A Prospective Study on Functional Outcome of Internal Fixation of Tibial Pilon Fractures with Locking Plate using Minimally Invasive Plate Osteosynthesis Technique

Does Anterior Impaction Affect Radiographic Outcomes of Pilon Fractures?

Background

The outcomes of pilon fractures are multifactorial. Anterior articular impaction requires sagittal plane correction (anterior distal tibia angle (ADTA)) with articular reduction. However, there is a risk of avascular necrosis of the articular fragments and postoperative tibiotalar arthritis. The purpose of this study was to determine if the presence of anterior impaction affects radiographic alignment after definitive fixation.

Methods

Retrospective cohort study of patients who underwent operative management for pilon fractures at two academic, level 1 trauma centers between September 2005-September 2016. Fractures were categorized as having anterior impaction or no anterior impaction after review of preoperative radiographic and computer tomography imaging. Patient demographics and postoperative time to union was recorded. Quality of reduction was measured using (ADTA) (degrees), lateral distal tibia angle (LDTA) (degrees), and lateral talar station (LTS) (millimeters) from postoperative radiographs. Statistical analysis compared fracture patterns with anterior impaction to those without.

Results

208 patients met inclusion criteria. 132 fractures (63.4%) were determined to have anterior impaction. Cohorts were similar in demographics and medical comorbidities (p>0.05). Mean ADTA, LTDA, and LTS for the anterior impaction group 83.5°, 89.7°, and 2.4mm versus 84.6°, 89.9°, and 2.0mm in the group without anterior impaction. Cohorts significantly differed in ADTA(p=0.01), but not LDTA(p=0.12) or LTS(p=0.44). No significant differences were found between cohorts with infection (>0.05), nonunion(p=0.76), unplanned reoperation(p=0.56), or amputation(p=0.34).

Conclusion

This study demonstrated no significant differences in the coronal or sagittal plane alignment when comparing definitively fixed pilon fractures with and without anterior impaction. Additional studies are needed to evaluate the longterm clinical impact of failing to restore ADTA. Level of Evidence: III.

Comparison Between the Modified External Fixation and Calcaneal Traction in Ruedi-Allgower Type II/III Pilon Fractures

Background

To compare the effect of modified external fixation and calcaneal traction in a staged management of Ruedi-Allgower type II/III tibial pilon fractures.

Material/Methods

The data of 62 patients with Ruedi-Allgower type II/III tibial pilon fractures who were treated in Liuzhou People’s hospital from January 2017 to December 2018 were extracted in this retrospective analysis. There were 32 patients in the temporary external fixation (TEF) group and 30 patients in calcaneal traction (CT) group. Outcomes, including the duration of the surgical procedure, pin track infection, degree of limb swelling, time to second-stage operation, postoperative comfort score, and visual analog scale (VAS) score, were compared.

Results

The effective rate of swelling reduction after treatment was 85% in the TEF group and 60% in the CT group; the average time to the second-stage operation was 8.34±1.29 days in the TEF group and 10.60±2.27 days in the CT group; the postoperative comfort scores were 70.1±3.2 and 61.3±3.5 in the TEF group and CT group, respectively; the postoperative VAS scores at 24 h, 48 h, and 7 days were 7.90±1.06, 4.88±0.83, 2.72±1.14 in TEF group, and 8.50±0.86, 6.27±1.36, 3.57±1.19 in CT group, respectively. There were 1 case of pin tract infection identified in the TEF group and 4 in the CT group. All differences were statistically significant (P<0.05).

Conclusions

The modified external fixation is more effective than calcaneal traction in treatment of Ruedi-Allgower type II/III tibial pilon fractures in the first-stage of combined management.

[Tibial pilon fractures : Advoidance and therapy of complications]

Because of the complex fracture morphology and vulnerable soft tissue coverage, fractures of the tibial pilon are difficult to treat. Complications are more common than in bi- or trimalleolar fractures. The surgeon has to know about the special risks of these injuries to avoid complications. Early complications are soft tissue necrosis, persisting fragment dislocations after surgery, loss of reposition and deep wound infection. The surgeon has to be aware of early signs of compartment-syndrome and chronic regional pain syndrome (CRPS). In late complications such as bony necrosis with or without deviation, non-union and osteoarthrosis of the ankle joint give the surgeon more time for planning the therapy. Intensive monitoring until bone healing is necessary in tibial pilon fractures to detect complications early and start the therapy immediately. This kind of therapy results in the best outcome for these patients.