Treatment of AO/OTA 43-C3 Pilon Fracture: Be Aware of Posterior Column Malreduction

Treatment of pilon fractures remains challenging due to the difficulty of fracture reduction and associated soft tissue complications. The aim of this study was to evaluate the pitfalls and strategies of posterior column reduction in the treatment of complex tibial pilon fractures (AO/OTA 43-C3). Thirteen AO/OTA classification 43-C3 type pilon fractures treated between January 2013 and January 2016 were retrospectively analyzed. Nine cases were treated by external fixation within 26 hours (range, 6–56 hours) after injury. The definitive open reduction and internal fixation (ORIF) was performed after the wound was healed without infection and soft tissue swelling had subsided. During the delayed/second-stage operation, the articular surface of the distal tibial plafond was reduced through the posterolateral and anterior approaches. X-ray and CT scans were performed pre- or postoperatively. The reduction quality was evaluated using Burwell–Charnley’s radiographic criteria. The follow-up was performed routinely and all complications were recorded. Ankle function was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. During the delayed/second-stage operation, primary reduction of the posterior column was performed entirely through posterolateral approaches. However, poor posterior column reduction was revealed by fluoroscopy in four cases, three of which were readjusted through the posterolateral and anterior approaches, and the fourth was adjusted directly through the anterior approach. Postoperative CT scan revealed that the step-off of the articular surface was less than 2 mm in 12 cases, and in only one case the step-off was greater than 2 mm but less than 5 mm. The satisfactory rate was 92.3% according to Burwell–Charnley’s reduction criteria. Eleven patients were followed up regularly; superficial infections occurred in two cases but healed after wound care treatment in 3 and 5 weeks, respectively. All eleven fractures were healed within an average of 3.6 months (range, 2.6–5 months). The average range of ankle motion was 19° of dorsiflexion and 28° of plantar-flexion. The mean AOFAS ankle-hindfoot score was 82 (range, 61–92). In our opinion, we suggest that the reduction of the articular surface should be performed through combined posterolateral and anterior approaches in a delayed operation, with flexible fixation of the posterior column. If the posterior column is poorly reduced, the articular surface can easily be manipulated through anterior approaches. According to this strategy, satisfactory outcomes of AO/OTA C3 pilon fractures would be anticipated.

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Tips and Tricks in surgical reduction of the posterior column of AO/OTA C3 pilon fractures

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04890-6 ◽

2022 ◽

Vol 23 (1) ◽

Author(s):

Moran Huang ◽

Qiuke Wang ◽

Junjie Guan ◽

Kexin Liu ◽

Yunfeng Chen ◽

...

Keyword(s):

Posterior Column ◽

Posterolateral Approach ◽

Foot And Ankle ◽

Two Stage ◽

Aofas Score ◽

Second Stage ◽

Controversial Topic ◽

The Mean ◽

Ankle Function ◽

Pilon Fractures

Abstract Background Accurate posterior column reduction remains a challenging and controversial topic in the management of complex pilon fractures (AO/OTA C3). We aim to report the outcomes of surgical treatment for 22 AO/OTA C3 pilon fracture cases between January 2015 and May 2017 and highlight some traps and tips. Methods Three patients underwent two-stage early plating on the posterior column through a posterolateral approach. The remaining 19 patients were treated with two-stage delayed plating on the posterior column: 11 patients were treated with a posterolateral approach, five patients with a modified posteromedial approach, and three patients with a single anterior approach. The reduction of the posterior column was evaluated according to the Burwell-Charnley’s radiographic criteria, and functional outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scores. Results Posterior column malreduction occurred in five cases, including in one case that was re-adjusted immediately and in another case that was re-adjusted during a two-staged delayed operation. According to Burwell-Charnley’s criteria, the satisfactory rate of fracture reduction was 81.8%. After 1 year, the mean AOFAS score was 81.9 (81.9 ± 9.9); the outcome was excellent in three (20.0%), good in nine (60.0%), and fair in three (20.0%). Excellent or good outcomes were noted in 12 patients (80.0%). Conclusions The combined anterior and posterior approach is suggested in the second stage of plating so that the posterior column fragments can be re-adjusted intraoperatively, if necessary. Following these procedures, satisfactory reduction and recovery of good ankle function can be anticipated.

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Open Reduction Internal Fixation versus External Fixation with Limited Internal Fixation for Displaced Comminuted Closed Pilon Fractures: A Randomised Prospective Study

Journal of Orthopaedics Trauma and Rehabilitation ◽

10.1016/j.jotr.2017.08.001 ◽

2018 ◽

Vol 24 (1) ◽

pp. 84-89

Author(s):

Rayan Ahmed ◽

Kotb Ahmed ◽

M. Elmoatasem Elhussein ◽

Samir Shady ◽

Tamer A. El-Sobky ◽

...

Keyword(s):

Soft Tissue ◽

Prospective Study ◽

Internal Fixation ◽

External Fixation ◽

Functional Outcomes ◽

Open Reduction ◽

Articular Surface ◽

High Energy ◽

Complication Rates ◽

Pilon Fractures

Background Pilon fractures involve the dome of the distal tibial articular surface. The optimal treatment for high-energy pilon fractures remains controversial. Some authors advocate the use of open reduction and internal fixation (ORIF) to avoid articular incongruence. Others advocate the use of bridging external fixation with limited internal fixation (EFLIF) to reduce soft tissue complications. Literature reports of prospective studies comparing the radioclinical outcomes of ORIF and EFLIF in high-energy fractures are scarce. Retrospective studies have their limitations because of insufficient randomisation. The objective of this randomised prospective study is to compare the clinical, radiologic and functional outcomes of displaced and comminuted closed pilon fractures, Rüedi and Allgöwer type II and III, treated by either ORIF or EFLIF. Materials and Methods Forty-two patients were selected for the study. Twenty-two patients were subjected to ORIF and 20 patients were subjected to EFLIF. We used the American Orthopaedic Foot and Ankle Society score as a standard method of reporting clinical status of the ankle. Patients were followed-up clinically and radiologically for over 2 years after the surgical treatment. Results The results of ORIF and EFLIF in treatment of high-energy pilon fractures are equally effective in terms of functional outcomes and complication rates on the short term. Conclusion Soft tissue integrity and fracture comminution seem to have a significant influence on outcomes of intervention. A prospective multicentre study with a larger sample size that controls for other associated variables and comorbidities is warranted. Level of evidence Level II.

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Intra- and interobserver agreement on the Oestern and Tscherne classification of soft tissue injury in periarticular lower-limb closed fractures

Colombia Medica ◽

10.25100/cm.v45i4.1476 ◽

2014 ◽

pp. 173-178 ◽

Cited By ~ 9

Author(s):

Carlos Oliver Valderrama-Molina ◽

Mauricio Estrada-Castrillón ◽

Jorge Andres Hincapie ◽

Luz Helena Lugo-Agudelo

Keyword(s):

Soft Tissue ◽

Tibial Plateau ◽

Interobserver Agreement ◽

Soft Tissues ◽

Tissue Injury ◽

Soft Tissue Injury ◽

Case Series ◽

Lower Extremities ◽

Tibial Pilon ◽

Pilon Fractures

Background: The soft tissues injury in periarticular fractures of the lower extremities determines the proper time to perform bone fixation. Objetive: The aim of this study was to determine the intra and interobserver agreement in the Tscherne classification. Methods: This is a descriptive, prospective study for patients admitted to the Pablo Tobón Uribe Hospital (PTUH) with tibial plateau or tibial pilon fractures. We performed a standardize evaluation using video photography at the time of admission and 24, 48, and 72 h after admission. Fifteen five reviewers who had various levels of training produced a total of 1,200 observations. The intra- and interobserver agreement was assessed using a weighted kappa for multiple raters and more than two categories. Results: Twenty patients were admitted with tibial plateau and tibial pilon fractures. The intraobserver agreement for all 15 raters was kappa 0.81 (95% CI 0.79-0.83), and the interobserver agreement for all 15 raters was kappa 0.65 (95% CI 0.55-0.73). The interobserver agreement at 24 h was kappa 0.67 (95% CI 0.46-0.86). Conclusions:Classifying the severity of soft tissue injury is critical in planning the surgical management of fractures of the lower extremities. Based on our results, we can reasonably argue that the Tscherne classification produced an adequate level of agreement and could be used to standardize and to guide the treatment, and to conduct research studies. Level of Evidence: Level IV, Case Series

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A Operative Treatment of the Tibial Pilon Fractures : For minimize soft tissue injury

Journal of the Korean Fracture Society ◽

10.12671/jksf.1997.10.2.346 ◽

1997 ◽

Vol 10 (2) ◽

pp. 346

Author(s):

Jae Do Kang ◽

Kwang Yul Kim ◽

Hyung Chun Kim ◽

Moon Sub Yim ◽

Sang Hoon Ko

Keyword(s):

Soft Tissue ◽

Operative Treatment ◽

Tissue Injury ◽

Soft Tissue Injury ◽

Tibial Pilon ◽

Pilon Fractures

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Soft Tissue Management of Closed Tibial Pilon Fractures

Techniques in Orthopaedics ◽

10.1097/bto.0000000000000052 ◽

2014 ◽

Vol 29 (1) ◽

pp. 2-7

Author(s):

John S. Early ◽

Shay Tenenbaum

Keyword(s):

Soft Tissue ◽

Soft Tissue Management ◽

Tibial Pilon ◽

Pilon Fractures

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Multifragmentary Tibial Pilon Fractures: Midterm Results After Osteosynthesis with External Fixation and Multiple Lag Screws

The Open Orthopaedics Journal ◽

10.2174/1874325001206010419 ◽

2012 ◽

Vol 6 (1) ◽

pp. 419-423 ◽

Cited By ~ 3

Author(s):

Johannes Kiene ◽

Jan Herzog ◽

Christian Jürgens ◽

Andreas Paech

Keyword(s):

Wound Healing ◽

High Risk ◽

Soft Tissue ◽

External Fixation ◽

Tissue Damage ◽

Soft Tissue Damage ◽

Tibial Pilon ◽

Comminuted Fractures ◽

Severe Soft Tissue ◽

Pilon Fractures

Osteosynthesis of intraarticular tibial pilon fractures is preferably achieved using locking plates via a minimally invasive technique. If combined with severe soft tissue damage there is a high risk of wound-healing deficits after plate osteosynthesis. Thus our aim was to find an alternative method of treatment for those cases with combined soft tissue injuries. We report on five cases with comminuted fractures of the joint surface combined with critical soft tissue condition that were treated with lag screws and external fixation (AO) applied across the ankle joint. All five patients were followed up, undergoing clinical and radiological examination. Using this approach we achieved fracture healing of comminuted fractures without further complications. Clinical follow-up after an average of 55.6 (36–75) months revealed a mean AOFAS score of 81 (62–100). We therefore propose combined treatment using lag screws with external fixation as a practical treatment option for those fractures for which lag screws combined with a locking plate are not feasible or when there is a high risk of wound-healing deficits due to severe soft tissue damage.

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

International Orthopaedics ◽

10.1007/s00264-003-0486-1 ◽

2003 ◽

Vol 27 (6) ◽

pp. 343-347 ◽

Cited By ~ 48

Author(s):

J. Conroy ◽

M. Agarwal ◽

P. V. Giannoudis ◽

S. J. E. Matthews

Keyword(s):

Soft Tissue ◽

Internal Fixation ◽

Tibial Pilon ◽

Soft Tissue Cover ◽

Pilon Fractures

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Management of Pilon Fractures—Current Concepts

Frontiers in Surgery ◽

10.3389/fsurg.2021.764232 ◽

2021 ◽

Vol 8 ◽

Author(s):

Olivia Mair ◽

Patrick Pflüger ◽

Kai Hoffeld ◽

Karl F. Braun ◽

Chlodwig Kirchhoff ◽

...

Keyword(s):

Soft Tissue ◽

Distal Tibia ◽

High Energy ◽

Classification Systems ◽

Early Years ◽

Long Term Outcome ◽

Soft Tissue Envelope ◽

Tibial Pilon ◽

Axial Forces ◽

Pilon Fractures

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.

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Ankle Motion after External Fixation of Tibial Fractures

Journal of the Royal Society of Medicine ◽

10.1177/014107688808100109 ◽

1988 ◽

Vol 81 (1) ◽

pp. 19-21 ◽

Cited By ~ 3

Author(s):

G J Taylor ◽

R L Allum

Keyword(s):

External Fixation ◽

Plantar Flexion ◽

Tibial Fractures ◽

Ankle Motion ◽

Ankle Movement ◽

The Mean ◽

The Difference ◽

Tissue Trauma ◽

Ankle Function

Loss of ankle movement is a complication of severe tibial fractures. This can be exacerbated if the foot is allowed to drop into equinus, particularly when an external fixator is employed. The range of ankle motion following external fixation of tibial fractures as compared to the opposite normal ankle was studied in 40 of 55 patients treated over a ten-year period. Nine were excluded due to other causes of ankle stiffness, leaving 31 cases for analysis. The mean follow up was 2 years 7 months (range 1 year to 8 years 3 months), and union had occurred by a mean of 35 weeks (range 9–100 weeks). The mean loss of ankle movement was 8° of plantar-flexion and 12° of dorsiflexion (overall loss 20°), the difference between the two being highly significant (P> 0.001, t test). Loss of ankle motion closely paralleled the degree of soft tissue trauma, being 6° for closed fractures and 22° for open fractures (0.05 > P> 0.02). Ankle function is therefore at risk when a severe tibial fracture is treated by external fixation, and appropriate measures should be taken to preserve movement and prevent an equinus contracture.

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