Tibial pilon fractures: a comparison of treatment methods

OBJECTIVE: This retrospective review of surgically treated distal tibia fractures was undertaken to determine whether treatment with open reduction and internal fixation (ORIF) was more efficacious in achieving fracture union than one of two external fixation methods. METHODS: Of the 60 study patients with pilon fractures, 21 patients were treated with an ankle-spanning half-pin external fixator, 15 patients with a single-ring hybrid external fixator, and 24 patients with ORIF. The severity of injuries was similar across groups. RESULTS: There was no significant difference in complication rates between groups, although two below-knee amputations were required in the ORIF group. A greater (p = 0.03) number of malunions occurred in the fractures treated with external fixation when compared with those treated with ORIF. Fractures in the external fixator groups showed this significant tendency to lose their initial adequate reduction, independent of bone grafting or fibula fixation. There was no significant difference between groups in the need for bone grafting. There was a trend for patients treated with a single ring hybrid frame to require late bone grafting for metaphyseal-diaphyseal nonunion. CONCLUSION: External fixation offers advantages in the treatment of the soft-tissue injury associated with pilon fractures, but malunion continues to be a problem with this method of fixation.     

Distal tibial nonunion using a contralateral anterior L-shaped locking compression plate through a posterior-lateral approach: A retrospective case series

BackgroundDistal tibial nonunion is usually due to severe open distal tibial fractures with high energy injury. The best surgical treatment is not well established because of the poor soft tissue condition. We retrospectively analyzed a series of patients with distal tibial nonunion after severe open distal tibial fractures; our purpose was to introduce a treatment using a contralateral anterior L-shaped locking compression plate through a posterior-lateral approach with Iliac crest bone graft and evaluate the outcomes of patients.MethodsAll patients with distal tibial nonunion who received a contralateral anterior L-shaped locking compression plate fixation through the posterior-lateral approach with Iliac crest bone graft by a single surgeon from 2014 to 2016 were reviewed. 9 patients met the criteria. Five of nine patients had varus deformities (range, 9–40°) and 4 patients had valgus deformities (range, 5–30°). Postoperative radiographs, Postoperative complications, limb alignment and limb functional outcome information of AOFAS ankle-hindfoot score were recorded.ResultsAll patients were followed up for at least 8 months (range, 8–16 months). Union was achieved in all patients after the index surgery without postoperative wound complications while one patient came up with checkrein deformity. Average time to radiographic union was 16 weeks (range, 12–24 weeks). All patients had correction to neutral alignment in both coronal and sagittal planes. The average AOFAS ankle-hindfoot score was 90 (range, 77–100) at the last follow-up of patients.ConclusionsUsing a contralateral anterior L-shaped locking compression plate fixation through a posterior-lateral approach with Iliac crest bone graft to reconstruct the distal tibial nonunion is a safe and reliable method that can successfully treat patients with poor soft tissue condition of anterior portion of leg because of its adequate exposure, both tibia and fibula rigid fixation and plenty of bone graft. We believe the application of this method resulting in a high union and low complication rate.     

胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折

目的探讨胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折的临床效果。方法2007年2月至2009年1月采用胫骨远端后内侧解剖接骨板固定后踝治疗三踝骨折患者11例,男7例,女4例;年龄23～58岁,平均41岁;左踝5例,右踝6例;开放骨折2例,闭合骨折9例。根据Lauge-Hansen分型均为旋前外旋型Ⅳ度,后踝骨折均超过关节面的25%。结果全部获得随访,随访时间为11～26个月,平均15.8个月。伤口均一期愈合,无一例发生感染。骨折愈合时间为10～15周,平均11.6周。术后采用AOFAS踝关节-后足评分标准,评分为83～100分,平均87.2分。结论胫骨远端后内侧解剖接骨板固定后踝是治疗三踝骨折的有效方法之一。     

经腓骨前方外侧入路治疗GustiloⅢ型胫腓骨远端骨折

目的:探讨经腓骨前方外侧入路结合外固定架治疗GustiloⅢ型胫腓骨远端骨折的方法及其疗效。方法:自2007年至2010年治疗9例GustiloⅢ型开放性胫腓骨远端骨折,男7例,女2例;年龄29～51岁,平均40岁。所有患者I期急诊清创后钢板内固定腓骨,外固定支架跨踝关节固定胫骨,待小腿内侧植皮成活后拆除外固定架,Ⅱ期采用I期腓骨切口经腓骨前方入路固定胫骨。早期行功能锻炼,观察骨折愈合及踝关节功能恢复情况。采用AOFAS踝-后足评分系统进行疗效评价。结果:所有患者均获随访,时间8～37个月,平均21个月。9例患者均获得骨性愈合,平均愈合时间24周,均无钢板断裂及螺钉松动。根据AOFAS踝-后足评分系统,优3例,良4例,中2例。结论:经腓骨前方外侧入路治疗GustiloⅢ型开放性胫腓骨远端骨折,复位质量高,可早期恢复踝关节功能,提高疗效。     

A Modified 2-Stage Treatment for AO/OTA 43-C1 Pilon Fractures Accompanied by Distal Fibular and Posterior Lip of the Distal Tibia Fracture

The management of pilon fractures remains challenging owing to the high-energy axial loading mechanism that produces comminution of the articular surface, displacement of tibia metaphysis, and severe soft tissue injury. How to preserve the vitality of soft tissue and achieve anatomic reduction has become a timely issue. We report and evaluate the effect of a modified staging treatment for AO Foundation/Orthopaedic Trauma Association (AO/OTA) 43C1 pilon fracture accompanied by distal fibular and posterior lip of the distal tibia fracture. We performed a modified 2-stage treatment of type C1 pilon fracture with distal fibular and posterior malleolar fractures. In the first stage, the posterolateral incision was used for simultaneous reduction of fibula and posterior malleolus, and the tibia was fixed with an external fixator. In the second stage, the external fixator was removed, and the medial malleolus and tibia were fixed after the edema of soft tissue had subsided. The following data were collected: Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short Form 36 (SF-36) score, Burwell-Charnley fracture reduction score, and postoperative complications. Twenty-seven patients were monitored for an average of 31.70 ± 7.38 months. The Burwell-Charnley fracture reduction scores had anatomic and fair ratings of 92.59%. SF-36 physical component score was 42.94 ± 12.47 and mental component score was 48.73 ± 9.79. Score data from the multiple scales of FAOS included pain, 88.79 ± 8.59; activities of daily living, 91.89 ± 7.50; quality of life, 90.26 ± 10.52; sports, 87.93 ± 11.64; and symptoms, 85.32 ± 8.65. The AOFAS ankle-hindfoot scores were 87.30 ± 13.45. Complications were reported in 5 patients (18.52%). Our study provides a good alternative to the existing protocol for type C1 pilon fractures with distal fibular and posterior lip of the distal tibia fracture and effectively reduces soft tissue complications.     

Combination of hook plate and tibial pro-fibular screw fixation of osteoporotic fractures: a clinical evaluation of operative strategy

BACKGROUND: Internal fixation of osteoporotic ankle fractures is technically difficult and may fail because of unreliable purchase. This study was undertaken to determine if a combination of a hook plate and tibial pro-fibular screws can provide secure fixation until fracture union. METHODS: Thirty-one patients between the ages of 55 and 90 years had open reduction and internal fixation of ankle fractures between April, 2001, and April, 2003. Sixteen patients with an average age of 71.4 years had ankle fracture fixation with a combination of hook plate and tibial pro-fibular screws for the distal fibular fracture, and 15 patients with an average age of 71.9 years had fixation of their ankle fractures with standard fixation technique using AO/ASIF principles but no tibial pro-fibular screws. All patients were followed with clinical and radiologic assessment at 2 weeks, 6 weeks, and 12 weeks postoperatively. At an average of 15.8 months after injury, patients also completed a mailed questionnaire with the Olerud-Molander ankle score and the AOFAS ankle-hindfoot score for preoperative and postoperative status. RESULTS: All patients who had tibial pro-fibular screw fixation had fracture union without hardware failure or complications. In the standard fixation group two patients had wound breakdown and one had a valgus malunion with screw pull out. The AOFAS and Olerud-Molander scores for the standard open reduction and internal fixation were 57.3 and 82.8 before injury and 37 and 43.8 postoperatively, respectively. The AOFAS and Olerud-Molander scores for the hook plate and tibial pro-fibular fixation group were 55.9 and 81.3 before injury and 42.4 and 50.3 postoperatively, respectively. CONCLUSIONS: The combination of hook plate and tibial pro-fibular screws in osteoporotic ankle fractures in a series of patients has not been reported before. This novel technique provides stable fixation for osteoporotic ankle fractures in elderly patients until union is achieved with good clinical scores.     

后外侧入路在Pilon骨折治疗中的应用

目的:评价在Pilon骨折治疗中后外侧入路的作用和并发症。方法:2009年8月至2011年3月,分期手术治疗15例Pilon骨折,AO/OTA分类B3型2例,其余均为C型骨折,均合并明显移位的后踝骨折。其中男12例,女3例,平均年龄37.9岁(21～51岁)。所有患者I期急诊手术使用超关节外固定架固定,Ⅱ期固定时首先通过后外侧入路固定腓骨,同时辅助复位和固定胫骨远端的后方骨折块,通过前内侧或前外侧入路复位和固定胫骨远端。结果:15例患者均获随访,平均随访时间14.2个月(12～17个月),13例骨折顺利愈合,2例需Ⅱ期自体髂骨植骨。后外侧伤口均未出现软组织并发症。术后影像学检查,14例关节面残留移位小于2mm。根据Baird-Jackson评价,优2例,良7例,可4例,差2例。结论:作为Pilon骨折前方入路的辅助切口,通过后外侧入路可以有效显露及固定后踝骨块及腓骨骨折,为前方骨折块的复位提供了标志,操作安全、简单、有效。     

Posterolateral approach for tibial pilon fractures: a report of two cases

Open reduction and internal fixation (ORIF) of displaced tibial pilon fractures can lead to a high percentage of good and excellent functional results, but has also been associated with a meaningful incidence of wound breakdown and infection. The use of the posterolateral approach to the distal tibia for ORIF of tibial pilon fractures is presented. This may be used instead of the standard anteromedial incision in certain fracture configurations. The flexor hallucis longus muscle coverage overlying the plate fixation of the tibia and ability to fix both the tibia and fibula through the same incision may decrease the risk of deep infection and wound complications in these injuries frequently associated with marked soft tissue trauma.     

Severe Fracture of the Tibial Pilon: Results with a Multidirectional Self-locking Osteosynthesis Plate Utilizing a Two-stage Procedure

The objective of this study is to determine the treatment result of severe fractures of the tibial pilon using a two-stage treatment plan with a singular implant type. The setting is a level 1 trauma centre, the design a consecutive series of patients with a retrospective data evaluation. Due to anatomical circumstances, soft-tissue treatment is extremely important for fractures of the tibial plafond. After promising results reported about a two-staged treatment plan with external fixation and secondary internal fixation, we incorporated this method in our treatment protocol. This consisted in a second stage of internal fixation with a specifically developed locked pilon plate with multi-directional applicable screws. Between March 2000 and February 2005, 42 patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: firstly the fracture was stabilized with an external fixator immobilizing the ankle joint. Secondly, after stabilization of the soft-tissue situation (mean 9.2 days) open reduction and internal fixation with a locked-screw plate was performed. Complications experienced included three cases of superficial wound necrosis, in two cases a deep vein thrombosis occurred. All fractures healed but two patients needed an early bone graft because of insufficient bony consolidation. At follow-up, six Patients had no deficit in the range of movement of the ankle compared with the unaffected side, 19 patients experienced a deficit of movement of less then one third compared to the opposite side. In 27 cases no or only mild post-traumatic arthritis of the ankle occurred. There was no secondary loss of reduction or need for arthrodesis. The mean AOFAS score was 73.4 (52–97). A two-stage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result.     

Complications associated with the posterolateral approach for pilon fractures

OBJECTIVE: To review the complication rates of open reduction and internal fixation (ORIF) of tibial pilon fractures using the posterolateral approach. DESIGN: Retrospective review. SETTING: Two level I trauma centers. PATIENTS: Nineteen consecutive pilon fractures at an average of 13 (range, 13-45) months follow-up. Average age 46 (range, 21-72) years. Four of 19 were open fractures. INTERVENTION: Because of the high incidence of wound complications associated with the anterior approach for pilon fractures, patients were treated with initial temporary external fixation followed by delayed ORIF through the posterolateral approach to the distal tibia. The hypothesis was that the abundant soft-tissue coverage of the posterior distal tibia would decrease the rate of wound complications. MAIN OUTCOME MEASUREMENTS: The incidence of wound complications, nonunion, and early posttraumatic arthritis. This was a chart and radiograph retrospective review. RESULTS: The mean time to definitive treatment was 13 (range 2-30) days. Nine of 19 patients (47%) developed complications. There were 6 patients with wound problems, 2 patients with aseptic nonunions, 2 patients with infected nonunions, 3 tibiotalar fusions, and 1 patient with a 3-mm step off. In total, there were 14 major complications in 9 patients. Ten of 19 patients did not have any complication. CONCLUSIONS: The posterolateral approach does not eliminate the complications common to other approaches, but does offer a potential alternative when soft tissue concerns prevent other approaches. We do not recommend the posterolateral approach for the routine treatment of tibial pilon fractures.     

Functional outcome after modified Blair tibiotalar arthrodesis for talar osteonecrosis

BACKGROUND: Osteonecrosis of the talar body is a challenging problem for both patient and surgeon. One reconstruction option is an arthrodesis of the tibia to the talar neck, as described by Blair, which has the theoretical advantages of salvaging some hindfoot height and motion of the subtalar joint. A few case series have been published describing outcome after modified Blair fusions, none with validated functional outcomes. The purpose of this article is to describe a modification of Blair's original technique, and report the functional outcomes in a series of patients undergoing this procedure. METHOD: A retrospective review of seven patients with talar osteonecrosis undergoing modified Blair tibiotalar arthrodesis was performed. The median patient age was 51 (range, 39-78). Median follow-up was 20 months (range, 12-112). Two patients required a repeat procedure for delayed/nonunion, with subsequent uneventful union. In all patients the procedure included compression screw fixation of the talar head to the anterior distal tibia, with the two repeat procedures and the most recent patient having an additional anterior compression plate and bone graft. Functional outcome measures using both the AOFAS ankle-hindfoot score and the SF-36 global health outcome measure were obtained at latest follow-up. In addition, radiographic assessment of bone union and time to union was determined. RESULTS: Median SF-36 physical and mental component scores were 46 and 61, respectively. The median AOFAS ankle-hindfoot score was 67 out of 100. Median visual analog scales for postoperative pain and function were 7.1 and 6.0 respectively, out of a best possible score of 10. CONCLUSION: Functional outcome scores after modified Blair arthrodesis are lower than similar scores after conventional tibiotalar fusion, and much lower than "normal" values; however, the procedure has similar, if not lower, complication rates to alternative complex hindfoot reconstructions, and this procedure is a valuable alternative in the management of talar osteonecrosis with arthrosis.     

采用MIPPO技术不同钢板内固定治疗胫骨远端骨折的疗效比较

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5月～2009年11月我院收治的82例胫骨远端骨折患者进行回顾性分析,其中经皮微创解剖钢板固定组(A组)35例,经皮微创锁定钢板固定组(B组)47例.比较两组的手术时间、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 82例均获得随访,时间16 ～48个月,平均(24.6±2.2)月.两组患者手术时间、术中出血量、住院时间、骨折愈合时间、末次随访AOFOS评分、并发症发生率差异无统计学意义(P＞0.05),A组的住院费用明显少于B组(P＜0.05). 结论 采用MIPPO技术两种钢板内固定治疗胫骨远端骨折均能够获得良好的临床效果,但应用传统解剖钢板能够明显降低医疗费用,适于临床推广.     

Treatment of an open distal tibia fracture with segmental bone loss in combination with a closed proximal tibia fracture: a case report

The treatment of open distal tibia fractures remains challenging, particularly when the fracture is infected and involves segmental bone loss. We report the case of a 38-year-old man who sustained an open distal tibiofibular fracture with segmental bone loss and a closed proximal tibial fracture. The fractures were initially fixed with a temporary external fixator. The open distal tibial fracture was infected, and the skin was covered after the wound became culture negative. The tibia was then internally transported with a ring external fixator; the closed fracture of the proximal tibia served as the corticotomy for internal transport without conventional corticotomy. After 5?cm internal transport, the docking site of the distal tibia was fixed with a locking plate and autogenous cancellous bone graft. Bone graft was also used to the distal tibiofibular space to achieve distal tibiofibular synostosis. We describe one treatment option for an infected open fracture of the distal tibia with segmental bone loss that is accompanied by a closed fracture of the proximal tibia. This method can treat two fractures simultaneously.     

后外侧联合内侧入路急诊内固定治疗三踝骨折

目的 探讨后外侧联合内侧入路急诊内固定治疗三踝骨折的疗效.方法 对23例三踝骨折患者急诊采用后外侧入路行后踝骨折复位空心螺钉或支撑钢板内固定、外踝骨折复位钢板内固定,内侧入路行内踝骨折复位空心螺钉内固定.末次随访时采用AOFAS踝-后足功能评分标准评价疗效.结果 患者均获得随访,时间10～32个月.切口均一期愈合.骨折...     

超关节外固定支架结合有限内固定治疗高能量Pilon骨折

目的：讨论超关节外固定支架结合有限切开内固定治疗高能量Pilon骨折的临床疗效.方法：自2003年9月至2011年4月应用超关节外固定支架结合有限内固定治疗36例高能量损伤的Pilon骨折患者.男25例,女11例;年龄16～72岁,平均38岁.患者术前可以通过常规X线检查或行三维螺旋CT检查明确诊断.术后采用AOFAS评分标准对疗效进行评定.对于骨折断端是粉碎的、不平整的,可以用螺钉、克氏针或钢丝固定,无须剥离骨膜,可以使骨折断端和骨折块之间相互靠拢以增强稳定性,然后超关节外固定支架固定.结果：所有患者获随访,时间4～27个月,平均13个月.32例伤口Ⅰ期愈合.骨折愈合时间2～6个月,平均3个月.踝关节活动度和骨折愈合按AOFAS评分标准进行评定,总分88.2±3.6;优13例,良20例,可3例.12例发生针孔感染,5例出现针孔处疼痛,1例因过度负重导致固定针断裂,经处理均获得痊愈.无神经、血管损伤及骨髓炎等并发症.结论：超关节外固定支架结合有限切开内固定治疗高能量Pilon骨折固定确切、操作简单、符合生物力学固定原则,有利于骨折愈合.     

内外翻不同损伤机制导致胫骨Pilon骨折的手术策略

 目的 探讨内外翻不同损伤机制导致胫骨Pilon骨折的特点、手术策略及疗效。方法 2008年6月至2012年8月收治胫骨Pilon骨折32例,内翻损伤17例、外翻损伤15例。内翻损伤组AO/OTA分型B型6例、C型11例,外翻损伤组均为C型。外翻损伤组中3例为GustiloⅡ型开放性骨折。根据主要骨折线及骨折块分布选择相应的手术入路行切开复位内固定,内翻损伤组主要支撑接骨板置于胫骨远端内侧,外翻损伤组置于胫骨远端前外侧;开放性骨折采用有限内固定结合外固定支架治疗。以Burwell-Charnley放射学评价标准判定关节面复位质量,记录美国矫形足踝协会（American Orthopedic Foot and Ankle Society,AOFAS）踝与后足评分。结果 全部病例随访12~24个月,平均16.9个月。两组AO/OTA分型、合并腓骨骨折发生率的差异有统计学意义。内翻损伤组2例并发浅表感染;外翻损伤组4例并发浅表感染,2例深部感染,1例骨折延迟愈合,4例需转移皮瓣修复创面。内翻损伤组解剖复位9例、复位较好7例、复位一般1例,外翻损伤组解剖复位6例、复位较好8例、复位一般1例。术后12个月内翻损伤组AOFAS评分（87.06±2.70）分,外翻损伤组（82.80±3.47）分,差异无统计学意义。结论 内外翻不同损伤机制导致的胫骨Pilon骨折不同,应选择不同的手术方式。对内翻损伤应将主要支撑接骨板置于胫骨远端内侧、外翻损伤置于胫骨远端前外侧,可降低手术并发症发生率,近期临床疗效满意。     

Subtalar arthrodesis for complications of intra-articular calcaneal fractures

Eighty six subtalar arthrodeses performed between 1985 and 1996 for complications associated with intra-articular calcaneal fractures were retrospectively evaluated. Patients were divided into three Groups: (I) 59 patients with calcaneal malunions (II) 13 patients with failed open reduction and internal fixation, and (III) eight patients undergoing open reductions and primary fusion for highly comminuted fractures. In each scenario, internal fixation was achieved with cancellous lag screws. Bone graft material consisted of either autogenous iliac crest graft, local graft obtained from the lateral wall exostectomy of the malunion, or freeze-dried cancellous allograft. Fusions in Groups II and III were performed in situ. Fusions in Group I were performed either in situ or utilizing a variety of reconstructive procedures depending upon the type of malunion encountered. Eighty three of the 86 fusion attempts were successful following the initial operations for a union rate of 96%. Fusion rates were similar regardless of the graft material used. Complications included four varus malunions, four cases of osteomyelitis, and two cases of reflex sympathetic dystrophy. A statistically significant shorter hospital stay was found for patients not undergoing iliac crest bone graft procedures. Eighty patients with at least two year follow up achieved a mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score of 75.0. Scores were similar for all three groups and for the various types of reconstructive procedures used. No correlation was found between postoperative talar declination angle and the AOFAS ankle-hindfoot score. Worker's compensation patients tended to have a poorer clinical outcome.     

小腿严重开放性骨折伴软组织缺损的治疗

目的 探讨小腿严重开放性骨折伴软组织缺损(Gustilo ⅢB型或ⅢC型)的治疗方法.方法 1990年1月至2008年12月,收治开放性胫腓骨骨折53例,其中Gustilo ⅢB型45例,ⅢC型8例.软组织缺损面积为6 cm×4 cm～18 cm×8 cm,8例伴骨缺损.急诊行骨折复位同定和血管修复,二期对软组织或骨缺损采用13种53块组织瓣移位或移植修复.骨折外固定支架固定35例,内固定16例,骨牵引及石膏固定2例.皮瓣或肌皮瓣47例,骨皮瓣6例.结果 51例获得随访,时间8个月～9年(平均18个月).骨折顺利愈合44例,愈合时间3.5～9.5个月,平均6.5个月.骨延迟愈合4例,骨不愈合3例,经手术植骨(5例)或骨外固定支架加压同定治疗(2例)均治愈.组织瓣移植53块,成活51块,坏死2块,成活率为96.2%.无截肢病例.结论 Gustilo ⅢB型或ⅢC型小腿严重开放性骨折,初期清创并采用以骨外支架为主的方法固定骨折,二期采用适当组织瓣移植修复软组织或骨缺损,是安全有效的治疗策略.     

不同内固定方式治疗Weber A型腓骨远端骨折的疗效

目的探讨Weber A型腓骨远端骨折的内固定选择及临床疗效。方法对48例Weber A型腓骨远端骨折患者采用克氏针张力带、Herbert螺钉、腓骨钩钢板3种内固定方法治疗。术后通过临床查体、影像学检查、AOFAS踝-后足功能评分评价疗效。结果患者均获得随访,时间10~26个月。切口均一期愈合,无感染及皮肤坏死。骨折均顺利愈合,未出现骨折复位丢失和内固定松动、断裂。末次随访根据AOFAS踝-后足功能评分判定踝关节功能:优20例,良27例,可1例。踝关节活动度:背伸8°~19°,跖屈28°~46°。3种内固定患者的手术时间比较差异有统计学意义(P<0.05),AOFAS踝-后足功能评分、骨折愈合时间比较差异均无统计学意义(P>0.05)。结论在Weber A型腓骨远端骨折的手术治疗中,根据骨折块大小和形态、骨质特点和局部皮肤软组织情况综合考虑,合理选择内固定方式,可以获得良好的临床疗效。     

Early prophylactic bone grafting of high-energy tibial fractures

Fifty-three high-energy tibial fractures treated with early prophylactic posterolateral bone grafting were retrospectively reviewed. The bone-grafting procedures were performed at a mean of ten weeks following injury and at a mean of eight weeks following soft-tissue coverage. Ninety-six percent of the fractures had associated injuries with a mean injury severity score of 20.9. Seventy-nine percent of the fractures were classified as Grade III open fractures, and 40% had bone loss greater than 50% of the cortical circumference. Ninety-six percent of the fractures healed at a mean time of 43 weeks after injury. Segmental bone loss and soft-tissue injury requiring flap coverage were the best predictors of prolonged time to union. Comparison with a matched historical control group of tibial fractures not receiving early bone grafts revealed a mean reduction in time to union of 11.7 weeks (p = 0.03). The incidence of chronic osteomyelitis was 1.9%. These results are attributed to early and repeated aggressive debridement, immediate rigid external fixation, early soft-tissue coverage, and early posterolateral bone grafting. Recommendations include posterolateral cancellous bone grafting two weeks following wound closure by delayed primary closure, split-thickness skin graft, or local rotational myoplasty. A six-week delay following freely vascularized soft-tissue coverage prior to bone grafting is suggested.