Results and outcomes after operative treatment of high-energy tibial plafond fractures.
ABSTRACT The purposes of this study were to evaluate the clinical and radiographic results and the functional outcomes after operative treatment of tibial plafond fractures treated with internal or external fixation.
A retrospective review identified 76 patients with 79 fractures (OTA 43-B or 43-C) of the tibial plafond. Their average age was 45 years. Twenty-one fractures (27%) were open, and 43 (54%) were type 43-C3. Five were type 43-B1, four were 43-B2, two were 43-B3, 15 were 43-C1, and 10 were 43-C2. Patients were treated with open reduction and internal fixation (ORIF) (n = 63) or limited open articular reduction and wire ring external fixation (EF) (n = 16). Tibial fixation was performed at a mean of 7.6 days after injury, with staged reconstruction in 56 fractures (71%). Bone graft was used initially in 32 fractures (41%). Early and late complications, secondary procedures, and radiographic evidence of post-traumatic arthritis were evaluated. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered.
Seventy-nine fractures were followed clinically and radiographically for a mean of 26 (range 24 to 38) months, and 33 patients completed outcomes questionnaires at a mean of 98 months after surgery. Early complications included two superficial wound problems and three deep infections. Late complications included two nonunions and four malunions. Thirty-one fractures (39%) developed post-traumatic arthritis. Complications occurred after six of 21 open fractures and after 11 of 43 type C3 fractures (p = 0.007). Patients treated with EF more frequently had type C3 fractures (88% versus 46%, p = 0.004) compared with patients treated with ORIF. The EF patients developed more complications (six of 16, p = 0.007) and post-traumatic arthritis (11 of 16, p = 0.01) when compared with ORIF. Patients treated with EF (88% were type C3 fractures) had lower FFI and MFA scores. The greatest impairment in outcome was noted after type C3 fractures, regardless of the method of treatment.
Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.
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ABSTRACT: The purpose of this study is to evaluate clinical results and outcomes of a strict cohort of high-energy injuries of the metaphyseal distal tibia with minimal or no intraarticular involvement treated using the minimally invasive plating concept. Level II trauma center. Retrospective analysis of a consecutive case series with limb-specific and whole-person outcomes measures. Minimally invasive medial plating for high-energy metaphyseal fractures of the distal tibia with little or no intraarticular involvement. Clinical and radiographic results were assessed at a minimum of 1 year, and outcomes measures were applied at final follow-up at a minimum of 2 years. Limbs were assessed with the American Orthopaedic Foot and Ankle Surgeons (AOFAS) ankle-hindfoot instrument and the method of Olerud and Molander. Patient outcomes were evaluated with the Short Form-36 (SF-36) and the Musculoskeletal Functional Assessment (MFA). Twenty-six patients were followed until healed at an average of 36 months (12-56 months). Mean fracture healing time was 35 weeks (12-112 weeks) with acceptable alignment restored (angulation<or=5 degrees or shortening<or=1 cm) in all but 1 case. Two patients (7%) had loss of fixation and 9 (35%) underwent secondary surgeries to achieve union. Risk factors for healing problems included high grades of fracture comminution, bone loss, and high-grade open injuries (P<0.05). SF-36 outcomes scores in 21 patients at >2 years were comparable to normative data of patients with uninjured limbs, whereas MFA results showed functional deficits in 4 of 10 subsections. Minimally invasive medial plating will restore limb alignment and yield successful clinical outcomes for high-energy metaphyseal fractures of the distal tibia. Despite the significant reoperation rate and prolonged time to union, most patients can expect a predictable return of function. Strong consideration should be given to adjunctive measures in at-risk patients, including those with highly comminuted fracture patterns, bone loss, or Type II or III open fractures.Journal of Orthopaedic Trauma 08/2007; 21(6):355-61. DOI:10.1097/BOT.0b013e3180ca83c7 · 1.54 Impact Factor
- The Journal of Bone and Joint Surgery 11/2007; 89 Suppl 3(suppl 3):15-28. DOI:10.2106/JBJS.G.00544 · 4.31 Impact Factor
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ABSTRACT: Intra-articular fractures of the tibial plafond are complex injuries which continue to challenge orthopaedic surgeons in achieving anatomic reduction, while allowing early weight bearing and return to activity. Although a wide range of treatment options has been described for fixation of pilon fractures, the unique characteristic of each injury makes it difficult to advocate a general method of choice. We have attempted to compare a subset of AO/OTA type C pilon fractures treated either by a staged procedure of external fixation and conversion to open reduction and internal fixation (ORIF) versus definitive external Ilizarov fixation. Between 1998 and 2004, 42 patients admitted to our level 1 trauma centre underwent either procedure and were followed prospectively. Twenty-eight patients were treated with ORIF and 14 were treated by Ilizarov ring fixator. The outcome measures included time to union, as well as the rates of union, nonunion, malunion and infection. Although the ORIF group had a longer time to heal, the rates of nonunion, malunion and infection were lower compared to the Ilizarov group. However, these differences between the groups were not statistically significant. Thus, based on these results, no clinical recommendation can be made as to which procedure is better and safer for the patient. Future prospective randomised trials are required to determine with more scientific accuracy the optimal treatment strategy for these challenging injuries.Injury 03/2008; 39(2):196-202. DOI:10.1016/j.injury.2007.09.003 · 2.46 Impact Factor