Stabilisation of the fractured fibula plays an important role in the treatment of pilon fractures: a retrospective comparison of fibular fixation methods

Ninety-eight pilon fractures associated with ipsilateral distal fibular fracture were included in this study. The pilon fractures were treated by open reduction and plating. The 98 fractures were divided into three groups based on the treatment method of fractured fibula. Group A was composed of 50 fibular fractures treated by open reduction and plate fixation. Group B was composed of 23 fibular fractures treated by open reduction and pin fixation. Group C was composed of 25 fibular fractures treated conservatively by closed reduction. The radiographs were reviewed for adequacy of fracture reduction and posttraumatic arthrosis. At the end of follow-up, the clinical outcomes were evaluated using a rating scale. The three groups were similar in respect to Ruedi type, open fracture grade, and demographics (all p values >0.25). Group A showed a decreasing trend of malunion and ankle arthrosis compared to group C (p = 0.091 and p = 0.099, respectively). Group A had a better clinical outcome than group C (p = 0.008). In addition, group A showed an increasing trend of satisfactory outcome compared to group B (p = 0.096). In conclusion, for pilon fractures associated with ipsilateral fibular fractures, stabilisation of the fractured fibula plays an important role in the decrease of distal tibial malunion and post-traumatic ankle arthrosis as well as improvement of clinical outcomes.     

不同方法固定胫骨不稳定 pilon 骨折的生物力学研究

目的 探讨不同方法 固定胫骨不稳定pilon骨折的生物力学性能. 方法 用7具新鲜国人踝关节标本制备Ruedi-Allgower Ⅲ型pilon骨折,根据不同固定方法 分5组,A组:内侧支撑钢板固定,B组:胫骨远端前外侧解剖型钢板加内侧空心钉固定,C组:外侧外固定支架加内侧空心钉固定,D组:外侧外固定支架加内侧支撑钢板固定,E组:内侧外固定支架加胫骨远端前外侧解剖型钢板固定.比较各组的强度、刚度、失效载荷等生物力学性能. 结果 A、B、C、D、E组胫骨远端的抗压应力值分别为(1.31±0.10)、(1.61±0.14)、(1.17±0.13)、(0.90±0.08)、(0.98±0.08)MPa,轴向刚度分别为(1224.49±115.40)、(1016.95±102.32)、(1395.34±140.12)、(1935.48±180.42)、(1764.71±174.76)N/mm,水平剪切刚度分别为(3076.92±304.20)、(2553.19±250.73)、(3529.41±344.42)、(4800.00±490.61)、(4444.45±451.52)N/mm,失效载荷分别为(2448±208)、(2034±184)、(2791±265)、(3871±382)、(3529±342)N,等效刚度值分别为(703±56)、(583±62)、(805±74)、(1100±108)、(1035±110)N·m/Deg. 结论 对于胫骨不稳定性pilon骨折,采用胫骨内侧支撑钢板或胫骨远端前外侧解剖型钢板附加外固定支架固定,不但具有优越的生物力学性能,等效刚度高,而且固定坚强、可靠,操作方便,踝关节稳定性好,为Ruedi-Allgower Ⅲ型pilon骨折切开复位手术固定选择提供了理论参考.     

Long-term results of various therapy concepts in severe pilon fractures

Introduction Intra-articular fractures of the tibia plafond are among the most challenging of orthopaedic problems. This is a retrospective case-control study of surgically treated pilon fractures which was undertaken to compare the internal fixation with the two external fixation methods. Methods This is a case-control study of 55 patients with 55 pilon fractures. There were 36 type C and 19 type B. Of these fractures, 24 were open and 31 closed. Three surgical protocols were used. In 20 patients, Group A, a half pin external fixator with ankle spanning was performed. The mean age of patients was 42.0 years (22.0–74.0), SD 14.1 and the mean follow-up was 77.7 months (38.0–132.0), SD 25.4. In 22 patients, Group B, a single ankle sparring ring hybrid external fixator under a small arthrotomy was performed. The mean age of patients was 48.4 years (28.0–76.0), SD 12.4 and mean follow-up was 67.9 months (36.0–132.0), SD 27.8. In 13 patients, Group C, a two-staged internal fixation was performed. The mean age was 45.6 years (30.0–66.0), SD 9.7 and the mean follow-up was 78.6 months (55.0–132.0), SD 25.4. We addressed the dissimilarity of the type of fracture in each group performing supplementary stratified analyses within each fracture type group. Results Group A had union in 6.9 months, group B in 5.6 months and group C in 5.1 months; P = 0.009. Six patients (Group A), two (Group B), and one (Group C) had limitation of ankle motion; P = 0.47. One patient from group C developed infection and the plate was removed. Four patients (Group A), one (Group B), and one (Group C) have developed posttraumatic arthritis (loss of joint space and pain); P = 0.25. Seven patients from Group A have reduced their activities; P = 0.004. In stratified statistical analysis by type of fracture, the associations noted for both fracture groups combined were also noted separately within each fracture group. Conclusion In this long term follow-up study, the two-staged internal fixation and the hybrid fixation with small arthrotomy were equally efficacious in achieving bone union. Patients in external fixation with the ankle spanning had a significantly higher rate of delayed union. Also more patients in this group have reduced their activities. Meeting at which the paper was presented: International Annual Meeting Of Orthopaedic Surgeons, 2003, Greece.     

经皮撬拨复位在Ⅱ、Ⅲ型Pilon骨折复位中的意义

目的 探讨经皮撬拨复位在内固定治疗Ⅱ、Ⅲ型Pilon骨折的临床意义.方法选取54例Ruedi-Allgower Ⅱ、Ⅲ型Pilon骨折患者,随机分为2组：A组29例,采用自行研制的骨撬拨器经皮对骨折撬拔复位后行切开内固定;B组25例,采用切开直视复位内固定术.以Mazur标准评判术后踝关节功能.结果 手术时间：A组1.5-3.0（2.4±0.3）h,B组2.0-3.5（2.8±0.4）h,差异有统计学意义（P〈0.05）.随访18-36（24.3±6.4）个月,骨折均一期愈合.A组骨折愈合时间为12-16（13.4±3.4）周,踝关节功能优15例,良9例,中3例,差2例,优良率24/29;B组骨折愈合时间12-18（15.2±3.5）周,踝关节功能优13例,良6例,中4例,差2例,优良率19/25;两组骨折愈合时间、踝关节功能优良率比较差异均有统计学意义（P〈0.05）.A组3例、B组6例术后出现皮肤坏死、踝关节功能障碍,两组差异有统计学意义（P〈0.05）.结论 采用撬拨复位Ⅱ、Ⅲ型Pilon骨折操作简单,具有保护骨折周围软组织及血供,缩短手术时间,减少并发症等优点,术后可获得良好踝关节功能.     

胫骨pilon骨折治疗中踝关节外侧结构损伤恢复的重要性

目的 探讨踝关节外侧结构稳定性在胫骨pilon骨折治疗中的意义.方法 从2005年7月至2008年1月共收治18例胫骨pilon骨折伴踝关节外侧结构损伤患者,其中男13例,女5例,平均年龄41.3岁.闭合性骨折16例,开放性骨折2例.AO分型:B1型3例,B2型5例;C1型3例,C2型7例.对于12例闭合性胫骨pilon骨折患者,首先采用后外侧切口进行腓骨复位和内固定,接着采用改良前内侧切口进行胫骨Chaput结节的复位和固定,中间关节面以及内侧骨块参照Chaput结节进行复位.对于2例开放性骨折和4例伴有严重软组织损伤或多发伤的闭合性胫骨pilon骨折患者,采用分期手术治疗,一期腓骨切开复位钢板内固定结合内侧胫骨跨踝关节外固定支架固定,对内侧结构只做克氏针或螺钉临时复位固定,二期(平均14 d后)拆除胫骨外固定支架或行胫骨切开复位钢板内固定. 结果 14例患者术后获8～30个月(平均18.4个月)随访,4例失访.14例骨折均获骨性愈合,平均愈合时间为5.4个月.关节面复位评价:解剖复位9例,一般4例,差1例.临床功能评价:优6例,良3例,可4例,差1例.1例开放性胫骨pilon骨折外固定后出现感染,在抗感染治疗后7周更换内固定,同时放置庆大霉素珠链,术后30周骨折愈合. 结论踝关节外侧结构稳定性的恢复在胫骨pilon骨折治疗中极其重要.     

What Is the Most Reliable Classification System to Assess Tibial Pilon Fractures?

The aim of this study was to assess inter- and intraobserver agreement of the traditional systems (Ruedi-Allgower, AO [Arbeitsgemeinschaft für Osteosynthesefragen], and Topliss) and the newly proposed Leonetti classification system of pilon fractures. We studied all patients at our center who underwent pilon fracture surgery over a 2-year period: 68 patients (70 legs) were included. Four observers independently classified each pilon fracture according to the Ruedi-Allgower, AO, Topliss, and Leonetti systems by evaluating radiographs and computed tomography images on 2 occasions. The inter- and intraobserver agreements were calculated using the Fleiss kappa test. Interobserver reliability was good for AO types (A, B, and C) and Ruedi-Allgower (κ = 0.71 and 0.61, respectively), whereas the interobserver reliability was moderate for AO groups (A1, A2, A3, B1, B2, B3, C1, C2, and C3), Topliss families, Topliss subfamilies, Leonetti types, and Leonetti subtypes. Intraobserver reproducibility was excellent for the Ruedi-Allgower classification, AO types, and Topliss families and good for AO groups, Topliss subfamilies, and Leonetti types and subtypes. Ruedi-Allgower and AO classification systems are the most reliable among those currently used for pilon fractures, but with lower agreement at the AO group level. The use of Topliss and Leonetti classification systems is not recommended because of less favorable results.     

Interobserver and intraobserver variations in tibial pilon fracture classification systems

BackgroundTibial pilon injuries are a complex group of fractures, whose classification and radiological assessment has been under constant reform. Till date, there is no universally accepted classification system.ObjectiveTo determine the interobserver agreement and intraobserver reproducibility of Ruedi and Allgower, AO, and Topliss et al. classification systems for tibial pilon fractures, with CT scans.MethodForty-seven CT scans of tibial pilon fractures were evaluated independently by 5 orthopaedic surgeons. Fractures were classified according to Ruedi and Allgower, AO and Topliss et al. types. Assessment was done on two occasions, eight weeks apart.ResultsThe interobserver reliability and intraobserver reproducibility for Ruedi and Allgower, AO and Topliss et al. classifications showed only moderate agreement. The interobserver agreement was dependent on the familiarity and specificity of the classification system.ConclusionCurrently used classification systems for tibial pilon fracture have moderate interobserver and intraobserver agreements, even with the help of CT scans. Therefore Tibial pilon fracture classification still remains largely undetermined.     

跨腕关节钢板与外固定支架治疗桡骨远端粉碎骨折的疗效比较

目的 比较跨腕关节钢板与外固定支架治疗桡骨远端粉碎骨折的疗效.方法 2007年3月至2010年4月采用跨腕关节钢板(钢板组)和外固定支架(外固定支架组)治疗57例桡骨远端粉碎骨折患者.其中钢板组28例,男18例,女10例;年龄21～67岁,平均44.7岁;左侧17例,右侧11例;C2型8例,C3型20例.外固定支架组29例,男19例,女10例;年龄21～69岁,平均49.4岁;左侧12例,右侧17例;C2型13例,C3型16例.对两组患者术中及住院期间的各项指标、术前与术后的影像学结果、临床疗效结果及并发症进行对比分析.结果 57例患者术后获12～35个月(平均24.4个月)随访.钢板组较外固定支架组手术时间长、术中出血量多、切口长度相对较长,两组比较差异均有统计学意义(P＜0.05).两组患者掌倾角、尺偏角、桡骨茎突长度在术前、术后及随访时比较差异无统计学意义(P＞0.05).两组患者关节面台阶术前、术后2 d比较差异无统计学意义(P＞0.05),术后12个月随访比较差异有统计学意义(P＜0.05).两组患者术后6个月、末次随访时旋前、旋后、掌屈、背伸活动范围比较,差异均无统计学意义(P＞0.05).根据Jakim评分标准,钢板组优于外固定支架组,但两组比较差异无统计学意义(P＞0.05).外固定支架组并发症发生率显著高于钢板组,两组比较差异有统计学意义(P＜0.05).结论 跨腕关节钢板与外固定支架治疗桡骨远端粉碎骨折,复位和治疗效果相当,跨腕关节钢板创伤较大,但复位稳定性好,并发症较少.     

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination

Summary There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.      

An evaluation of the Weber classification of ankle fractures

This retrospective study over a 3 year follow-up was designed to establish the significance of the Weber classification of ankle fractures with regards to functional and radiographic outcome. One hundred and seven patients were available for follow-up, of which 88 ankles could be classified with the Weber system. Medial malleolar fractures alone and pilon fractures could not be classified with this system. A correlation was found between the type of Weber fracture and the overall ankle score. This held true for unimalleolar fractures alone. More complex bimalleolar and trimalleolar fractures did not follow this convention. Logistical regression analysis was used to evaluate other predictors of outcome. Bimalleolar and trimalleolar fractures were statistically significant predictors of a poorer outcome (P = 0.033, P = 0.021). The initial degree of displacement was also determined to be a predictor of outcome (P = 0.0133) as was the operative reduction (P = 0.0113). Using linear regression, older age (> 62 years) was also established as a predictor of a poorer outcome (P < 0.05). The Weber classification was found to be a predictor of outcome in unimalleloar ankle fractures and not for multimalleolar fractures. We have identified further predictors of a poorer outcome in ankle fractures as the degree of initial injury, the number of malleoli fractured and older age. These factors were found to have greater significance in predicting outcome than the level of fibular fracture alone. We have identified a deficiency of the Weber system in excluding these criteria and have addressed this by modifying the existing system to include the number of malleoli involved, thus providing a more useful prognostic tool.     

复杂闭合性踝关节骨折的治疗

目的　探讨复杂闭合性踝关节骨折的治疗方法。　方法　将 82例 85侧AO Danis Weber分型中的B、C型踝关节骨折的患者 ,随机分为两组。A组 3 0例 3 3侧采用闭合复位石膏外固定 ,B组 5 2例 5 2侧采用开放复位内固定治疗。比较两组患者踝关节疼痛、肿胀、功能恢复情况。　结果　参照Teenny和Wiss评分系统 ,A组的优良率为 3 6% ,B组的优良率为 70 % ,B组疗效优于A组 (P <0 .0 5 )。　结论　开放复位内固定是治疗复杂踝关节骨折的有效方法。     

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination Eine h?ufige, aber wenig beachtete Kombination

There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.     

Complications encountered in the treatment of pilon fractures.

A total of 52 tibial plafond (pilon) fractures in 51 patients were retrospectively reviewed from the years 1985-1990 to define the rate of complications encountered during their management. All fractures were managed under faculty supervision at a level I trauma center and its two affiliated institutions. The follow-up period was scrutinized to determine whether or not a complicating event occurred. Major local complications, termed events, were defined as those requiring unplanned surgery due to infection, wound breakdown with subsequent flap coverage, and failure of fixation or fracture healing. Reduction accuracy and final clinical results were not specifically examined. There were 14 (27%) type I, 17 (33%) type II, and 21 (40%) type III Ruedi-Allgower fracture types. The majority (79%) of the fractures were closed and 89% were treated by open reduction and internal fixation. The overall local complication rate was 54%. A total of 21 (40%) pilon fractures (six type I, six type II, and nine type III) had major local complicating events requiring 77 additional operations. Patient follow-up time ranged from 1 week (the occurrence of a major local complication) to 200 weeks (no complication), with a mean of 67 weeks. Kaplan-Meier survivorship (K-M) analysis was utilized to statistically estimate the complication rate in this patient population accounting for the occurrence of censored events. The K-M-determined event rate was 42 +/- 7%. Ten (of 21) pilon fractures had events by 3 weeks, while only two occurred beyond 40 weeks.     

手术治疗Pilon骨折的难点及对策

摘要：目的 探讨Pilon骨折的手术治疗难点及对策。 方法 手术治疗88例Pilon骨折患者。闭合性骨折41例,开放性骨折47例。开放性骨折根据不同的骨折类型和软组织损伤情况选择不同治疗方法。术后比较开放性骨折和闭合性骨折手术治疗效果进行及不同Gustilo分型的治疗效果。 结果 本组所有患者均得到随访,平均随访时间14-29（22.4±6.57）月,采用Mazur踝关节症状与功能评分系统评价：优31例,良35例,可17例,差5例。开放性骨折优良率61.7%,闭合性骨折优良率。90.2%。两种骨折治疗结果差异明显（P﹤0.05）。开放性骨折GustiloⅡ型优良率71.8%;ⅢA 型优良率45.4%;ⅢB型优良率25.0%,统计学比较差异有意义（P﹤0.05）。 结论 软组织处理和骨折复位程度是治疗Pilon骨折的关键。     

Pilon fractures. Treatment protocol based on severity of soft tissue injury

One hundred seven pilon fractures in 107 patients were treated according to a staged prospective protocol. All pilon fractures were stabilized immediately by the application of calcaneal traction. Open fractures or fractures in patients with multiple injuries were stabilized with traveling traction that was applied in the operating room. A distraction computed tomography scan was obtained before definitive treatment. Treatment groups were based on the degree of soft tissue compromise. Forty-one patients with Tscherne Grade 0 or Grade I injuries underwent open reduction and internal fixation (open plating) using contemporary techniques and low-profile implants. Sixty-four patients with Tscherne Grade II and Grade III closed injuries and all patients with open fractures underwent definitive treatment with limited open reduction and stabilization using small wire circular external fixators. Clinical and radiographic evaluations were performed at an average 4.9 years after injury. For all fracture types (AO classification), 81% of the patients who were treated with external fixation and 75% of the patients who were treated with open plating had good or excellent results. For severe fracture patterns (Type C), patients in both groups had significantly poorer results than patients with Types A and B fractures. The patients in the open plating group had a significantly higher rate of nonunion, malunion, and severe wound complications compared with the patients who received external fixation for Type C fracture patterns. Because of the increased incidence of bony and soft tissue complications when treating open or closed Type C fractures, use of limited exposures and stabilization with small wire circular external fixators is recommended.     

跨腕关节支撑钢板与外固定架治疗桡骨远端粉碎性骨折的临床研究

目的比较跨腕关节支撑钢板与外固定架治疗桡骨远端粉碎性骨折的临床疗效。方法对自2007年7月~2010年6月收治的57例闭合性桡骨远端粉碎骨折(AO C2、C3型)采用跨腕关节钢板和外固定架进行治疗。结果术后12个月随访,两组桡骨茎突长度无统计学差异(P>0.05),关节面台阶有统计学差异(P<0.05)。术后6、12个月随访时,两组间旋前、旋后、掌屈、背伸活动范围比较,无统计学差异(P>0.05)。根据Jakim评分标准,两组优良率差异无统计学意义(P>0.05)。外固定架组并发症发生率显著高于钢板组(P<0.05)。结论①跨腕关节钢板和外固定架治疗桡骨远端粉碎骨折,骨折复位情况和临床治疗效果相当;②跨腕关节钢板固定手术创伤较大,但稳定性好,并发症较少;③跨腕关节钢板和外固定架结合克氏针固定后,可减少术后碎骨块再移位的可能性;④跨腕关节钢板固定治疗桡骨远端粉碎性骨折,骨折复位好,能保持骨折部的撑开以维持桡骨长度,防止短缩,可以取得较好的疗效。     

前内侧与前外侧入路内固定治疗C型pilon骨折的疗效比较

背景：C型pilon骨折多为高能量损伤造成,治疗困难。正确地选择手术入路至关重要。目的：比较前内侧与前外侧入路内固定治疗C型pilon骨折的疗效。方法方法：回顾分析2008年5月至2011年9月在我院行切开复位内固定治疗的C型pilon骨折43例的病例资料。男28例,女15例;年龄18-64岁,平均35.3岁。采用前内侧入路26例,前外侧入路17例。比较两组的手术时机、骨折愈合时间、Burwell-Charnley复位学放射学评价、Tornetta踝关节功能评价结果。结果：两组的手术时机、骨折愈合时间、术后即刻Burwell-Charnley复位解剖学评分、术后12个月Tornetta踝关节功能评分均无显著统计学差异（P〉0.05）。结论：Pilon骨折前外侧及前内侧入路手术在手术时机、骨折愈合时间、骨折复位效果及踝关节功能恢复方面并无差别。C型pilon骨折应依据骨折块的大小、位置及骨折断端的走向、移位和皮肤软组织条件选择手术径路。     

A staged protocol for soft tissue management in the treatment of complex pilon fractures

OBJECTIVE: To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C. Fifty-six fractures were included in a retrospective analysis of a treatment protocol. Injuries were divided into Group I, thirty-four closed fractures, and Group II, twenty-two open fractures (three Gustilo Type 1, six Type II, eight Type IIIA, and five Type IIIB). METHODS: The protocol consisted of immediate (within twenty-four hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided. Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of twelve months. RESULTS: Group 1 (closed pilon): Follow-up was possible in twenty-nine out of thirty fractures (97 percent). Average time from external fixation to open reduction was 12.7 days. All wounds healed. None exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively. Seventeen percent (five out of twenty-nine patients) had partial-thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal. Group II (open pilon): Follow-up was possible in seventeen patients with nineteen fractures (86 percent). Average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days). By definition, all Gustilo Type IIIB fractures required flap coverage for the injury. Two patients experienced partial-thickness wound necrosis. These were treated with local wound care and antibiotics. All surgical wounds healed. There were two complications (10.5 percent), both deep infections. One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection. One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation. CONCLUSION: Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.     

Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function –Clinical study and MRI evaluation

PurposeTo compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up.Patients and methodsOne hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36.ResultsNo tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups.ConclusionThree-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.     

微创经皮解剖钢板治疗胫骨远端骨折的病例对照研究

目的:探讨应用经皮微创钢板固定(minimally invasive percutaneous plate osteosynthesis,MIPPO)技术治疗胫骨远端骨折的临床疗效。方法:对2006年2月至2009年3月收治的87例胫骨远端骨折患者的临床资料进行回顾性分析。经皮微创解剖钢板固定组(A组)35例,男25例,女10例;年龄(34.12±7.10)岁;采用闭合复位、解剖钢板内固定;经皮微创锁定钢板固定组(B组)11例,男8例,女3例;年龄(29.03±4.12)岁;采用闭合复位、锁定钢板内固定;传统切口解剖钢板固定组(C组)26例,男15例,女11例;年龄(31.07±6.31)岁;采用切开复位、解剖钢板内固定;传统切口锁定钢板固定组(D组)15例,男9例,女6例;年龄(30.27±6.52)岁;采用切开复位、锁定钢板内固定。比较4组手术时间、术中出血量、住院时间、住院费用、骨折愈合时间、末次随访AOFOS评分、并发症发生情况等指标。结果:87例均获随访,时间16～48个月,平均(24.6±2.2)个月。4组手术时间、末次随访AOFOS评分差异均无统计学意义。A、B组的术中出血量少于C、D组,住院时间、骨折愈合时间短于C、D组。A、C组的住院费用少于B、D组。结论:应用微创内固定技术创伤小、住院时间短,特别是应用经皮微创技术结合传统解剖钢板能够降低医疗费用。