computed tomography (CT) scan. The anterior-posterior distance in CT (APDc), medial-lateral distance in CT (MLDc), coronal and sagittal height, and articular surface area of the anterolateral fragment were measured in CT. Four types of anatomically precontoured locked plates were used for cadaveric measurement. Four cadaveric parameters were also evaluated; anteroposterior distance in plate (APDp), height of the screw in the medial plate, medial-lateral distance in plate (MLDp), and height of the screw in the anterolateral plate. RESULTS The anterolateral fragment was described with a mean surface area of 167.13 mm2 (APDc: 10.89 ± 4.64 mm, MLDc: 15.02 ± 6.56 mm, sagittal height: 14.85 ± 6.25 mm, and coronal height: 17.27 ± 6.88 mm). The cadaveric measurement showed that the juxta-articular screw of the medial distal tibia plate was placed away from the anterolateral fragment. The anterolateral distal tibia plate did not purchase the anterolateral fragment due to the higher position of the most distal-lateral screw (Synthes 18.37 ± 1.86 mm and Zimmer 17.78 ± 2.37 mm of the height of screw in the anterolateral plate). CONCLUSION Anatomical distal tibial locked plates did not take purchase on the anterolateral fragment in pilon fracture in the best anatomical fit. Preoperative CT measurement can be used for determining a fixation strategy for the anterolateral fragment. In addition, a newly designed anterolateral distal tibia plate can be another solution when the usual anatomically precontoured distal tibia locked plate fails to cover the anterolateral fragment.
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Affiliation(s)
- Hoon-Sang Sohn
- Department of Orthopaedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Guro Hospital, Korea University College of Medicine, Seoul, Korea,Address for correspondence: Prof. Jong-Keon Oh, Department of Orthopaedic Surgery, Guro Hospital, Korea University College of Medicine, 80 Guro 2-dong, Guro-gu, Seoul 152-703, Korea. E-mail:
| | - Ha Sol Yang
- Department of Orthopaedic Surgery, National Medical Center, Seoul, Korea
| | - Hyeong Rang Kim
- Department of Nursing, College of Nursing Science, Kyung Hee University, Seoul, Korea
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Liangjun J, Qiang Z, Hang L, Zhijun P. Injury mechanism, fracture characteristics and clinical treatment of pilon fracture with intact fibula-A retrospective study of 23 pilon fractures. J Clin Orthop Trauma 2017; 8:S9-S15. [PMID: 29158644 PMCID: PMC5681230 DOI: 10.1016/j.jcot.2017.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 05/04/2017] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The effect of intact fibula on pilon fracture is not completely elucidated. We retrospectively analysed pilon fractures with intact fibula at our hospital over a 4 year period to understand the injury mechanism, fracture characteristics, treatment strategy and prognosis of this fracture. METHODS Pilon fracture patients with intact fibula treated in our hospital from January 2010 to December 2014 were observed. OA/ATO fracture type, Ruedi-Allgower classification and fracture characteristics were summarised. The following data were collected from the charts: operative time, operative approach, fixation, fracture healing time, ankle joint Mazur scores, Burwell-Charnley fracture reduction scores and postoperative complications. RESULTS Twenty-two patients were followed up with a mean follow-up time of 17.6 months (10-27 months). The examination results showed the existence of distal tibiofibular syndesmosis injuries, medial malleolus, posterior malleolar, and anterior tibial fractures, and talus-fibula relationship changes, which accounted for 65.2%, 69.3%, 73.9%, 100% and 26.1%, respectively. 19 cases underwent internal fixation, with an average operation time of 108 min. The mean fracture healing time was 6.74 months. The Mazur ankle score showed excellent and good ratings of 86.9%. The Burwell-Charnley fracture reduction score had good and fair ratings of 95.7%. Skin infection occurred in two cases. CONCLUSION Pilon fracture with intact fibula is mostly caused by medium-low energy injury when the ankle is at neutral or varus position. Multi-part fractures commonly occur at the distal tibial articular surface because the energy is concentrated on the tibia. In general, one single anterior approach can complete open reduction and internal fixation operation with satisfactory clinical outcomes in most cases.
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Liu J, Smith CD, White E, Ebraheim NA. A Systematic Review of the Role of Surgical Approaches on the Outcomes of the Tibia Pilon Fracture. Foot Ankle Spec 2016; 9:163-8. [PMID: 26644032 DOI: 10.1177/1938640015620637] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The role of each surgical approach on the outcomes of pilon fractures has not been investigated in a systematic review. METHODS This systematic review was conducted with a thorough literature search on PubMed using the keywords ("pilon" OR "plafond") "fracture." Only articles written in the English language that have been published within the past 15 years and discussed the surgical approach were considered. RESULTS A total of 733 patients were included in this review. All the fractures were either OTA Type B or C fractures: 157 were Type B and 576 were Type C. Anterior and medial approaches have some of the best results in the literature with respect to complication rate. The posterolateral and anteromedial approaches have markedly higher complication rates. CONCLUSIONS The anterolateral group had the largest number of patients-comprising one third of the entire study population. The anterior approach had one of the lowest complication rates with a patient base that had a high proportion of OTA Type C fractures. The medial approach produced a low complication rate over a larger patient base that had a higher proportion of OTA Type B fractures. LEVELS OF EVIDENCE Therapeutic, Level IV: Systematic review.
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Affiliation(s)
- Jiayong Liu
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Carson D Smith
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Erik White
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Nabil A Ebraheim
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
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Kuyucu E, Koçyiğit F, Erdil M. The association of calcaneal spur length and clinical and functional parameters in plantar fasciitis. Int J Surg 2015; 21:28-31. [DOI: 10.1016/j.ijsu.2015.06.078] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/15/2015] [Accepted: 06/26/2015] [Indexed: 10/23/2022]
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