Postero-medio-anterior approach of the ankle for the pilon fracture

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.

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.

[Retrospective study of 50 cases of tibial pilon fractures in adults at the Department of Orthopedics of the University Hospital Center Habib Bourguiba, Sfax, Tunisia]

Tibial pilon fractures are polymorphic fractures posing therapeutic and prognostic challenges. The purpose of this study is to examine the epidemiological profile of these fractures and to assess our findings from an anatomical and functional point of view. We collected data fom 50 medical records of patients treated for tibial pilon fractures and monitored over the period 2004-2013 at the Orthopedic-Trauma Department of the Habib Bourguiba University Hospital in Sfax. Functional outcomes were assessed using the Ankle-Hindfoot score. Radiological findings were used to determine fracture healing. Treatment was based on internal osteosynthesis in 30 cases, external fixation in 11 cases and on a combination of both techniques in 9 cases. At the end of this study, functional outcomes were good and very good in 36 cases. Thirty cases of fracture healing were reported, with 18 cases of vicious callus and two cases of pseudosteoarthritis. Therapeutic management of tibial pilon fractures is difficult in some cases. Solid osteosynthesis with anatomical reduction is the only therapeutic option to secure a satisfactory functional outcome.

Pilon Fractures: Challenges and Solutions

Pilon fractures include a wide range of complexity. The timing and type of definitive fixation is dictated by the soft tissue injury and energy imparted to the fracture. One should have a low threshold for staged protocols and delayed definitive fixation to avoid complications. Proper radiographs and advanced imaging should be obtained for an exacting diagnosis and preoperative planning. Diligent management of the soft tissue and anatomic restoration of the articular surface, length, rotation, and axial alignment with stable fixation to the diaphysis should be obtained once feasible. Intramedullary implants with percutaneous articular fixation for simple or extra-articular patterns provide good results with little soft tissue insult in the zone of injury. Minimally invasive plate osteosynthesis techniques can help mitigate some concerns with soft tissue compromise while obtaining good articular alignment. Locking or conventional plating with lag screw fixation is used for complex articular injuries with or without fibular fixation. External fixators are generally used for temporizing measures but can be utilized as definitive fixation when indicated. There is a role for acute fusion in severely comminuted, osteoporotic, or arthritic fractures in patients with poor healing potential. This article outlines the diagnostic workup and treatment of these vexing injuries with solutions to challenges that arise.

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Comparison of Posteromedial Versus Posterolateral Approach for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures

OBJECTIVE

To compare clinical and radiographic outcomes of posterior malleolar fractures (PMF) treated with lag screws from anterior to posterior versus posterior to anterior approach.

METHODS

We retrospectively analyzed 48 patients with trimalleolar fractures who underwent open reduction and internal fixation (ORIF) with either posteromedial (PM) or posterolateral (PL) approaches between January 2012 and December 2014. Fixation of the posterior malleolus was made with anteroposterior screws in 20 patients using the PM approach and posteroanterior screws in 28 patients using the PL approach. The American Orthopedic Foot and Ankle Society (AOFAS) scores and range of motion (ROM) of the ankle were used as the main outcome measurements, and results were evaluated at the 6-month, 12-month and final follow-up. Postoperative radiographs and computed tomography scans were used to evaluate the residual gap/step-off. The degree of arthritis was evaluated on final follow-up using Bargon criteria. Other complications were also recorded to compare the clinical outcomes of the two approaches.

RESULT

The mean duration of follow-up regardless of the approaches was 21.1 months (range, 15-54 months). None of the patients developed delayed union or nonunion. Functional bone healing was obtained in all patients at 10.7 weeks (range, 8-16 weeks). The mean AOFAS scores of the PM group at the postoperative 6-mouth, 12-month, and final follow-up were 91.4 (range, 82-100), 92.5 (range, 84-100), and 92.9 (range, 86-100), respectively. In the PL group, the mean AOFAS scores were 89.9 (range, 72-100), 91.4 (range, 77-100), and 91.9 (range, 77-100), respectively. At the final follow-up, the median loss of range of motion (ROM) for dorsiflexion and plantaflexion were 0°(0°, 5°) and 0°(0°, 0°), respectively, in both groups. There were no significant differences between the two approaches in AOFAS scores and ROM of the ankle in each period postoperatively (P > 0.05). Two patients in the PL group and 1 in the PM group developed Bargon grade 2 or 3 arthritis. We detected a 2-mm and 3-mm step-off in 1 patient in the PM and PL groups, respectively.

CONCLUSION

Satisfactory results were obtained by using the two approaches for fixation of posterior malleolus, and the approaches have similar clinical and radiographic outcomes. Surgeons should choose the appropriate approach based on their experience.

Direct medial approach in surgical fixation of fractures in the posterior aspect of the medial malleolus

Fractures in the posterior aspect of the medial malleolus form an important subset of ankle fractures and the indications for fixation include involvement of > 25% of the articular surface or an articular step off by > 2 mm. Several approaches have been described but there has been no recent study on the direct medial approach. Five fresh frozen cadaveric ankles were dissected using the direct medial approach. A longitudinal incision of 10 cm was centered directly over the medial malleolus and deepened straight down to the bone. The periosteum was identified over the distal tibia and careful subperiosteal dissection yielded access to the posterior aspect of the medial malleolus. We investigated the relationship of the neurovascular bundle to the incision by measuring the distance from the center of the medial malleolus to the closest aspect of the bundle. The mean distance from the center of the medial malleolus to the neurovascular bundle was only 2.64 cm (95% CI: 2.06 to 3.22 cm). We found that the neurovascular bundle could be avoided if a periosteal sheath was developed during the dissection and elevated off the posterior aspect of the medial malleolus. The direct medial approach can be performed safely by creating a periosteal sheath through subperiosteal dissection, and the distance of the neurovascular bundle from the incision allows for a good margin of safety during surgery. This approach can be extended proximally and distally and the medial malleolus can be fixed concurrently. Clin. Anat. 31:605-607, 2018. © 2017 Wiley Periodicals, Inc.

Modified posteromedial approach for treatment of posterior pilon variant fracture

Background

Posterior pilon variant fracture is a recently described posterior malleolus fracture characterized by the involvement of both posterolateral and posteromedial malleolar fragment. The associated surgical approach remains controversial. The aim of this study was to present the application of modified posteromedial approach in the treatment for posterior pilon variant fracture.

Methods

Sixteen patients were identified with posterior pilon variant fractures. All fractures were operated via modified posteromedial approach. Fragment length ratio, area ratio and height were measured as morphologic assessments. The clinical outcome was evaluated with American Orthopaedic Foot & Ankle Society ankle-hind foot score and visual analogue scale. Radiological images were evaluated using osteoarthritis-score.

Results

According to the radiological measurements, the average fragment length ratio of posteromedial and posterolateral fragment was 25.3 and 31.5 % respectively. All fractures healed within a mean period of 13.1 weeks without malalignment or articular step-off. Fourteen patients were followed up, and all achieved good or excellent ankle function. The average score of American Orthopaedic Foot & Ankle Society and visual analogue scale at rest, motion and weight bearing walking was 85.6 and 0.25, 0.81, 1.31 respectively.

Conclusion

Modified posteromedial approach provides an alternative surgical treatment for posterior pilon variant fractures, and the short-term outcome was good.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1182-9) contains supplementary material, which is available to authorized users.

Single Oblique Incision for Simultaneous Open Reduction and Internal Fixation of the Posterior Malleolus and Anterior Syndesmosis

Several surgical approaches to the posterior malleolus have been described. However, these approaches may make it difficult for fixation of associated lateral malleolar and anterior syndesmotic fractures. A single incision approach is described that allows safe access to the posterior malleolus while also facilitating access to the lateral malleolus and anterior syndesmosis.

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

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

A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/OTA 43-C)

The anterior approaches that have been described for open reduction internal fixation of multifragmentary pilon fractures are designed to reconstruct the comminuted and impacted anterior articular surface onto a stable posterior column. Thus, reduction of the posterior column, particularly proper length, is critical. There are differing opinions of how best to surgically approach the posterior pilon fracture. There is also no clear indication as to the timing of both anterior and posterior reconstructions. Our objectives were (1) to develop a more midline posterior approach that might provide better visualization of the posterior aspect of the posterior column and juxtametaphyseal/diaphyseal parts of the tibia, first on the cadaver and then with patients, and (2) to use this as part of a combined posterior and anterior approach during the same anesthesia for complex tibial pilon fractures (AO/OTA 43-C) in a preliminary study of 6 patients.

Decisions and staging leading to definitive open management of pilon fractures: where have we come from and where are we now?

Historically, the treatment and outcomes related to pilon fractures have been variable despite anatomical reduction and fixation. However, with the advent of newer implant technologies, improved surgical techniques, and the management via a staged protocol, results have indicated encouraging clinical outcomes with minimization of postoperative complications. This review focuses and outlines the current strategies, decision-making processes, and definitive treatment options regarding the notoriously difficult to treat pilon fracture.

LEVEL OF EVIDENCE

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

Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures

OBJECTIVE

Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures.

DESIGN

Prospective clinical cohort.

SETTING

A Level I trauma and tertiary referral center.

PATIENTS/PARTICIPANTS

From January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months).

INTERVENTION

All patients were treated with open reduction and internal fixation for their pilon fractures.

MAIN OUTCOME MEASUREMENTS

Quality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications.

RESULTS

There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group.

CONCLUSIONS

The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.

Posterolateral approach for treatment of posterior malleolus fracture of the ankle

Treatment of the posterior malleolus has been debated among orthopedic surgeons. Most orthopedic surgeons will fix the posterior malleolus if it is larger than 25% to 30% of the distal articular surface. The most common method of fixation of the posterior malleolus is by indirect reduction and anteroposterior screws. In the present study, we describe the technique and results of treatment of the posterior malleolus by direct reduction through the posterolateral approach to the ankle. The decision to fix the posterior malleolus was determined by its size and displacement. A total of 12 consecutive patients underwent the posterolateral approach to reduce the posterior malleolus, and these were fixed by posterior plate. Two patients were lost to follow-up in the early postoperative period (both after 2 months). No deep infection or wound dehiscence occurred. Ten patients had adequate (<2-mm displacement of the articular surface) radiologic reduction at the final follow-up visit. There were 2 cases of 2 mm or more of articular surface displacement at the final follow-up visit (1 patient had 2-mm displacement noted in the immediate postoperative period and 1 patient had adequate reduction in the beginning but was displaced with additional follow-up). The posterolateral approach to the ankle is a useful tool to treat certain cases of posterior malleolus fracture. It allows good visualization and stable fixation of the posterior malleolus.

A surgical approach to posterior pilon fractures

Posterior pilon fractures are injuries of the posterior tibial plafond that likely occur through a combined rotational and axial load mechanism and are often difficult to treat with standard surgical approaches to the ankle. We describe an alternative surgical approach to this injury using posteromedial, posterolateral, or combined approaches and present a series of patients with either radiographic or functional outcomes at a minimum of 1-year follow up that were treated by this method.

Posterior fracture dislocation of the ankle: technique and clinical experience using a posteromedial surgical approach

OBJECTIVE

The purpose of this study is to revisit the posteromedial surgical approach to the ankle and report the clinical outcomes of this technique in a cohort of 17 patients.

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Seventeen patients between 1990 and 2006 were treated using a posteromedial surgical approach to the ankle. Thirteen presented with a posterior ankle fracture dislocation and 4 with an ankle fracture without dislocation producing a large posterior malleolar fragment. There were 6 males and 11 females, from 23 to 80 years of age (mean 45.2 years).

INTERVENTION

All but 2 patients underwent open reduction and internal fixation of the posterior malleolar fracture using a single posteromedial approach. A combined surgical approach (posteromedial and posterolateral) to the ankle was used in 2 cases.

MAIN OUTCOME MEASUREMENTS

The Foot and Ankle Outcomes Questionnaire was used to evaluate postoperative ankle pain, function, stiffness and swelling, and giving way. Posttraumatic osteoarthritis was assessed using an adapted 4-point radiographic grading system.

RESULTS

Follow-up data on 12 patients were obtained at a mean interval of 9.4 years. There were no wound complications. The average global foot and ankle score was 87 points (range 69-100). The degree of arthrosis was grades 0 in 3 ankles, I in 1 ankle, II in 5 ankles, and III in 3 ankles.

CONCLUSIONS

The posteromedial approach offers an effective technique for fracture reduction and buttress plate fixation of large posterior malleolar fragments. Good short- and mid-term clinical results should be expected.

The extensile approach for the operative treatment of high-energy pilon fractures: surgical technique and soft-tissue healing

Perhaps the most important advancement in the surgical treatment of high-energy pilon fractures has been the recognition of the need to delay primary surgery. However, at open reduction internal fixation an adequate incision must be made to clearly visualize the articular surface in an attempt to restore intraarticular anatomy. This article illustrates our extensile approach and its effect on soft-tissue healing. The approach allows complete access to the ankle joint to achieve reduction and fixation of the articular surface, as far medially or laterally as is necessary. In addition, it allows for easy placement of plates medially, laterally, or anteriorly. For fractures extending more proximally, plates can be placed subcutaneously from distal to proximal through the open incision.