Tibial plafond fractures treated by articulated external fixation: a randomized trial of postoperative motion versus nonmotion

Evolution in Management of Tibial Pilon Fractures

PURPOSE OF REVIEW

Tibial plafond, or pilon, fractures can be some of the most difficult fractures to manage. As they are often associated with high-energy trauma, both the soft tissue involvement and the comminuted fracture pattern pose challenges to fixation. Furthermore, the complex anatomy and trauma to the cartilage at the time of injury predispose pilon fractures to poor functional outcomes and high rates of posttraumatic arthritis. This review will discuss the recent developments in the treatment of tibial pilon fractures.

RECENT FINDINGS

Historically, surgical management of pilon fractures has been associated with high rates of complications, including wound complications, infections, nonunions, and even the need for amputation. In response, staged protocols were created. However, recent studies have called this into question, demonstrating low wound complications with early definitive fixation. Additional studies are evaluating adjuvants to minimize wound complications, including the use of vancomycin powder and oxygen supplementation, while another study challenges the 7-cm myth regarding the distance needed between skin incisions. Additional research has been focused on alternative methods of managing these complex, and sometimes non-reconstructable, injuries with the use of external fixation, minimally invasive internal fixation, and primary arthrodesis. Tibial pilon fractures remain difficult to treat for even the most skilled orthopedic trauma surgeons. With improvements in surgical techniques and implants, complication rates have declined and outcomes have improved; however, the overall prognosis for these injuries often remains poor.

Does external fixation result in superior ankle function than open reduction internal fixation in the management of adult distal tibial plafond fractures?

BACKGROUND

Traditionally distal tibial plafond fractures were managed with open reduction internal fixation however, high complication rates have prompted the use of external fixation as an alternative. No definitive review has been conducted and the issue of superior treatment method remains contentious. This review assesses the comparative effectiveness of both with regards ankle function.

METHOD

A search strategy was formulated with keywords ensuring full use of Medical Subject Headings terms for maximum sensitivity with Boolean combinations. Multiple databases were used.

RESULTS

All papers had limitations, hence results and conclusions must be considered conservatively. Paper-1 demonstrated an association between ORIF and superior ankle function (P<0.05). Papers-2 and -3 demonstrated no significant difference (P>0.05) between treatment techniques.

CONCLUSIONS

Neither method can yet be widely advocated as superior with the treatment method chosen remaining primarily on surgeon preference and experience. This review highlights the requirement for further, high-quality research in this area.

Does the Fibula Need to be Fixed in Complex Pilon Fractures?

OBJECTIVES

To review a series of patients with complex plafond injuries with a metadiaphyseal dissociation who did not have the fibula fixed and compare with patients who had their fibula fixed using patients without a fibula fracture as a control group.

DESIGN

Retrospective case-control study.

SETTING

Level 1 Trauma center at a university hospital.

PATIENTS/PARTICIPANTS

Skeletally mature patients with a complete metadiaphyseal plafond fracture, and adequate presentation, postreduction, and healed radiographs to measure varus and valgus alignment.

INTERVENTION

Surgical treatment [external fixator or open reduction internal fixation (ORIF)] of high energy pilon fractures.

MAIN OUTCOME MEASUREMENTS

Metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications.

METHODS

From 364 patients with plafond fractures, 111 had high energy injuries with metadiaphyseal dissociation and form the basis of the study. Radiographs and charts were reviewed for fracture characteristics, metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications.

RESULTS

Of the 111 study patients, 93 patients were treated definitively with ORIF of the tibia and 18 patients were treated definitively in an external fixator. Within the 93 patients treated definitively with ORIF of the tibia, we identified 3 groups of patients those with a fibula fracture that was fixed (26 patients), those with a fibula fracture that was not fixed (37 patients), and those without a fibula fracture acting as the control group (30 patients). Between the 2 groups having a fibula fracture treated with ORIF of the tibia, there was no difference in fibula fracture pattern or location. For the 26 patients who had fibular fixation, it was performed in 11 patients at an average of 17 days for inability to hold length and alignment and in 15 patients to augment fixation in poor bone stock or to aid in the reduction. Patients with initial valgus deformity were more likely to have their fibula fixed. There was no difference in the postoperative or final alignment between the patients with fibula fractures (with or without fixation) and those without fibula fractures (P = 0.92). When comparing the 3 groups, the only statistical finding between the 2 groups was that those with fibula fixation required plate removal (P < 0.0001).

CONCLUSIONS

Fibular fixation is not a necessary step in the reconstruction of pilon fractures, although it may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation. We found a higher rate of plate removal if the fibula was fixed.

LEVEL OF EVIDENCE

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

The reconstruction of tibial metaphyseal comminution using hybrid frames in severe tibial plafond fractures

OBJECTIVES

To evaluate the treatment alternatives for the management of the metaphyseal tibial comminution in severe plafond fractures, and to investigate the role of the fibula fracture fixation.

DESIGN

Retrospective clinical study.

SETTING

Level-2 trauma hospital.

PARTICIPANTS

Patients with highly comminuted tibial plafond fractures.

INTERVENTION

All patients were treated with open reduction and internal fixation of the articular surface and external fixation of the metaphyseal fracture. If metaphyseal comminution was minimal, bone graft was applied and the fibular was plated (group 1); if comminution was between 1 and 3 cm, acute shortening and distraction osteogenesis was performed (group 2); and if comminution was >3 cm, distraction osteogenesis without acute shortening was performed (group 3).

MAIN OUTCOME MEASUREMENTS

Radiographic union, AOFAS ankle score.

RESULTS

Of 30 fractures, 15 fractures (50%) had an anatomic reduction of the joint. Union occurred in all but 2 fractures. Group 1 fractures healed at an average of 19 weeks (16-22). Four fractures had associated malalignment problems. The mean AOFAS score was 72.5 (range 45-100). Group 2 fractures healed at an average of 18.3 weeks (16-21). One fracture healed with 5-degrees of angulation. Group 3 fractures healed at an average of 17.5 weeks (14-24). Two fractures healed with malalignment. When groups 2 and 3 were combined to evaluate the AOFAS outcome for fractures treated with distraction osteogenesis, a score of 75.83 was obtained (45-90). There was no difference between the Group 1 versus combined Groups 2/3 with regard to this latter score (P = 0.372). Additionally, when fibula fixation (Group 1) was compared with those fractures where it was not performed (groups 2/3), no difference was seen (P = 0.276).

CONCLUSIONS

The reconstruction of severe tibial plafond fractures treated with small wire hybrid fixation may be achieved by different techniques leading to a satisfactory result. The fixation of the fibula fracture is dependent mainly on the treatment chosen for the management of the metaphyseal lesion.

LEVEL OF EVIDENCE

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

Pilon fractures

The nature of the pilon fracture has caused evolution of treatment methods and its historically high rate of complication and poor outcome continue to direct choice of treatment. Attention to the delicate soft tissue envelope surrounding the ankle and recognition of the severity of the initial injury is crucial to ensure a satisfactory outcome and to minimize complications. Understanding the importance of staging surgical interventions will help to improve outcomes, but even optimal treatment may result in less than satisfactory results.

Lower extremity-specific measures of disability and outcomes in orthopaedic surgery

Outcome measures may be simple questions or complex measures that assess multiple interrelated domains affecting treatment outcomes. Outcome measures should be relevant to patients, easy to use, reliable, valid, and responsive to clinical changes. Joint and disease-specific outcome measures have been developed for the hip, knee, and foot and ankle. Many of these measures would benefit from further research into their validity, reliability, and optimal applicability. General health measures and activity level scores should be included in outcome assessments after treatment for orthopaedic conditions.

Pilon fractures: advances in surgical management

Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. Variables such as fracture pattern, soft-tissue injury, and preexisting patient factors can lead to unpredictable outcomes. Avoiding complications associated with the soft-tissue envelope is paramount to optimizing outcomes. In persons with soft-tissue compromise, the use of temporary external fixation and staged management is helpful in reducing further injury and complications. Evidence in support of new surgical approaches and minimally invasive techniques is incomplete. Soft-tissue management, such as negative-pressure dressings, may be helpful in preventing complications.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.