Long-term results of pilon fractures

INTRODUCTION: The long-term results of pilon fractures are rarely documented. The present study evaluated the long-term results related to each fracture pattern of a pilon fracture treated with open reduction and plating. PATIENTS: One hundred and twenty-eight pilon fractures with a mean 10-year follow-up were divided into three groups, based on the Ruedi-Allgower classification. Group A was composed of 39 patients with Ruedi-Allgower type I fractures; group B comprised 62 patients with type II fractures; and group C included 27 patients with type III fractures. The radiographs were reviewed for adequacy of fracture reduction and posttraumatic arthrosis. At the end of follow-up, the clinical results were evaluated using a rating scale. RESULTS: Group C had significantly lower excellent and good reduction rates than group A or B (P < 0.05). Groups B and C had progressively increased ankle arthrosis with time (P = 0.043, P = 0.049, respectively). Group C had more unsatisfactory clinical outcomes than group A or B (P < 0.05). Operative concurrent fixation of the fractured fibula resulted in a better outcome than non-operative treatment (P < 0.05). Open fractures had significantly lower satisfactory outcomes than closed fractures (60.5% versus 78.9%, P < 0.05). CONCLUSIONS: Open reduction with plating was a reasonably effective procedure for the treatment of Ruedi type I pilon fractures. The long-term outcome of pilon fractures was affected by fracture patterns, fibular length restoration, quality of reduction, and severity of soft tissue injury. Posttraumatic arthrosis affecting the ankle after a severe pilon fracture (Ruedi type II or III) was a progressive disease, and required long-term follow-up.     

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.     

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.     

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.     

Fractures of the coronoid process

INTRODUCTION: A retrospective study has been made of a series of 22 cases, and the classification and treatment of fractures of the coronoid process of the ulna have been discussed. MATERIAL, METHODS AND RESULTS: A report has been made of 22 cases of coronoid process fracture (18 males and four females). The mean age was 26 years (range: 19-47 years). According to the Reagan and Morrey Classification, there were 11 type I (avulsion of the tip of the bone), seven type II (a fragment of less than 50% that was detatched from the coronoid process), and four type III cases (a fragment of more than 50% that was detatched from the coronoid process). Elbow dislocation was present in 16 cases, and a radial head fracture was associated in four cases. All type I fractures were treated by immobilization of the elbow in a plaster cast for ten to 15 days, with eight excellent and three good results. In type II fractures, open reduction, internal fixation with antero-posterior lag-screw and early post-operative movement in three patients gave better results than immobilization for three weeks, which was the procedure used in four cases (after transosseous reinsertion in one case). In type III fractures, good results were obtained following open reduction and internal fixation with antero-posterior lag-screw in three patients. The result was average in the fourth case, with immobilization for four weeks. CONCLUSION: The Reagan and Morrey classification is most useful for the classification of coronoid process fractures. If there is no comminution of the detatched fragment, open reduction and internal fixation with antero-posterior lag-screw is the treatment of choice in type I and II fractures. In type I fractures, immobilization for about two weeks gives good results.     

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.     

切开复位内固定治疗移位的跟骨关节内骨折

目的探讨切开复位跟骨钢板内固定治疗跟骨关节内骨折的效果。方法自2001年8月至2003年4月,采用切开复位内固定治疗移位的跟骨关节内骨折34例35足。所有骨折均采用Sanders分型,应用广泛外侧入路,AO跟骨钢板内固定。对有选择的病例进行了植骨。应用影像学检查和美国足踝协会的后足评分系统进行结果评价,患者全部获得随访。平均随访时间18.3个月(12～32个月)。结果共完整随访Ⅱ型骨折30足,Ⅲ型骨折5足。术前平均Bhler角是5.6°,随访时平均Bhler角是28.2°。X线测量表明在单侧跟骨骨折患者跟骨高度恢复为健侧的97.7%。80%的患者取得关节面的解剖复位或近解剖复位。平均评分在SandersⅡ型骨折为88分,Ⅲ型骨折为79分。优良率在SandersⅡ型骨折为83%,Ⅲ型骨折为60%。总的优良率为79%。结论对于SandersⅡ型和Ⅲ型骨折患者采用切开复位内固定治疗,效果较好。     

Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus

BACKGROUND: Thirty-two displaced intra-articular fractures of the calcaneus in 30 patients were treated with open reduction and internal fixation. Fracture classification was based on Sanders computed tomographic classification. There were 18 type II fractures, 10 type III fractures, and 4 type IV fractures. METHODS: The operations were performed using a standard extended lateral approach, and the fractures were fixed with small-fragment AO T-plates without bone grafting. Average follow-up was 35.4 months (range, 24-53 months). The Creighton-Nebraska Health Foundation Assessment score for fractures of the calcaneus was used for evaluation. RESULTS: The average score was 86.7 for type II, 82.3 for type III, and 59.2 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures (p < 0.0001). CONCLUSION: On the basis of our result, we recommend that type II and type III fractures be treated with open reduction and internal fixation. Despite the results of type IV fractures being significantly worse than that of type II and type III fractures, we recommend open reduction and internal fixation for type IV fractures to restore the hindfoot architecture and the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond the surgeon's ability to reconstruct, primary subtalar arthrodesis should be performed in addition to open reduction and internal fixation.     

Early complications in the management of open femur fractures: a retrospective study

Fifty patients with 53 open fractures of the femur were reviewed retrospectively. There were three subtrochanteric, 32 shaft, and 18 supraintercondylar fractures. Eleven were type I open fractures, 20 were type II open fractures, and 22 were type III open fractures. After initial debridement, 33 fractures had immediate internal fixation, nine had delayed internal fixation, one had external fixation, and 10 were treated with traction and cast bracing. Nine (16%) fractures, two type II and seven type III, developed deep infection. Five infections persisted at 6 months. Immediate internal fixation was followed by deep infection in one of 22 type I or II fractures and six of 11 type III fractures. There were five nonunions and seven delayed unions. Five of 44 uninfected and seven of 10 infected fractures had delayed union or nonunion. In this series, most patients with type III open femur fractures had severe associated multiple trauma. Immediate internal fixation was associated with greater local complications. We have concluded that immediate internal fixation of type III femoral fractures is only relatively indicated and must be applied with caution.     

Immediate internal fixation of open fractures of the diaphysis of the forearm.

Immediate (within 24 h) open reduction and internal fixation of 103 open fractures of one or both bones of the forearm was accomplished in 69 patients between 1980 and 1989. Fifty-four of the 103 patients were reevaluated 1 to 7 years postinjury (average 2.5 years) to determine the efficacy of this treatment. Forty-five (90%) of the 50 patients with Grade I, II, or IIIA injuries had satisfactory results. The four patients with Grade IIIB or IIIC injuries had unacceptable results. This study demonstrates, as have previous investigations, that immediate open reduction and internal fixation of open forearm fractures provide acceptable results in Grades I, II, and selected Grade III injuries. The subdivision of Grade III fractures into A, B, and C types provides a previously unreported statistically significant difference in the results obtained in management of these injuries. The difference in results in Grade I, II, and IIIA injuries as compared to the Grade IIIB and C injuries was statistically significant (p = 0.0004). The difference in Grade IIIA injuries as compared to Grade IIIB and C injuries was also significant (p = 0.014). Immediate open reduction and internal fixation can be recommended in Grade I, II, and IIIA open forearm fractures. Although it is unclear from this report whether the results in Grade IIIB and C fractures were due to the management protocol, the severity of the initial injury, or combined factors, immediate open reduction and plate fixation yielded poor results in these injuries.     

Part I: Arthroscopic management of tibial plateau fractures

Arthroscopy is a valuable tool for the assessment of tibial plateau fractures and is the treatment of choice for associated intra-articular pathology. In addition, (all)-arthroscopic reduction and internal fixation (ARIF) is recommended for type III fractures and is a consideration for types I, II, and IV. Published outcome studies of ARIF of tibial plateau fractures describe results that appear to equal outcomes of open reduction and internal fixation, but these studies suffer from susceptibility bias.     

Two-staged delayed open reduction and internal fixation of severe pilon fractures

OBJECTIVE: To evaluate the use of a two-staged technique for the treatment of C3 pilon fractures. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-one consecutive patients with twenty-two C3 pilon fractures. Patients with C1 or C2 fractures and patients with open growth plates were excluded. INTERVENTION: All patients underwent immediate fibular fixation and placement of a medial spanning external fixator. After, on average, twenty-four days, patients underwent removal of the external fixator and formal open reduction and internal fixation of the pilon fractures. MAIN OUTCOME MEASUREMENTS: At average follow-up of twenty-two months, all patients were evaluated by using subjective, objective, and radiographic measurements as described by Burwell and Chamley (J Bone Joint Surg 1965;47B:634-659). Range of motion and postoperative complications were also recorded. RESULTS: Twenty-one of the twenty-two fractures healed within an average of 4.2 months. Average range of motion was 7 degrees of dorsiflexion, 33 degrees of plantar flexion, 17 degrees of eversion, and 11 degrees of inversion. Subjective and objective measurements showed 77 percent good results, 14 percent fair results, and 9 percent poor results. Radiographic reduction showed 73 percent anatomic and 27 percent fair reductions. There were no infections or soft tissue complications. The arthrodesis rate was 9 percent. CONCLUSIONS: A two-staged approach offers acceptable results for the treatment of severe pilon fractures. These results compare favorably with those of primary open reduction and of internal fixation and external fixation techniques. The major advantages include limited soft tissue complications and improved articular reconstruction.     

Omnidirectional Internal Fixation by Double Approaches for Treating Rüedi-Allgöwer Type III Pilon Fractures

In the present study, we explored the effectiveness and complications of omnidirectional internal fixation using a double approach for treating Rüedi-Allgöwer type III pilon fractures. A retrospective analysis was performed of 19 cases of Rüedi-Allgöwer type III unilateral closed pilon fracture. With preoperative preparation and correct surgical timing, the reduction was performed using anteromedial and posterolateral approaches, and the fracture fragments were fixed by omnidirectional internal fixation. Imaging evaluation was performed using the Burwell-Charnley scoring system. The Johner-Wruhs scoring system was used to assess the functional status of the patients. A comprehensive evaluation of efficacy was performed using a 5-point Likert score. The complications were also recorded and analyzed. All patients were followed up for an average of 16.2 months. The operative incisions of 15 cases healed by primary intent and with delayed healing in 4. All patients had achieved bony union at an average of 16 weeks postoperatively. No deep infection, broken nail or withdrawn nail, exposed plate, or skin flap necrosis occurred. The Burwell-Charnley imaging evaluation showed that 14 patients had anatomic reduction of the articular surface and 5 had acceptable reduction. Using the Johner-Wruhs scoring system, the results were excellent for 8, good for 7, fair for 2, and poor for 2 patients; the combined rate of excellent and good results was 78.9%. The Likert score of efficacy self-reported by the patients was 3 to 4 points for 12 patients, 2 points for 4 patients, and 0 to 1 point for 3 patients. The Likert score of therapeutic efficacy reported by the physicians was 3 to 4 points for 10 patients, 2 points for 5 patients, and 0 to 1 point for 4 patients. Omnidirectional internal fixation using double approaches was an effective method to treat Rüedi-Allgöwer type III pilon fractures with satisfactory reduction and rigid fixation, good joint function recovery, and few complications.     

The adolescent pilon fracture: management and outcome

Pilon fractures in the adolescent are complicated by the presence of the adjacent physis. These fractures usually result from high-energy trauma, frequently associated with soft-tissue trauma, further potentiating treatment difficulties. Although rare, such fractures are associated with a high complication rate, including physeal arrest. It was the objective of this review to increase awareness of this fracture pattern in the adolescent, to determine the types of complications in this difficult group, and to develop a treatment plan to improve the outcome of treatment. Seven children, with a total of eight pilon fractures were treated at a major pediatric tertiary referral center over the past 10 years. The average age of the children was 15 years 10 months (range, 13 years 6 months to 17 years 7 months). The average length of follow-up was 16 months (range, 3 months and 3 years 10 months). There were three Reudi type II equivalent fractures and two Reudi type III equivalent injuries. Three fractures did not fit the Reudi classification system as there was an associated ankle dislocation. All fractures were treated with open reduction and internal fixation. There were two cases of posttraumatic osteoarthritis and one physeal arrest. Results were good to excellent in 63% of cases. A new classification system for pediatric pilon fractures has been proposed.     

Korreliert der Grad der Dislokation mit dem Therapieverfahren bei suprakondylären Humerusfrakturen im Kindesalter?

Hundred and twenty-eight supracondylar fractures of the humerus were studied retrospetively after an follow-up time of 4.3 years (1 to 17.8 years). In 87 cases (68%) the operative procedure was the closed reduction and percutaneous crossed-pin fixation for 19 fractures type III (56%), 22 fractures type II (76%) and 46 fractures type I (85%), whereas 41 fractures were treated by open reduction and crossed-pin fixation. The findings were evaluated according to “Flynn’s criteria” leading to the following results: “excellent” 77 times (60.2%), “good” 44 times (34.4%) “fair” 3 times (2.3%) and “poor” 4 times (3.1%). Our results show that with approximately 50% of all fractures type III the treatment by closed reduction and percutaneous crossed-pin fixation leads to a very good long-term result. On the other hand, rotated or interponated fractures type I and II require an open reduction and crossed-pin fixation. Independent of the type of fracture, the closed reduction and percutaneous crossed-pin fixation should always be taken into consideration. Exceptions are open fractures and those with multiple fragments.     

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.     

Surgical treatment of open pilon fractures

Objective: To discuss the methods, timing and clinical outcomes of surgical treatment for open pilon fractures. Methods: From April 2003 to July 2008, 28 patients with open pilon fractures were treated. All had type C fractures according to the Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO/ASIF) classification. Three operative methods were applied, the methods being determined by the types of fracture, soft tissue damage and time interval after injury. Seven cases were treated by debridement and internal fixation with plate; 19 by limited internal fixation combined with external fixation; and 2 by delayed surgery. The clinical outcomes were evaluated by the Burwell‐Charnley score. Results: All cases were followed up for from 6 to 48 months (average 24 months). The Burwell‐Charnley score of clinical outcomes: anatomic reduction achieved in 12 cases, functional reduction in 15, and unsatisfactory reduction in 1. The healing time was from 2.5 to 11 months (average 4.7 months). Two cases had delayed union. According to the American Orthopaedic Foot and Ankle Society (AOFAS) scale for the ankle joint, there were excellent results in 8 cases, good in 14, fair in 5 and poor in 1. Complications included four cases of skin superficial sloughing, two of superficial infection, one of deep infection, two of delayed fracture union and ten of post‐traumatic arthritis. Conclusion: It is important to perform appropriate surgeries for open pilon fracture according to fracture classification, different damage to skin and tissue and time interval after injury. Thorough debridement, proper use of anti‐infective medication, appropriate bone grafting, and postoperative ankle function exercise can reduce the occurrence of complications.     

Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation

PURPOSE: The purpose of this study was to evaluate the treatment of patients with Mason type III radial head fracture with and without elbow dislocation by open reduction with internal fixation, collateral ligament repair, and early mobilization. An additional purpose was to investigate whether there is any effect of elbow dislocation on the severity and functional outcome. METHODS: Twenty-five patients were treated with open reduction with internal fixation using low-profile miniplate and screws for comminuted fracture of the radial head. Eighteen fractures were Mason type III, and 7 fractures were Mason type III with elbow dislocation. There were 5 women and 20 men with a mean age of 34 years. The mean follow-up time was 27 months. Patients were reviewed for functional ability, physical examination, and radiographic assessment. RESULTS: The mean functional index in Mason type III fracture and Mason type III fracture with elbow dislocation was 87 for both groups. The mean range of motion at the elbow joint was calculated as 5 degrees extension to 136 degrees flexion for Mason type III and 7 degrees extension to 133 degrees flexion for Mason type III with elbow dislocation. The mean pronation and supination for all patients were 74 degrees and 67 degrees , respectively. CONCLUSIONS: Selected Mason III radial head fractures and fracture dislocations could be stabilized satisfactorily with internal fixation. Meticulous surgical technique, combined with rigid internal fixation, can allow early motion of the forearm and elbow after fixation of Mason type III radial head fractures with and without elbow dislocation and ligamentous injury. We believe there is still a role for prosthetic replacement in comminuted Mason III radial head fractures that cannot reliably be treated with open reduction and internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.     

Open reduction and internal fixation for distal radius fractures.

From a series of 650 dorsally angulated fractures of the distal radius, 32 intra-articular fractures were treated by open reduction and internal fixation. The 32 fractures were classified according to the Frykman criteria as type VII (5) or type VIII (27). On the basis of the location of intra-articular involvement, the fractures were further subdivided into Mayo type II (4), type III (18), and type IV (10). Results were analyzed by the methods of Gartland and Werley (functional) and Lidstr?m (radiographic). After open reduction and internal fixation, 90% of the patients had satisfactory results on the basis of the subjective criteria of minimal deformity, absence of pain, and good strength. Objective assessment demonstrated that the patients had 80% of normal motion and 73% of normal grip strength at a minimum of 2 years after the operation. On the basis of radiographic and functional evaluation, results were good to excellent in 87%. When intra-articular step-off exceeded 2 mm or the radius was shortened more than 5 mm, the results were only fair and posttraumatic arthritis was evident.     

Langzeitergebnisse nach operativer Versorgung von Pilon-tibial-Frakturen Eine retrospektive Untersuchung

Background: While Pilon fractures of the tibia have been treated for decades by primary open reduction and internal fixation by plate osteosynthesis, during the last 10 years differential treatment was developped: After primary open reduction nowadays patients are treated with (according to type of fracture and tissue damage). As well as primary open reduction and internal fixation a two-step treatment (primary external fixator and delayed ORIF) or consolidation by external fixator combined with minimal invasive osteosynthesis (cannulated screws and K-wires) has been implemented. Furthermore, the significance of primary bone grafting in comminuted fractures to prevent aseptic pseudarthrosis has been acknowledged. Methods: Of 151 patients with 160 pilon fractures treated from January 1979 to May 1995, 107 patients (113 fractures) were evaluated. Only the results of C2 and C3 fractures could be compared, as only in these groups were all three types of treatment used. Results: Over 75% of the treated fractures were closed fractures, most of them being fractures with a soft tissue damage grade 2 of the Oestern and Tscherne classification. In the open fractures we found mainly grade 3 fractures according to the Gustilo and Anderson classification. In 54.9% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications (25.7%) were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication. Highest infection rate (55.5%) was in the two-step treatment group (primary external fixator and delayed ORIF) and lowest in the primary internal stabilization group, although especially in the C2 and C3 fractures best clinical late results were obtained with the two-step procedure. Conclusion: The complication rate in the treatment of pilon fractures depends mainly on the type of fracture, the soft tissue damage and the type of treatment. The results of primary ORIF varied. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the two-step treatment. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires. We consider ORIF of the fibula necessary as stabilization of the second column of the ankle joint.