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.     

Instrumente f��r die minimalinvasive Unfallchirurgie

For some time now minimally invasive techniques have been implemented in surgical disciplines, including trauma surgery. Indirect reduction techniques, minimal approaches and preservation of soft tissue cover have reduced the incidence of local complications and systemic stress and promoted fracture healing by conserving the biological soft tissue environment. Subtle surgical techniques are required to achieve all this and reduction aids and instruments for minimally invasive surgery are needed. In some cases minimally invasive methods make some otherwise impossible portals and approaches possible. Manual dexterity is of special merit for reduction of soft tissue injury as well as practice and the tips and tricks which should be passed on from one surgeon to another. Minimally invasive trauma surgery is not a black and white image contrasting minimally invasive and conventional surgery but comprises techniques and principles that merge seamlessly into one another. For an experienced surgeon, this is multi-facetted trauma surgery.     

Biological internal fixation of fractures

Summary Trauma centers treat more and more patients who have sustained multiple injuries during high energy accidents. The techniques of internal fixation of such fractures may be dictated by the concomitant soft tissue trauma, rather than by the bony injury. Three stages of soft tissue injuries are recognised: Stage I delineates compromised soft tissues which may be treated with standard techniques of internal fixation, provided that further devialization by surgery is avoided. Stage II implies partial, non-circumferential destruction of soft tissues, requiring alternative techniques of internal fixation to prevent (mainly septic) complications. In stage III, the soft tissues about the fracture site are destroyed and need early, specific soft tissue reconstruction. Indirect reduction without further devascularization of bone, aiming at perfect alignment rather than anatomical reduction of extraarticular fractures, optimal rather than maximal internal fixation as well as the inclusion of soft tissue reconstructive procedures into the armamentarium of the orthopaedic surgeon, require an intellectual and technical reorientation but can be shown to improve the results of the treatment of fractures with concomitant soft tissue injury.     

Tibial pilon fractures

Tibial pilon fractures are severe injuries to the distal articular surface of the tibia. Such injuries frequently result from high-energy axial impact and are often associated with extended soft tissue injury. Various treatment methods are available, depending not only on the fracture type but mostly on the extent of the soft tissue injury; one of the most frequent procedures is a two-stage surgery: the initial closed reduction of the fracture via primary placement of an ankle joint-spanning external fixator, if possible in conjunction with open reduction and internal fixation of the fractured fibula followed by a secondary procedure after soft tissue recovery by open reduction and internal fixation of the tibial plafond. By now, new types of low-profile and locking plates are available for internal fixation allowing the anatomical reconstruction of the fractured articular surface while sparing the soft tissue. Nonetheless, the treatment of tibial pilon fractures is technically demanding because of their potential for severe complications.     

Minimally Invasive Treatment of Ankle Fractures in Patients at High Risk of Soft Tissue Wound Healing Complications

The complex nature of ankle fractures is magnified when seen in patients at high risk of soft tissue wound healing complications. The major categories include associated soft tissue injury, diabetes, tobacco use, peripheral vascular disease, malnutrition, alcoholism, and corticosteroid use. Because of the potential for wound dehiscence and infection with open reduction and internal fixation of ankle fractures in these patients, minimally invasive procedures have been described. The aims of the present study were to assess the possibility for, and evaluate the results and complications of, minimally invasive techniques for different types of malleolar fractures in high-risk patients. We report the clinical results of 47 high-risk patients who presented with malleolar fractures from January 2007 to December 2012 and underwent minimally invasive reduction and fixation. One patient (0.5%) developed a superficial infection; however, none of the patients displayed wound dehiscence or deep infection. Five patients (10.6%) required open reduction because of intraoperative failure to achieve anatomic reduction. Using the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, 15 of the patients (36%) treated with minimally invasive techniques experienced an excellent outcome. In contrast, 23 patients (55%) had a good, 3 (7%) a fair, and 1 (2.5%) a poor outcome. The results of our study have shown that minimally invasive fixation appears to be a satisfactory method for the management of malleolar fractures in high-risk patients and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation.     

踝关节骨折合并下胫腓联合损伤的诊治策略

目的通过踝关节骨折伴下胫腓联合损伤临床诊断、治疗、疗效的分析,探索较为优化的诊疗方案。方法手术治疗踝关节骨折伴下胫腓联合损伤75例,其中男51例,女24例,年龄18～72岁,平均42岁。根据损伤机制、损伤类型、受伤时间、软组织情况,实施术前正确评估、术中解剖复位固定、术后渐进性康复等策略。其中急诊手术组40例,择期手术组35例。随访观察治疗效果并进行疗效评定。结果75例均获得随访,随访时间5—24个月,平均13个月。根据Baird—Jackson踝关节功能评分标准进行疗效评价,急诊手术组优良率87．5％。择期手术组优良率85．7％,总优良率86．7％。急诊手术组与择期手术组疗效评定中各项指标差异无统计学意义。结论只有非常重视软组织情况,充分利用辅助检查手段,术前仔细评估,术中解剖复位固定,术后处理到位,早期康复,才能重新获得一个无痛的、满意的踝关节。     

Endoscopic-assisted,minimally invasive anterior pelvic ring stabilization: a new technique and case report

This report describes the technique of endoscopic-assisted reduction and stabilization of the anterior pelvic ring with endoscopic visualization of all critical bone and soft tissue structures. Compared with the conventional ilioinguinal approach of Letournel, the endoscopic technique facilitates a reliable internal fixation of anterior pelvic ring fractures with minimal soft tissue trauma. Thus, the use of the endoscope enables us to apply the concept of minimal invasive plate osteosynthesis to the pelvis. We recommend the described technique for complex anterior pelvic ring fractures, in which the anterior stabilization has to be achieved with a plate from the symphyseal region to the iliac wing.     

Intramedullary transmetatarsal Kirschner wire fixation of Lisfranc fracture-dislocations

Lisfranc joint injuries are frequently the result of high-energy accidents. The usual method of treatment is open reduction and internal fixation or closed reduction with percutaneous pinning. In cases in which soft tissue injury may compromise open reduction and internal fixation or traditional pinning techniques, transmetatarsal Kirschner wire fixation may be performed, allowing the placement of temporary hardware away from the site of soft tissue injury. The following report details this technique as it has been used in 3 patients.     

Minimal-invasive, ballonassistierte Aufrichtung und innere Fixation von Tibiaplateaufrakturen

The management of tibial plateau fractures can be challenging because of the scarcity of soft tissue associated with a high rate of wound healing disorders. Classic open reduction and internal plate fixation require extensive soft tissue dissection and periosteal stripping, and elevation of depressed fragments and maintenance of the reduction is difficult. In the current report the authors describe a novel operative approach to percutaneously reduce depressed tibial plateau fractures using an inflatable balloon in combination with minimally invasive plate fixation. The results of the first 5 cases treated with this technique are reported.     

Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques

OBJECTIVE: To determine whether long-term results of one of three different management protocols for severe tibial pilon fractures offer advantages over the other two. DESIGN: In a retrospective study, patients were examined clinically and radiologically after internal fixation of severe tibial plafond fractures (i.e., 92 percent Type C fractures according to the AO-ASIF classification). SETTING: Department of Traumatology, Hanover Medical School. Level I trauma center. PATIENTS: Fifty-one of seventy-seven patients treated between 1982 and 1992 were examined clinically and radiologically at an average of sixty-eight months (range 13 to 130 months) after injury. INTERVENTIONS: The patients were treated in three different ways: primary internal fixation with a plate following the AO-ASIF principles (n = 15), which was reserved for patients with closed fractures without severe soft tissue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least four weeks (n = 28); and a two-stage procedure entailing primary reduction and reconstruction of the articular surface with minimally invasive osteosynthesis and short-term transarticular external fixation of the ankle joint followed by secondary medial stabilization with a plate using a technique requiring only limited skin incisions (a reduced invasive technique) (n = 8). MAIN OUTCOME MEASUREMENTS: Objective evaluation criteria were infection rate, amount of posttraumatic arthritis, range of ankle movement, and number of arthrodeses. Subjective criteria were pain, swelling, and restriction of work or leisure activities. RESULTS: Because only closed fractures were treated by primary internal fixation with a plate, there was a statistically significant difference (p < 0.005) in the distribution of open fractures between the three treatment groups. Fracture classification in these groups were not significantly different. All but four fractures were classified as Type C lesions according to the AO-ASIF system. The soft tissue was closed in 63 percent (n = 32) and open in 37 percent (n = 19). No significant relationship could be found between the soft tissue damage and degree of arthritis or between the type of surgical treatment and extent of posttraumatic arthritis. However, none of the patients who required secondary arthrodesis (23 percent of all cases) were in the group who had undergone two-step surgery (p < 0.05). The range of ankle movement was much greater in the two-step group than in the others; these patients also had less pain, more frequently continued working in their previous profession, and had fewer limitations in their leisure activities. These differences did not reach statistical significance. The incidence of wound infection did not differ significantly among the three groups. CONCLUSIONS: On the basis of our results, we now prefer a two-step procedure for the treatment of severe tibial pilon fractures with extensive soft tissue damage. In the first stage, primary reduction and internal fixation of the articular surface is performed using stab incisions, screws, and K-wires. Temporary external fixation is applied across the ankle joint. After recovery of the soft tissues, the second stage entails internal fixation with a medial plate using a reduced invasive technique.     

Technique for Minimally Invasive Reduction of Calcaneal Fractures Using Small Bilateral External Fixation

Soft tissue complications are well known after extensile exposure of the calcaneus for open reduction internal fixation of fractures. A variety of recommendations have been proposed to reduce soft tissue healing issues and infection. Despite these recommendations, some surgeons believe that soft tissue complication rates have remained unacceptably high with lateral extensile incisions. Recently, interest in minimally invasive repair techniques for calcaneal fractures has increased. These techniques have been purported to avoid some of the common soft tissue problems seen with calcaneal open reduction internal fixation. The focus of the present communication is to share a minimally invasive surgical method for the reduction and fixation of calcaneal fractures. Percutaneous fixation of the posterior facet fragments can be facilitated by distraction of the fractured calcaneus using skeletal traction and a small bilateral external fixator. Final stability is achieved with a combination of the external fixator and percutaneous screws and/or wires. We present our technique and discuss recent published studies on minimally invasive repair of calcaneal fractures.     

Open reduction and internal fixation of tibial pilon fractures

Although it is evident that the fracture of the tibial plafond is a complex, often debilitating injury, its management is not clear. These injuries generally fall into one of two categories. The low-energy, rotational type of fracture has been shown to have excellent clinical and functional results with open reduction and internal fixation. The high-energy, compression type of fracture has had uniformly moderate results and historically high complication rates. Some authors think that bridging external fixation with or without limited internal fixation should be employed in high-energy fractures. Others believe that open reduction and internal fixation to avoid articular incongruence and development of axial malalignment is needed for good long-term outcome. The authors believe the latter. Staging the treatment of the patient can minimize development of soft tissue complications. The authors follow the recommendations of Patterson and Sirkin and believe that high-energy pilon fractures should be temporized with an external fixator with or without fibular plating to restore length. Any open would should be addressed at this time. Definitive fixation should be planned for between 10 and 14 days, by which time the soft tissue envelop is likely to be ready to accept the further insult of surgery. The surgical technique should be well planned for and include the use of meticulous soft tissue techniques and indirect reduction methods. With the proper attention to detail, long-term results will be maximized.     

Operative Therapie der distalen Radiusfraktur

Distal dislocated radius fractures are now mostly treated surgically. Closed reduction and internal fixation with Kirschner wires are increasingly giving way to internal fixation with screws or fixed-angle plates and to the use of the fixateur externe. For fractures with concomitant severe soft tissue injury treatment with a bridging external fixator and adequate soft tissue management are first necessary. External fixation is needed in addition, however, once soft tissue repair has been achieved by means of internal fixation with screws or K-wires, and the external fixator should remain in place until the fracture has started to heal. If possible preference should be given to the use of nonbridging fixators. Conservative treatment can now no longer be justified except for stable and nondislocated fractures. Arthroscopy/assisted reconstruction of the carpal articular surface is the subject of some controversy and is not yet accepted as a standard procedure.     

James traction splinting for PIP fractures.

Comminuted phalanx fractures about the PIP joint are a common injury seen in sports and recreational activities. Corrective treatment frequently requires some form of open reduction with internal fixation. These types of invasive treatments are insulting of soft tissue and often create significant secondary problems. These authors have designed a splint that attempts to optimize outcomes following fracture and surgical treatment.     

Distale Tibiafrakturen

Distal tibial fractures can be divided by mechanism into injuries caused by torsion trauma or by compression trauma. The latter ones are often associated with a complete destruction of the tibial joint surface, so-called tibial plafond fractures. Another group of fractures are the distal metaphyseal fractures of the tibia with only minimal involvement of the ankle as a result of low energy torsion trauma. Multiple factors can be held responsible for posttraumatic complications and poor outcome: malalignment, nonanatomic reduction of the joint surface or bone defects, and severe soft tissue injury. Therefore a sophisticated therapeutic regime of distal tibial fractures is necessary, which we present in detail in this article. In cases with only minor soft tissue injury a primary definitive open reduction internal fixation (ORIF) of the tibial fracture is possible. Fractures with severe soft tissue injury should be initially fixed with an external fixator. Definitive fixation and reconstruction should here be performed in subsequent operations. Early functional therapy can be attempted if fractures are reliably stabilized.     

Postoperative management: hand therapy program following intrafocal pinning for juxtaarticular phalanx fractures

Intrafocal pinning is a fracture management technique for reduction and stabilization of juxtaarticular phalanx fractures. This technique provides fracture stability with minimal soft tissue disruption from surgery and allows early range of motion (ROM) of the interphalangeal joints. The purpose of this article is to discuss postoperative rehabilitation specific to the management of this fracture and fixation technique that facilitates early ROM, edema control, pin care, custom splinting, and therapeutic exercise.     

经皮微创椎弓根螺钉内固定治疗胸腰椎压缩性骨折的短期临床疗效研究

目的 探讨经皮微创椎弓根螺钉内固定治疗胸腰椎压缩性骨折的短期临床疗效.方法回顾性研究2012年1月至2015年6月我院收治的胸腰椎骨折且无脊髓神经损伤病人44例,均为单节段椎体骨折,采用经皮微创椎弓根螺钉内固定术的22例纳入经皮微创组,行常规后路切开复位内固定术的22例纳入切开复位组.对比两组病人的手术时间、术中出血量、住院天数、椎体前缘高度比、矢状位后凸Cobb角、疼痛视觉模拟量表(visual analogue scale,VAS)评分等指标.结果两组病人均未出现术后感染、内固定松动断裂、脊髓神经损伤等并发症.两组病人的术中出血量和住院天数组间比较,差异均有统计学意义(t=21.966,P<0.0001;t=8.278,P<0.0001);两组病人术后1、6、12个月的椎体前缘高度比和Cobb角均较术前明显改善,经皮微创组和切开复位组术后1个月的椎体前缘高度比分别为(91.68±1.94)%、(94.73±0.88)%,差异有统计学意义(t=8.512,P<0.0001);但两组术后6、12个月的椎体前缘高度比及术后1、6、12个月的Cobb角比较,差异均无统计学意义(P均>0.05);经皮微创组术后1个月的VAS评分为(2.91±0.75)分,明显低于切开复位组的(3.95±1.13)分,差异有统计学意义(t=3.609,P=0.001),但两组病人之间术后6、12个月的VAS评分差异均无统计学意义(P均>0.05).结论经皮微创椎弓根螺钉内固定技术具有损伤小、出血少、术后疼痛轻、康复快的特点,是治疗无脊髓神经损伤的胸腰椎压缩性骨折的有效方法.     

后外侧入路钢板和拉力螺钉内固定治疗踝部皮肤损伤Pilon骨折

目的:探讨后外侧入路钢板和拉力螺钉内固定治疗踝部皮肤损伤Pilon骨折的临床疗效。方法:选取2013年5月至2016年6月行后外侧入路手术治疗踝部皮肤有损伤的Pilon骨折患者25例,其中男15例,女10例;年龄25~61(39.6±0.2)岁;采用后外侧为主的手术入路使用钢板固定,并辅助使用空心钉三维固定手术治疗。观察并记录踝部伤口及受伤时软组织挫擦伤愈合情况,采用Burwell-Charnley标准和美国足踝外科协会AOFAS踝-足评分系统进行功能评价。结果:25例患者获得随访,时间6~24个月,平均12个月。患者手术伤口及皮肤挤压擦伤均愈合。按照Burwell-Charnley标准,解剖复位22例,不满意2例,差1例。AOFAS踝-足评分为90.2±7.5,结果优20例,良3例,可2例。结论:后外侧入路钢板和拉力螺钉内固定治疗踝部皮肤损伤Pilon骨折可以完全避开前内侧损伤的皮肤及软组织,骨折固定牢固,有效地避免了软组织的进一步损伤坏死。     

The Use of Pediatric Flexible Intramedullary Nails for Minimally Invasive Fibular Fracture Fixation

Fibular fractures in the setting of an unstable ankle joint require surgical fixation; however, several factors contradict open surgical correction. Severe soft tissue compromise can delay adequate fracture reduction and preclude the standard incisional approach. The soft tissue envelope in the setting of obesity, diabetes, and/or peripheral vascular disease further complicates definitive treatment. Poorly timed open fixation can lead to delayed healing of the incision site, with wound breakdown and the potential for hardware failure. Proximal fibular fractures are also at unique risk of neurovascular compromise with open reduction and internal fixation. Surgical fixation has now focused on minimizing the soft tissue insult using percutaneous techniques in the comorbid patient. We present a case that highlights a minimally invasive technique that provides dynamic stable internal fixation of fibular fractures with the use of flexible pediatric intramedullary nails, typically used in long bone fractures of children.     

Fractures of the distal tibia: minimally invasive plate osteosynthesis

Unstable fractures of the distal tibia that are not suitable for intramedullary nailing are commonly treated by open reduction and internal fixation and/or external fixation, or treated non-operatively. Treatment of these injuries using minimally invasive plate osteosynthesis (MIPO) techniques may minimise soft tissue injury and damage to the vascular integrity of the fracture fragments. We report the results of 20 patients treated by MIPO for closed fractures of the distal tibia. Their mean age was 38.3 years (range: 17-71 years). Fractures were classified according to the AO system, and intra-articular extensions according to Rüedi and Allg?wer. The mean time to full weight-bearing was 12 weeks (range: 8-20 weeks) and to union was 23 weeks (range: 18-29 weeks), without need for further surgery. There was one malunion, no deep infections and no failures of fixation. MIPO is an effective treatment for closed, unstable fractures of the distal tibia, avoiding the complications associated with more traditional methods of internal fixation and/or external fixation.