1343 Post-Operative Outcomes of Circular External Fixation in The Treatment of Tibial Plafond Fractures: A Systematic Review

Introduction Tibial plafond fractures (TPF) are uncommon but potentially devastating injuries to the ankle. Meticulous care of the associated soft tissue injury is imperative in managing these fractures. The reported benefits of circular external fixation (CEF) include the ability to affect fracture reduction and create stable fixation, while limiting further soft tissue insult. This article provides the systematic review of the clinical and functional outcomes of TPF treated definitively with CEF. Method A literature search from inception to 13th November 2020 was performed. Quality and risk of bias was assessed using standardised scoring tools. Results 16 studies were included. 303 patients were analysed. Mean follow-up was 35 months. The mean time in CEF was 18 weeks and mean time to union was 21 weeks. Non-union and malunion occurred in 3.2% and 12.4% respectively. The overall complication rate was 12.3%. The rate of deep infection was 4.8%. No amputations were reported. Minor soft tissue infection (including pin site infections) accounted for 56.7% of complications. Almost two-thirds achieved good-to-anatomic reduction radiologically. Mean range of motion assessments were 11.8 and 24.8 degrees in dorsiflexion and plantarflexion, respectively. Approximately one-third reported excellent functional outcome scores. Quality of the studies was deemed satisfactory. A moderate risk of bias was acknowledged. Conclusions This systematic review provides an evidence-based summary, which highlights CEF as an acceptable treatment option with comparable complication rate and outcome scores to that of internal fixation. However, we acknowledge that high quality evidence is still lacking.

Outcomes and Complications With Treatment of Open Tibial Plafond Fractures With Circular External Fixator

Background: Open tibial plafond fractures (Orthopaedic Trauma Association and AO Foundation [OTA/AO] 43) are associated with severe complications, including deep infection (closed fractures, 20%; open fractures, 30%), amputation (3%-14%), and nonunion (up to 25%). Circular external fixators (CEFs) can minimize soft tissue injury. This study aimed to report the rate of union and occurrence of severe complications in patients with open tibial plafond fractures treated with CEFs. Methods: A retrospective review of case series was conducted at 3 level I trauma centers. The study included patients older than 18 years with open tibial plafond fractures treated with CEFs. The reported outcomes included union rate, deep infection, operative complications, and limb alignment. The radiographic measurements of anatomic alignment were obtained. Fifty-two patients were included in the study. Results: The primary union rate was 79%. No deep infection occurred in the majority (92%) of patients. No patient required amputation of the affected limb or free flap coverage. Conclusion: Definitive fixation of open tibial plafond fractures with CEFs avoided severe soft tissue complications but resulted in variation in final radiographic alignment. Level of Evidence: Level IV, case series.

A fibular notch approach for the treatment of ankle fractures involving the distal tibial plafond

Background Although efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here, we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes. Methods Twenty-two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment. Results All surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3 ± 3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last follow-up. Conclusions The fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

A Fibular Notch Approach for the Treatment of Ankle Fractures Involving the Distal Tibial Plafond

BACKGROUND: Although efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes.METHODS: Twenty two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment.RESULTS: All surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3±3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last followup.CONCLUSIONS: The fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

Independent Inter- and Intra-Rater Reliability of the New AO and Leonetti/Tigani Systems for Pilon Fractures based on CT-Scan

Category: Basic Sciences/Biologics; Trauma Introduction/Purpose: There is still no consensus regarding which is the best classification system for the management of tibial plafond fractures. The goal of this study is to perform a independent agreement evaluation to compare two recently published systems: Leonetti/Tigani and the new AO classification. Methods: Seventy-five patients with tibial plafond fracture and preoperative CT scan were included. Six raters with different level of expertise (two foot and ankle surgeons and three orthopedic surgery residents) classified the fractures using CT scans according to the morphological grading of both systems. The Leonetti/Tigani classification system considers four types (I, II, III and IV) and six subtypes (I, IIF, IIS, IIIF, IIIS, IV). The AO system considers three types (A, B, C) and nine subtypes (A1, A2, A3, B1, B2, B3, C1, C2, C3). After six weeks all cases were randomly re-evaluated by the same raters. The kappa coefficient (κ) was used to determine the degree of reliability. Results: Inter-observer reliability: strong using the Leonetti/Tigani classification system considering types, with a κ of 0,65 (0,60 - 0,69), and subtypes, with a κ of 0,62 (0,58 - 0,66). Reliability for the AO system was strong considering types with a κ of 0,72 (0,66 - 0,78), but moderate when including subtypes with a κ of 0,54 (0,50 - 0,57). Intra-rater reliability: Almost perfect using the Leonetti/Tigani classification considering both types and subtypes with a κ of 0,94 (0,88- 1,01) and 0,94 (0,89- 0,96), respectively. Reliability for the AO system was almost perfect considering types with a κ of 0,83 (0,75- 0,92), but strong when including subtypes with a κ of 0,61 (0,57- 0,66). No statistically significant difference between different levels of expertise. Conclusion: The system proposed by Leonetti/Tigani demonstrated a strong and almost perfect inter and intra-rater reliability, respectively. Although the new AO classification has a strong inter-rater reliability when including the main categories, it only reached a moderate reliability when including subtypes.