Salvage of tibial pilon fractures using fusion of the ankle with a 90 degrees cannulated blade-plate: a preliminary report.

Six patients with ankle joint destruction and delayed metaphyseal union after tibial plafond fracture were surgically treated with tibiotalar arthrodesis and metaphyseal reconstruction, using a fixed-angle cannulated blade-plate. The procedure was performed through a posterior approach in five cases and a lateral approach in one case. The subtalar joint was preserved in all cases. Metaphyseal union and a stable arthrodesis were obtained in all cases without loss of fixation and with no mechanical failure of the blade-plate. Union was obtained in an average of 26 weeks. No secondary procedures were required to obtain union. All six patients were ambulatory at last follow-up. Stable internal fixation for simultaneous tibiotalar fusion and metaphyseal reconstruction can be achieved with a cannulated blade-plate while preserving the subtalar joint in complex plafond fractures.     

Surgical management of pilon fractures with large segmental bone defects using fibular strut allografts: a report of two cases

We present two patients with open pilon fractures with large bone defects treated successfully with fibular strut allografts. The patients were initially treated by massive irrigation, wound debridement, and temporary external fixation. After complete wound healing, the bone defects were managed. Because autologous iliac crest or fibular bone grafts were impossible to be harvested due to multiple fractures, the bone defects were reconstructed with fibular strut allografts. Fixation was performed with a periarticular distal tibia locking plate. At 2 months postoperatively, the patients ambulated with partial weight-bearing; at 6 months, they had full range of motion of the ankle joint and full weight-bearing.     

Salvage of distal tibia metaphyseal nonunions with the 90 degrees cannulated blade plate

Nonunion of distal tibia metaphyseal fractures after trauma is a major problem. Treating these nonunions is made more challenging by the presence of symptomatic ipsilateral tibiotalar arthrosis. The current study examined the use of the 90 degrees cannulated blade plate as an alternative method of stable internal fixation for 13 distal tibia metaphyseal nonunions and simultaneous fusion of three arthritic tibiotalar joints in 13 patients (seven males and six females) with an average age of 42.4 years (range, 21-73 years). Each patient had an average of three prior procedures (range, 2-6). Patients were followed up for an average of 34.2 months (range, 24-55 months). All 13 patients achieved radiographic and clinical union an average of 15.6 weeks (range, 12-20 weeks) from the date of the definitive procedure. There were two broken screws, but no secondary procedures were required to obtain fusion. All patients were ambulatory without support at the last followup. The implant proved effective for stable internal fixation of distal tibia metaphyseal nonunions alone or with simultaneous fusion of the tibiotalar joint.     

交锁髓内钉和经皮钢板固定治疗胫骨远端干骺端骨折的疗效比较

目的 比较交锁髓内钉和经皮钢板固定治疗胫骨远端干骺端骨折的疗效。方法 回顾性分析2004年5月～2005年8月采用交锁髓内钉或经皮钢板固定的51例胫骨远端干骺端骨折的治疗效果，根据内固定方式分成髓内钉组（n=27）和钢板组（n=24），比较两组的手术时间，出血量，透视次数，骨折愈合时间，踝关节前后向、内外翻成角，踝关节最大背伸度及并发症，并采用Olerud-Molander踝关节评分评价结果。结果 所有患者获得12—27个月（21．2个月）随访，两组患者在手术时间、透视次数、踝关节最大背伸度方面差异无统计学意义（P〉0．05）。所有骨折均获得愈合，平均愈合时间髓内钉组为20．0周，钢板组为18．6周。Olerud-Molander踝关节评分结果均为优良。髓内钉组具有较少的手术出血量，钢板组具有更好的骨折对线；髓内钉组有5例发生畸形愈合，钢板组有4例发生局部软组织并发症。结论 对于胫骨远端骨折，交锁髓内钉和经皮钢板固定都是有效的固定方式，经皮钢板能够提供更好的骨折端稳定性，而交锁髓内钉有利于处理伴有局部软组织损伤的骨折。     

踝关节镜下微创经皮钢板内固定治疗胫骨Pilon骨折的临床研究

目的探讨踝关节镜下微创经皮钢板内固定技术（MIPPO）治疗胫骨Pilon骨折的手术方法和临床疗效。方法本组47例患者运用关节镜下撬拨复位,行MIPPO治疗。38例获得随访,随访时间6—23个月,平均（10．6±5．4）个月。结果所有患者创口愈合良好,均在术后2周拆线。骨折临床愈合时间为6—18周,平均（9．5±4．2）周,无骨折不愈合。随访x线检查显示骨折对位对线良好,无畸形愈合,仅有3例胫骨远端关节面尚不平整,出现轻度骨关节炎的表现;仅1例主诉长距离行走后踝关节肿痛。按Mazur等踝关节症状和功能评分系统进行疗效评定,优24例,良19例,可4例。结论运用关节镜下撬拨复位尽可能保证重建后的踝关节面接近正常解剖,防止日后创伤性踝关节炎的发生。MIPPO的微创方法可以避免软组织广泛剥离,最大限度保留软组织的覆盖和血液供应,提高局部抗感染能力,促进骨折的愈合。     

Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities

PURPOSE: The purpose of this investigation was to evaluate the outcome of tibiocalcaneal arthrodesis using an adolescent condylar blade plate for severe ankle and hindfoot deformities. MATERIALS AND METHODS: We retrospectively reviewed the records of patients managed at our institutions between 1989 and 1996 whose tibiocalcaneal arthrodeses were performed with adolescent condylar blade plates and allograft bone. In these 30 patients (14 men, 16 women; average age, 53 years), the etiologies of the nonbraceable deformity included: diabetic neuroarthropathy with talar fragmentation and resorption (26), inflammatory arthritis (3), and posttraumatic avascular necrosis of the talus with collapse (1). Due to the severity of the deformity in 28 of these patients, the alternative treatment would have been amputation. Thirteen patients had undergone previous surgeries, eight had documented osteomyelitis, and 13 had ulcers ranging from 2 to 27 mm. At surgery, the remnants of the talus were removed. Morcellized bone graft mixed with tobramycin/vancomycin powder was inserted into the arthrodesis site and then fixed with a rigid plate. Intravenous antibiotics, followed by oral antibiotics, were given until wound healing and suture removal. Follow-up averaged 48 months (19 to 112 months). RESULTS: Tibiocalcaneal fusion was achieved in 28/30 patients at an average of 16 weeks (12 to 18 weeks). Complications occurred in seven patients: two developed stress fractures of the tibia at the proximal end of the blade plate, three had superficial cellulitis that resolved with antibiotic therapy, and two had nonunions. CONCLUSION: Tibiocalcaneal arthrodesis using an adolescent condylar blade plate and allograft bone can be a successful procedure in the patient with severe neuropathic ankle deformity and can achieve a stable plantigrade foot for limited community ambulation with relatively few complications.     

Functional outcome after blade plate reconstruction of distal tibia metaphyseal nonunions: a study of 11 cases

OBJECTIVES: To present the functional outcome of a cohort of 11 patients prospectively followed before and after blade plate reconstruction of a distal tibia metaphyseal nonunion. DESIGN: Prospective case series. SETTING: University hospital tertiary referral center. PATIENTS: Eleven patients with an average age of 48 years. Average duration of nonunion was 11 months. Patients had undergone an average of 3.1 procedures before the index surgery. Three patients had prior deep infections, and one patient had an active infection. INTERVENTION: A precontoured 4.5-mm cannulated blade plate was applied to the medial tibial surface through a posteromedial approach. Autograft was added in eight patients to fill bone voids. MAIN OUTCOME MEASURES: AOFAS scores were assigned to each patient preoperatively and at most recent follow-up. RESULTS: All patients healed their nonunions after the index surgery. Average time to radiographic union was 16 weeks. Average time to full weight bearing was 12 weeks. AOFAS scores improved in all patients from an average preoperative score of 29 to an average postoperative score of 89. The only complication was a deep infection, which was treated successfully with one irrigation and débridement and 6 weeks of intravenous antibiotics. CONCLUSION: Blade plate reconstruction of distal tibia metaphyseal nonunion is a safe and reliable method that results in a high union and low complication rate.     

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

IntroductionThere are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy.Presentation of caseThe patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws.DiscussionThe patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain.ConclusionWe reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach.     

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.     

踝关节镜监视下微创治疗胫骨Pilon骨折

目的探讨在关节镜监视下微创钢板内固定技术治疗胫骨Pilon骨折的临床疗效.方法采用关节镜监视下小切口撬拨复位、微创经皮钢板固定技术（MIPPO）治疗32例胫骨Pilon骨折患者.结果所有病例创口愈合良好，均在术后2周拆线.27例获得随访，时间3～19（9．5±6．2）个月.骨折临床愈合时间为8-17（10．3±3．7）周，无骨折不愈合：随访X线显示骨折对位对线良好，无畸形愈合：植骨区骨痂生长良好，新生骨与植入骨紧密结合.3例胫骨远端关节面尚不平整，出现轻度骨关节炎的表现，1例主诉长距离行走后踝关节肿痛.按Mazur等踝关节症状和功能评分系统进行疗效评定：优14例，良12例，可1例.结论关节镜监视下小切口撬拨复位，尽可能使重建后的踝关节面接近正常解剖．可防止创伤性踝关节炎的发生，临床效果满意．     

Technic and results of covered ankle joint arthrodesis with autocompression angle plates

In 1973, Mittelmeier introduced a new technique of arthrodesis of the ankle joint by internal osteosynthesis using an autocompression plate with additional compression screwing of fibula to tibia and talus in order to avoid the disadvantages of previous operative methods of arthrodesis by bone splinting or external fixation (longer cast immobilisation, handicap by external fixator, danger of bone hole osteomyelitis a.o.). Regarding this new technique, the fibula works as a petiolated well vascular bone chip which bridges the joint. Representation of the special operative technique of covered autocompression arthrodesis of the upper ankle joint rsp. - in case of special indication - the combined arthrodesis of the upper and lower ankle joint. Representation of our casuistry of 43 patients who underwent this operation. With the exception of one case (osteomyelitis recidivation with following pseudarthrosis) a fast bony consolidation of the arthrodesis was achieved. In the meantime the osteosynthesis material is removed in 35 cases. One third of the patients gets along with conventional shoes.     

Ankle arthrodesis with bone graft after distal tibia resection for bone tumors

BACKGROUND: Treatment of distal tibial tumors is challenging due to the scarce soft tissue coverage of this area. Ankle arthrodesis has proven to be an effective treatment in primary and post-traumatic joint arthritis, but few papers have addressed the feasibility and techniques of ankle arthrodesis in tumor surgery after long bone resections. MATERIALS AND METHODS: Resection of the distal tibia and reconstruction by ankle fusion using non-vascularized structural bone grafts was performed in 8 patients affected by malignant (5 patients) or aggressive benign (3 patients) tumors. Resection length of the tibia ranged from 5 to 21 cm. Bone defects were reconstructed with cortical structural autografts (from contralateral tibia) or allografts or both, plus autologous bone chips. Fixation was accomplished by antegrade nailing (6 cases) or plating (2~cases). RESULTS: All the arthrodesis successfully healed. At followup ranging from 23 to 113 months (average 53.5), all patients were alive. One local recurrence was observed with concomitant deep infection (a below-knee amputation was performed). Mean functional MSTS score of the seven available patients was 80.4% (range, 53 to 93). CONCLUSION: Resection of the distal tibia and arthrodesis of the ankle with non-vascularized structural bone grafts, combined with autologous bone chips, can be an effective procedure in bone tumor surgery with durable and satisfactory functional results. In shorter resections, autologous cortical structural grafts can be used; in longer resections, allograft structural bone grafts are needed.     

Subtalar arthrodeses and arthrodeses of the ankle joint (author's transl)

We present a check-up study of five arthrodeses of the ankle joint and five subtalar arthrodeses. The arthrodeses of the ankle joint were indicated because of hard pains after bimalleolar fractures and fractures of the pilon tibial. Subtalar arthrodeses were indicated in posttraumatic arthritis of the calcaneus after intraarticular fractures of the calcaneus. Resection-compression-arthrodesis following Charnley was used for the ankle joint, subtalar arthrodesis was done by the technic of using a corticocancellous bone graft from the iliac crest. With an average postoperative follow-up period of four years four from five patients in every group had a good results. In cases clear indication the early arthrodesis should be preferred.     

手法复位空心螺钉固定治疗儿童胫骨远端三平面骨折

目的 评估采用手法复位、经皮空心螺钉固定方法治疗儿童胫骨远端三平面骨折的疗效.方法 2004年9月至2009年3月,采用手法复位、空心螺钉固定方法治疗胫骨远端三平面骨折15例.男9例,女6例.术前经X线片或CT检查确诊.全部病例均为闭合性骨折,经手法复位治疗失败(X线片上骺板及关节面骨折间隙＞2mm)后行手术治疗.手术在"C"型臂X线机监视下进行,行踝关节轴向牵引,根据骨折类型内旋或外旋足,达到解剖复位后行经皮空心螺钉固定.术后行CT检查,确定骨折解剖复位,骺板及关节面骨折间隙＜2mm.术后石膏托固定8周.以改良Weber评估标准评价踝关节功能及愈合情况.结果 全部病例随访15-68个月,平均26个月.末次随访时按改良Weber评分,优13例,良2例.X线片检查所有病例均骨性愈合,未发现骨桥形成及关节面不平整现象,无肢体旋转和短缩畸形.所有患儿均能参加正常的体育活动.2例结果为良的患儿均与负重过早有关,主要表现为充分用力时患侧踝关节有轻度疼痛感.结论 对于闭合性胫骨远端三平面骨折手法复位失败者,采用手法复位、经皮空心螺钉固定方法手术操作简单,疗效满意.     

Tibio-talo-calcaneal fusion after limb salvage procedures—A retrospective study

BackgroundThe treatment of limb threatening trauma on the distal tibia or hindfoot often results in posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to present a case series of patients undergoing various techniques of joint fusion after bone reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by presenting options and treatment strategies.Patients and methodsEight patients (4 male, 4 female) after TTC arthrodesis as a definitive procedure after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this retrospective analysis. We included patients treated by external ring fixation (1 case), external fixation + wires (1 case), external fixation + screws (1 case) and intramedullary nailing (1 ante- and 5 retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess foot deformities in the lateral radiographic view and clinical results were presented.ResultsIndependent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures in the lateral radiographs showed values typical for a pes cavus tendency.ConclusionTibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde intramedullary nailing does provide acceptable results providing stability, low invasiveness and low infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring fixator may be necessary when the surgeon is confronted with large bone defects – often followed by a nailing after lengthening procedure. This study shows that limb preservation after limb threatening trauma with hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice with reasonable clinical results.Level of Evidence: IV, Case series     

Die tibiotalare Arthrodese mit dem Kompressionsmarknagel

OBJECTIVE: Arthrodesis of the ankle joint in proper position (neutral position in respect to flexion/extension, 5 degrees external rotation, 0-5 degrees of valgus). Pain-free weight bearing of the affected limb. INDICATIONS: Painful osteoarthritis of the ankle joint resistant to conservative approaches even in the presence of poor bone quality of the distal tibia such as after pilon fractures and osteoporosis. Failure of other methods of internal fixation. CONTRAINDICATIONS: Osteitis. Partial necrosis of the talar dome. Medullary canal of tibia not patent. SURGICAL TECHNIQUE: Lateral approach and resection of lateral malleolus. If the joint position is normal, removal of articular cartilage of tibia and talus. If axial correction is necessary, wedge resection of articular surfaces with underlying bone. Opening of proximal tibial medullary canal, insertion of compression nail into tibia and talus. Compression osteosynthesis and cancellous bone grafting. Alternatively, the arthrodesis can be achieved with the dowel technique. RESULTS: Between September 1993 and March 2001, 137 patients (43 women, 94 men, average age 49 years [21-79 years]) were operated. Follow-up of 110 patients after 42 months: successful bony fusion in 99 patients (90%). In six patients (5.5%) the goal of treatment was obtained after revision with recompression of the nail and bone grafting. Nonunion in five patients (4.5%). Complications: one tibial shaft fracture, one hematoma needing evacuation, three superficial infections, and eight deep infections. Three patients developed an osteoarthritis of the subtalar joint. 70 patients (63.6%) reported an improvement, 37 (33.6%) no notable change of symptoms, and three (2.7%) a deterioration.     

不同方法固定胫骨不稳定 pilon 骨折的生物力学研究

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

Reconstruction of distal tibia fractures using a posterolateral approach and a blade plate

OBJECTIVE: The aim of this article is to report a technique for the management of distal tibia fractures with significant anteromedial soft-tissue injury. The patients were initially treated with a spanning external fixator, open reduction and internal fixation (ORIF) of the fibula at the discretion of the surgeon, and soft-tissue management or flap coverage. ORIF of the tibia was performed on a staged basis, using a 90-degree cannulated blade plate and autogenous iliac crest bone graft through a posterolateral approach. DESIGN: Retrospective analysis of a consecutive series of patients. SETTING: Two academic level-1 trauma centers. PATIENTS: Fifteen patients with 15 distal tibia fractures (13 open fractures), Orthopedic Trauma Association (OTA) type 43A3 and 43C1, were definitively treated and followed to union between July 2000 and July 2004. Five patients were referred from outside sources after initial stabilization. INTERVENTION: Initial stabilization in an external fixator and management of the open fracture and soft tissue. Staged ORIF of the tibia with bone graft was performed through a posterolateral approach when the soft tissues allowed. OUTCOME MEASUREMENTS: Radiographic union, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and complications. RESULTS: All 15 fractures were followed to union. Average time to union was 20 (12 to 47) weeks from the time of fixation with blade plate and bone grafting. (AOFAS) ankle-hindfoot score was used to measure outcome. The average score was 81 (60 to 97) out of a possible 100. There were no deep infections. There was one nonunion; the fracture united after revision with a locked plate and bone graft. The average length of follow-up was 14 months (4 to 37). CONCLUSIONS: The staged treatment of high-energy distal tibia fractures with soft-tissue injury can lead to good outcomes and consistent bone union. Our results were obtained by the combination of the posterolateral approach, careful soft-tissue management, and stable internal fixation.     

Arthrodesis for ankle osteoarthritis after harvesting of free vascularized fibular bone: a case report

Introduction Although free vascularized fibular bone grafting is a good method for the reconstruction of large bone defects, it might cause morbidity of the donor leg. Progression of ankle osteoarthritis, valgus deformity and instability of the donor leg subsequently leading to arthrodesis has rarely been reported. Materials and methods A 53-year-old man suffered from a left tibial comminuted and Gustilo type IIIb open fracture. A folded free vascularized osteoseptocutaneous flap was harvested from the right fibula and transferred to the left tibial bone defect. After the reconstructive surgery, the patient obtained a solid union of the left tibial shaft uneventfully. Ten years later, he suffered intermittent pain on his right ankle. Plain radiographs revealed progressive tibiotalar osteoarthritis. Right ankle arthrodesis with crossed cannulated screws fixation and osteosynthesis of the fibula to the tibia and talus were performed. However, this procedure failed due to a deep infection and osteomyelitis. A revision of the failed ankle fusion was performed by using a vascularized iliac bone flap to strut the anterolateral aspect of the tibiotalar bone defect. A ventral plate fixation and supplementary onlay bone grafting were applied across the anterior aspect of the tibiotalar joint. At the 2-year follow-up, the patient had no pain and resumed his regular daily activities. Conclusions Harvesting of the fibula may cause longterm ankle osteoarthritis that requires ankle arthrodesis. In revision arthrodesis a ventral plate fixation and vascularized iliac bone flap may be the treatment of choice, neutralizing the large moment due to the long lever arms.     

A Systematic Review Of Primary Ankle Arthrodesis In The Treatment Of Pilon Fractures

BackgroundPilon fractures are severe, intra-articular and comminuted fractures to the distal tibia. They are uncommon injuries and are often associated with fibular fractures. The optimal management of these fractures is widely debated. Open reduction and internal fixation (ORIF) and external fixation have been used to treat these fractures. Ankle arthrodesis is often used in the latter stages of management for end-stage ankle arthritis. The aim of this systematic review was to identify the outcomes associated with using primary ankle arthrodesis in pilon fractures.MethodsOvid Medline and PubMed were searched from the inception of their databases until October 2018. Eligible literature for use in our review included patient cohorts that had been operated in the form of primary ankle arthrodesis. All relevant data was included that met the inclusion criteria. The demographic of the patients with pilon fractures and this operative management were identified. The outcomes of interest were fusion rate, infection rate, length of follow-up and patient reported outcomes. 8 papers were deemed eligible for review.ResultsOf the 8 papers that were eligible, 6 were retrospective studies, 1 was a case report and 1 was an abstract. There were a total of 109 patients included. Fusion rate was 100% in 5 of the studies. 6 of the 7 studies that reported on infection rate had no post-operative infections. Outcome assessment scores were used in 5 of the studies. The SF-36 score, the FOAS and the AOFAS were used.ConclusionsThis review shows that primary ankle arthrodesis yields reasonable results in the management of pilon fractures. However, the quantity and quality of current literature is not sufficient and further studies with larger cohorts and longer follow-up times are warranted.