CT mapping for complex tibial pilon fractures: Understanding the injury pattern and its relation to the approach choice

Posterior Plating Versus Anterior to Posterior Screws in Fixation of Posterior Column in Pilon Fractures

OBJECTIVES

To compare the results of anterior to posterior screws (AP screws) versus posterior buttress plating in the fixation of posterior column fractures in pilon injuries regarding the (1) functional and (2) radiological outcomes and (3) the incidence of complications.

METHODS

DESIGN

Prospective, randomized clinical trial.

SETTING

Single Center, Level 1 trauma Center.

PATIENT SELECTION CRITERIA

All patients with 2-, 3-, and 4-column fracture according to the 4-column classification (orthopedic trauma association/Arbeitsgemeinschaft für Osteosynthesefragen 43-C1 and 43-C2) during the study period were eligible for inclusion. Patients were randomized into 2 groups: direct reduction and fixation by posterior buttress plating (group A) and indirect reduction with fixation by AP screws (group B). Exclusion criteria included pediatric age group with open physis, pathological fractures, open fractures, and fractures with neurovascular injuries. The minimum follow-up period was 24 months.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the quality of reduction as evaluated using postoperative plain radiographs and computed tomography. Secondary outcomes included the functional American Orthopaedic Foot and Ankle Society (AOFAS) score and the incidence of complications.

RESULTS

Thirty patients were included, 15 patients were randomized to group A [mean age 42.3 (range 19-65)] and 15 patients in group B [mean age 38.0 in group B (range 23-58)]. The mean follow-up was 32 months (24-45 months). Anatomical reduction was achieved in 80% and 26.7% of group A and group B, respectively. The AOFAS score was significantly higher in group A compared with group B ( P = 0.03). There was no statistically significant difference between the 2 groups regarding the time to union and the complication rates ( P > 0.05).

CONCLUSIONS

A higher percentage of anatomical reduction was associated with direct reduction and posterior buttress plating compared with indirect reduction and AP screws. This was reflected by a significantly higher AOFAS score.Clinical Trials Registration Number: NCT05303389.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Progress of fracture mapping technology based on CT three-dimensional reconstruction

Fracture Mapping is a new technology developed in recent years. This technology visually representing the morphology of fractures by overlaying fracture lines from multiple fracture models onto a standard model through three-dimensional reconstruction. Fracture mapping has been widely used in acetabular fracture, proximal humerus fractures, Pilon fracture, tibial plateau fractures, and so on. This technology provides a new research method for the diagnosis, classification, treatment selection, internal fixation design, and statistical analysis of common fracture sites. In addition, the fracture map can also provide a theoretical basis for the establishment of a biomechanical standardized fracture model. Herein, we reviewed various methods and the most advanced techniques for fracture mapping, and to discuss the issues existing in fracture mapping techniques, which will help in designing future studies that are closer to the ideal. Moreover, we outlined the fracture morphology features of fractures in various parts of the body, and discuss the implications of these fracture mapping studies for fracture treatment, thereby providing reference for research and clinical decision-making on bone and joint injuries to improve patient prognosis.

A study of fracture lines distribution characteristics in complete articular fractures of the patella

Objective

The objective of this study was to unveil the characteristics of fracture lines distribution and explore its clinical significance of complete articular fractures of the patella.

Methods

A consecutive series of image data from 88 patients with complete articular patella fractures were retrospectively included. Three-dimensional reconstruction images of the patella fractures were created and collected. Subsequently, these reconstructed images were visually overlaid onto a standard anterior and posterior patella template. The fracture lines were then identified, traced onto the template, and utilized to generate patella fracture maps. Furthermore, the incidence rate of patella fracture lines involving the distal pole was analyzed.

Results

The maps depict the fracture lines of complete articular patella fractures. For simple and complex patella fractures, the primary fracture lines primarily converge within the Middle and Lower regions, exhibiting a transverse pattern. Conversely, the primary fracture lines in comminuted patella fractures are randomly dispersed across the patella. Examining the maps, approximately 63.6% (56/88) of complete articular patella fractures exhibited involvement of the distal pole in the anterior view, while 48.9% (43/88) displayed distal pole fractures in the posterior view. The incidence of distal pole injury increased progressively with the severity of patella fractures.

Conclusion

The patterns and distribution of fracture lines in cases of complete articular patella fractures are prominently illustrated on the constructed fracture maps. Familiarity with these common characteristics of complete articular patella fracture, especially with the distal pole injury, can aid surgeons in developing preoperative planning, executing surgical strategies effectively, and reducing inappropriate treatment.

Pilon fractures: Consensus and controversy

Pilon fractures are complex injuries that require an individualized approach to treatment to avoid complications and achieve good outcomes. Staged open reduction internal fixation remains the gold standard for most cases to achieve anatomic articular reduction while minimizing soft tissue complications and infection. Careful preoperative planning based on computed tomography dictates the surgical approach for reduction. A subset of cases may be amenable to early definitive or provisional open reduction and internal fixation based on fracture pattern. In some cases of severe articular comminution where reconstruction is not possible, primary ankle arthrodesis may be a good alternative.

Medial malleolar window approach for varus-type tibial pilon fractures: a retrospective study

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.

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.

Fracture mapping of adult femoral neck fractures with three dimensional computed tomography

PURPOSE

Femoral neck fractures (FNFs) are a commonly encountered injury in orthopaedic practice. It is essential that surgeons recognize specific fracture patterns to effectively manage these fractures. The purpose of this study was to analyze the fracture morphology of FNFs by three-dimensional (3D) mapping of the fracture.

METHODS

The fracture line location and distribution of 120 FNFs were identified using computed tomography reconstructions. After segmentation and virtual reduction, the fracture line was revealed. The femoral neck region was divided into zones according to anatomical localization, and the zones through which the fracture lines passed were recorded. All fracture lines are superimposed on the standard model to create fracture mapping.

RESULTS

A total of 120 patients with FNFs were analyzed. The mean age of the patients was 67 (18-96) years. Of all patients, 59 were male, and 61 were female. The most affected region was Zone 4. The least affected region was Zone 6. The displacement in Zone 1 and Zone 4 was found to be significantly higher. The displacement in patients under 65 years was found to be significantly higher. Zone 2 and Zone 5 involvement was significantly higher in patients under 65 years.

CONCLUSION

The fracture map showed fracture patterns of FNFs. It was found that fracture displacement and transcervical region involvement were more common in patients under 65 years. It was also found that the displacement rate was high in fractures of the subcapital region.

Is the T-shaped acetabular fracture really likes a "T"? A study based on three-dimensional fracture mapping

OBJECTIVES

To explore the morphological pattern of T-shaped acetabular fractures (T-SAFs) by mapping the fracture line using 3D software.

MATERIAL AND METHODS

We retrospectively reviewed 1298 consecutive patients with acetabular fractures, and a total of 56 T-SAF patients were enrolled. After the simulated reduction of each fracture in the software, the fracture lines of all patients were overlaid and plotted on a template. A frequency heat map was generated according to the differences in fracture line density distribution. According to the location of fracture lines, all cases were divided into three groups: posterior group, anterior group, extra-posterior group. In surgically treated patients, the surgical approach, fixation methods, and reduction quality were recorded or evaluated.

RESULTS

The transverse fracture line was sinuous without involving the acetabular roof, and the longitudinal fracture line sloped forward or backward along the edge of the acetabular fossa to split the obturator foramen. The anterior and posterior edges of the acetabular fossa, the transition zone of the acetabular roof and anterior wall, the transition zone of the superior pubic ramus and anterior wall, and the posterior wall near the greater sciatic notch were areas with high rates of fracture incidence. The posterior group included 26 patients (46.4%) and the distribution of fracture lines resembled a "T" or "Y". The anterior group included 25 patients (44.6%) and the distribution of fracture lines resembled a "7″. The extra-posterior group included 5 patients (8.9%) and the fracture lines run through the ischial body. The surgical strategies vary among different groups of T-SAF patients.

CONCLUSION

Our findings shed light on the characteristics of fracture lines for T-SAFs and provide a reference for surgical treatment strategies.

Anterior Tibial to Dorsalis Pedis Bypass to Manage Acute Ischemia Attributed to Pilon Fracture

Pilon fractures of the distal tibia are usually the result of a high-energy trauma and can affect seriously the arterial vasculature carrying an increased risk of amputation at the malleolar level or higher. Such cases represent a challenge for the orthopedic surgeons and a multidisciplinary approach is mandatory in order to salvage the threatened limb. We present an unusual case of a closed pilon fracture with injury of all tibial vessels leading to acute limb threatening ischemia. The patient was treated successfully with external fixation and a short tibial-pedal bypass with use of an autologous reversed saphenous vein graft. This example dictates how a distal leg fracture can be dramatic and that awareness of vascular examination coupled with high suspicion of vascular damage can be limb-saving. Multidisciplinary approach is warranted since the topology and complexity of the ankle lesions necessity staged orthopedic reconstructions with tibio-distal bypass and appropriate skin coverage of the distal anastomosis.

Management of Pilon Fractures-Current Concepts

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.