Open reduction and internal fixation of tibial pilon fractures using a lateral approach

OBJECTIVES: To assess the wound complications and reductions achieved in a cohort of patients with pilon fractures who were treated using a novel lateral approach. DESIGN: Retrospective review. SETTING: Two level 1 trauma centers affiliated with academic institutions. PATIENTS/METHODS: All 44 fractures (in 43 patients) treated by the senior authors with open reduction and internal fixation (ORIF) using the lateral approach as the primary approach were included. INTERVENTION: Data regarding medical comorbidities, mechanism of injury, soft-tissue injury sustained during the injury, treatment, wound healing, and secondary surgeries were recorded. Fractures were classified using the AO/OTA system with most being type C3. Eighteen fractures were open injuries (10 type 3). Fracture reductions were scored using the criteria of Teeny and Wiss. MAIN OUTCOME MEASUREMENTS: Quality of articular reduction and soft-tissue healing. RESULTS: An anatomic or good fracture reduction was achieved in 41 fractures (93%), and a fair reduction was obtained in 3 fractures. Two patients were successfully treated for deep infection (4.5%), and 2 patients developed a wound dehiscence (4.5%). There were no amputations. Twelve patients underwent secondary surgeries (27%). Five of these were for symptomatic screw removal (related to the fibular hardware in all cases), and the sixth was for planned removal of a syndesmotic-type screw (13.6%). Four were for nonunion, representing 9% of all cases. The remaining secondary surgeries (2 cases) were performed for infection. Overall, 13.6% of patients underwent a secondary surgical procedure to address nonunion or infection. CONCLUSIONS: When applied in a staged fashion, the lateral surgical approach for pilon fractures provides excellent protection of the soft-tissue envelopes by creating thick flaps while allowing excellent visualization for reconstruction of the anterior and lateral distal tibia.     

Open reduction and internal fixation of high-energy tibial plateau fractures

Proximal tibial articular fractures are caused by a variety of mechanisms and are characterized by numerous distinct fracture patterns. Surgical treatment for other than minimally displaced or nondisplaced fractures is recommended to restore joint congruity and limb alignment, and to allow early, stable, knee motion.     

Open reduction and internal fixation of 117 tibial plateau fractures

This retrospective study evaluated the surgical management of 117 tibial plateau fractures treated between 1990 and 1998. At last patient follow-up, results were rated good to excellent in 94, fair in 13, and poor in 10 cases. Follow-up radiographs showed degenerative changes in the lateral compartment in 29 cases. Other complications included five wound infections, two deep venous thromboses, five delayed unions, and three nonunions. Operative treatment of tibial plateau fractures is recommended as it enables better alignment, meniscal access, and other soft-tissue injury repair.     

复位内固定并植骨治疗胫骨平台骨折

2002年11月～2008年2月,我们采用复位内固定并植骨治疗高能量损伤型胫骨平台骨折18例,疗效满意. 1 材料与方法 1.1 病例资料本组18例,男11例,女7例,年龄18～72岁.闭合性损伤12例,开放性损伤6例.按Schatzker分类:Ⅳ型10例(见图1A),Ⅴ型5例,Ⅵ型3例.致伤原因:重物致伤3例,交通事故伤10例,高处坠落伤5例.合并半月板损伤4例,外侧副韧带损伤2例,交叉韧带损伤2例.受伤时间至手术时间4 h～14 d.     

Arthroscopic ankle arthrodesis after tibial pilon open reduction internal fixation

Ankle arthrodesis is an essential tool in the foot and ankle surgeon's armamentarium. Despite the evolving technology and ongoing research in ankle arthroplasty, arthrodesis continues to be a proven and safe option for the majority of patients with ankle arthritis refractory to conservative management. Here, the authors present their technique of an arthroscopic ankle arthrodesis specifically in the setting of a previous open-reduction internal fixation (ORIF) for a tibia plafond type fracture. They have found this to be a reliable technique to achieve a solid ankle arthrodesis while minimizing soft-tissue trauma and dissection in an already compromised soft-tissue envelope.     

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.     

External fixation versus open reduction and internal fixation for tibial pilon fractures: A meta-analysis based on observational studies

Purpose: Tibial pilon fractures remain challenging for an orthopaedic surgeon to repair. External fixation (ExFix) and open reduction and internal fixation (ORIF) are two widely used methods for repairing tibial pilon fractures. However, conclusions of comparative studies regarding which method is superior are controversial. Our aim is to compare ORIF and ExFix and clarify which method is better in terms of reduction and union results and major complications.Methods: A computerized research of MEDLINE, EMBASE, Springer, and Cochrane Library (beforeDecember 2014) for studies of any design comparing ORIF and ExFix was conducted. Weighted meandifference (WMD), risk ratio (RR) and corresponding 95% confidence intervals (CI) were used for estimating the effects of the two methods. Statistical analyses were done using Review Manager Version 5.2. Results: Ten cohort studies and one randomized clinical trial were included in our ultimate analysis. Andthe analysis found no significant difference between the two methods in deep infection (p=0.13),reduction (p=0.11), clinical evaluation (p=0.82), post-traumatic arthrosis (p=0.87), and union time(p=0.35). Besides, ExFix group was found to have a higher rate of superficial infection (p=0.001),malunion (p=0.01) and nonunion (p=0.02), but have a lower risk of unplanned hardware removal(p=0.0002).Conclusions: We suggest that ORIF has a relatively lower incidence rate of superficial infection, malunion and nonunion, but a higher rate of unplanned hardware removal. No difference was found in deep infection, reduction, clinical evaluation, post-traumatic arthrosis and union time.     

Hybrid external fixation of tibial pilon fractures

Although external fixation reduces drastically the number of iatrogenic complications compared with acute open reduction and plate fixation, the prognosis for functional recovery after a pilon fracture remains guarded. Many authors have applied validated patient outcome measures to patients who have had pilon fractures. These studies confirmed that there are significant decreases in general health perceptions, physical and emotional role function, pain, and energy levels in patients who have suffered pilon fractures, regardless of the treatment modality. The high-energy tibial pilon fracture with soft tissue compromise remains a treatment dilemma. Hybrid external fixation with limited open reduction has proved to be a safe, reproducible, and effective treatment modality for this complex fracture.     

Early internal fixation and soft tissue cover of severe open tibial pilon fractures

We studied 32 consecutive patients with open distal tibial pilon fractures. All patients had radical debridement with immediate skeletal stabilisation and early soft-tissue cover with a vascularized muscle flap. The minimum follow-up was 1 (range 1–8) year. There were four superficial infections, two deep infections and two amputations. There were no long-term problems with union and no patient required an ankle fusion. Patients were assessed using the SF-36 questionnaire. There were significant differences from the US norm in physical function score (p<0.01), role physical score (p<0.05) and physical component score (p<0.01). Physical component score of 38.5 was significantly better (p<0.01) when compared with amputees from severe lower-extremity trauma. Our protocol for management resulted in a good functional outcome with low infection and amputation rates.

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Résumé Nous avons étudié 32 malades consécutifs avec une fracture ouverte du pilon tibial. Tous les malades avaient un débridement radical avec stabilisation squelettique immédiate et couverture tissulaire précoce avec un lambeau musculaire vascularisé. Le minimum de suivi était une année (1à 8 années). Il y avait 4 infections superficielles, 2 infections profondes et 2 amputations. Il n'y avait pas de problèmes de consolidation à long terme et aucune arthrodèse de cheville ne fut nécessaire. Les malades ont été étudiés à partir du questionnaire SF-36. Il y avait des différences significatives selon la norme américaine du score de la fonction physique (p<0.01), le rôle du score physique (p<0.05) et le score de la composante physique (p<0.01). Le score composant physique de 38.5 était considérablement meilleur (p<0.01) comparé aux amputés pour traumatisme distal sévére. Notre protocole de gestion de ces fractures a conduit à un bon résultat fonctionnel avec un taux d'infection et d'amputation très bas.

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Open reduction and internal fixation of acetabular fractures

Summary. Between 1982 and 1995, 84 patients with displaced acetabular fractures underwent open reduction and internal fixation in our institution. The mean follow-up was 5.5 years with a minimum of 2 years. There were 33 simple and 51 complex fractures according to the classification of Judet and Letournels. Reduction after operation was anatomical in 49% of the patients, satisfactory in 24%, and unsatisfactory in 27%. Using Merle d’Aubigné’s scale, the clinical results were excellent in 39% of the patients, good in 29%, fair in 8%, and poor in 24%. Factors of statistical significance associated with a poor clinical outcome were T-shaped fractures, unsatisfactory reduction (>3 mm residual displacement), age >40 years and development of avascular necrosis. Acetabular surgery is demanding, and a high rate of complications can be expected. Trauma centres should designate a group of surgeons who will consistently treat these fractures in order to obtain more experience and better results.

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Résumé. Entre 1982 et 1995, 84 patients présentant des fractures déplacées de l’acétabulum ont eu une réduction ouverte avec fixation interne. Le suivi a été en moyenne de 5,5 ans avec des extrêmes de 2 à 13 ans. Selon la classification de Judet et Letournel, 33 fractures étaient simples (39%) et 51 complexes (61%). Après l’opération, la réduction était considérée anatomique dans 49% des cas, satisfaisante dans 24% et mauvaise dans 27%. Avec l’échelle de Merle d’Aubigné, les résultats cliniques ont été excellents dans 39% des cas, bons dans 29%, médiocres dans 8% et mauvais dans 24%. Les facteurs statistiquement significatifs des mauvais résultats ont été: les fractures en ”T”, la réduction non satisfaisante (+ de 3 mm de déplacement résiduel) à l’age de plus de 40 ans et la survenue d’une nécrose avasculaire. Le résultat de cette série confirme que la chirurgie acétabulaire est difficile et que le taux de complications peut être élevé. Il est recommandable de limiter à un groupe de chirurgiens le traitement opératoire de ces fractures afin d’obtenir une plus grande expérience et des meilleurs résultats.

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Accepted: 2 July 1998     

Calcaneus fractures. Open reduction and internal fixation

AIM OF THIS STUDY: Critical analysis of the medium-term results of open reduction and internal fixation (ORIF) of displaced intra-articular calcaneus fractures with a standardized protocol in a greater patient cohort. METHODS: From October 1993 to December 1999 314 patients (mean age 42.3 years) with 348 calcaneus fractures were seen at the Dresden University Hospital. 41 fractures were open, 4 with 1st degree, 28 with 2nd and 9 with 3rd degree soft tissue damage. 275 displaced intra-articular fractures were treated with ORIF, 262 (95.3 %) with plate osteosynthesis via an extended lateral approach. 169 patients could be evaluated at a mean of 18 months (range 10-47 months) postoperatively with an extended protocol of questionnaire, physical and radiographic examination. RESULTS: The Maryland Foot Score after 18 months follow-up averaged 80.8/100, the mean Zwipp score averaged 146.4/200. The functional result with the Merle d'Aubigné score was judged good to excellent in 86% of cases. Rates of deep infection and superficial wound edge necrosis increased significantly with open fractures and delay in surgery of more than 2 weeks after injury in closed fractures. Clinical results were adversely affected by even minor residual steps in the posterior facet (1-2 mm) as judged by CT or Brodén views (p < 0.001). B?hler's tuberosity-joint-angle had an impact on the final result when falling short compared to the unaffected contralateral side by more than 30% (p < 0.001). CONCLUSIONS: Management of intra-articular calcaneus fractures with a standardized protocol of ORIF and early mobilization leads to reproducible good or excellent clinical results in a majority of patients. New approaches like an interlocking calcaneus plate, the use of subtalar arthroscopy, early soft tissue coverage for complex open injuries and percutaneous screw fixation for selected fractures should further improve prognosis.     

后方入路治疗胫骨平台后方骨折

目的:探讨后方入路治疗胫骨平台后方骨折的骨折类型、手术方法和临床疗效。方法:回顾性分析自2008年6月至2011年2月采用后方入路治疗且随访完整的8例胫骨平台后方骨折,男5例,女3例;年龄23～55岁,平均41.1岁。致伤原因:车祸伤5例,高处坠落伤3例。2例胫骨平台后方冠状面骨折伴后交叉韧带撕脱和1例后外侧平台劈裂伴塌陷骨折采用正后方"S"形入路,2例后内侧平台骨折采用后内侧倒"L"型入路,3例同时累及胫骨平台前后侧及胫骨干骺端骨折者采用后内侧倒"L"形入路联合前外侧入路行钢板螺钉内固定。关节面塌陷者采用同种异体骨或自体髂骨植骨术。结果:所有患者获得随访,时间8～39个月,平均20个月。全部病例获得影像学上的骨性愈合,愈合时间11～21周,平均14.5周。术中未出现血管、神经损伤,术后无一例出现切口感染、内固定松动及断裂。所有患者术后即刻与术后6个月胫骨平台内翻角(TPA)、内外侧平台后倾角(PA)度数均无统计学差异。术后末次随访Rasmussen膝关节功能评分为19～29分,平均25.60分,其中优4例,良3例,可1例。术后末次随访Rasmussen放射学评分14～18分,平均17.25分,其中优6例,良2例。结论:胫骨平台骨折以后侧为主时,后方入路能得到很好的骨折端暴露,有利于直视下复位固定,术后近期疗效满意。     

Closed tibial pilon fractures treated with external fixation

Fractures of tibial pilon are due to a high energy trauma. Associated skin complications are frequent as those of surgery of this pattern. Thus we performed external fixation as treatment for these fractures. Authors report a retrospective study of 17 closed fracture of tibial pilon, type C of Ruedi and Heim classification, treated by osteotaxis using external fixation of Hoffman with osteosynthesis of fibula by screwed plate. Our patients are of a mean age of 34 years with 11 men and 6 women. The right side was most frequently involved (12 patients). Skin injuries as phlyctena were seen in 6 patients. Delay of treatment did not exceed 72 h. We performed a closed reduction of the fracture of tibial pilon after internal fixation of fibula by screwed plate. Results were assessed after 24 months of study. Track pins infection was noted in three cases. Reduction was usually good, despite one case of recurvatum, one case of valgus, one case of Sudeck’s atrophy, three cases of arthritis have been noticed. Mobility decreased at about 30%. External fixation is a real alternative solution for treatment of these fractures for which osteosynthesis is not suitable. It allows us to avoid skin complications despite mobility decreasing.      

Open reduction and internal fixation of intraarticular tibial plateau nonunions

The vast majority of tibial plateau fractures heal uneventfully, and no case series on intraarticular tibial plateau nonunions exists. The purpose of the present study was to evaluate the radiographic and clinical outcome of these nonunions following surgical treatment in a single surgeon series. Five patients with tibial plateau nonunions were treated at our institution using a specific treatment protocol consisting of open reduction and debridement, deformity correction, internal fixation including lag screws, bone graft augmentation, and selective knee joint arthrolysis. Patient outcomes were assessed using radiographs and the Knee Society questionnaire scores. Following surgical treatment of the nonunion, all healed at an average of 12.8 weeks, and average follow-up was 44 months. Preoperative coronal plane deformity was corrected in all patients. The final knee motion arc averaged 120 degrees postoperatively. Both the pain and function subscales of the Knee Society Rating scale improved significantly. Four of the five returned to their normal pre-injury activities, but two patients required total knee arthroplasty which was performed successfully after healing of the nonunion. With meticulous surgical technique and a standard protocol, healing may be reliably achieved. Arthrosis occurs frequently, and may occur primarily at the time of injury or from chronic alteration of intraarticular contact forces secondary to development of a nonunion.     

Open reduction and internal fixation of radial head fractures

This study examines 32 patients operated for radial head fractures, mean age 48.7 years (range 26-76 years), Mason type II in 25 cases and Mason type III with 3 main fragments in 7 cases. Fractures were surgically reduced and fixed with Herbert's (12 cases) or Osteomed (20 cases) cannulated screws. The latter have a head that is <1 mm high and are only threaded distally. Both types of screw provide compression across the fracture. In Mason type II cases, the mean MEPS score was 98.4 and the DASH score 6.8. In Mason type III cases, MEPS was 99.3 and DASH 9.5. We believe that fixation can be carried out with screws alone, which are less invasive, and that the screw heads should preferably be completely buried, to avoid stiffness in prono-supination. In addition, suturing of the annular ligament and the joint capsule is made easier by the reduced invasiveness of screws. Screw treatment is effective in non-comminuted fractures of the radial head.