Tratamiento mínimamente invasivo/percutáneo de fracturas de pilón tibial con asistencia artroscópica en Hospital Regional de Talca / Minimally invasive/percutaneous treatment of tibial pilon fractures with arthroscopic assistance at the Regional Hospital

Tibial pilon fractures are a complex injury to treat due to the great involvement of soft and bone tissues. The classic surgical treatment is based on open reduction with internal fixation (ORIF), adding morbidity to the soft tissues, increasing the risk of complications. This has motivated the development of minimally invasive and/or percutaneous techniques to reduce complications, and with the advent of arthroscopy, achieve anatomical reductions. METHODS: A retrospective observational study of twelve patients with tibial pilon fractures who were treated in our center with minimally invasive and/ or percutaneous osteosynthesis with arthroscopic support was carried out between January 2019 and June 2021. Fractures were characterized using the AO/OTA classification for tibial pilon. Age, sex, fracture mechanism, exposure and initial management in the emergency department (cast immobilization or external fixation), definitive treatment, complications and clinical and functional evaluation twelve months after definitive osteosynthesis. For this last point, plantar flexion, dorsiflexion and the AOFAS and FAOS Score were measured. RESULTS: The operated patients were 12, 8 were men (67%) and 4 were women (33%). The average age was 49 (17-68) years. The definitive treatment was carried out after an average of 8 days (5-12 days). Surgical treatment schemes were as follows: percutaneous osteosynthesis with medial anatomical plate and arthroscopic support (OPAA), minimally invasive osteosynthesis with cannulated screws and arthroscopic support (OMIAA) and osteosynthesis with external circular guide and arthroscopic support (OTCAA). In the AOFAS Score, three patients had excellent results (≥ 90 points), 6 patients had good results (≥ 80 points) and 3 patients had acceptable results (≥ 70 points). In the FAOS Score, eight patients had over 80% (good results) and 4 patients had over 60% (accep - table results). DISCUSSION: Historically, tibial pilon fractures have been considered non-reconstructable and with poor long-term results. Initially this paradigm changed with the principles of Rüedi for the reconstruction of the tibial pilon and improve the results. ORIF has been widely used until today, it allows achieving an anatomical joint reduction, it allows to give stability and length to the fibula, graft contribution and sta - bilization with the medial plate. Today this concept is changing again, since the emphasis is on the care of the soft tissues to allow a better recovery of the patient and reduce the complications of the classic approach, it is in this context that the appearance of minimally invasive and/or percutaneous techniques with arthroscopic assistance has allowed us to have excellent functional and clinical results with less da - mage to the soft tissues. CONCLUSION: The proper management and care of the soft tissues in a high-energy fracture of the tibial pilon is essential to obtain favorable clinical results and thus achieve restoration of ankle function. Percutaneous and minimally invasive management has optimized management of the tibial pilon, redu - cing the rates of complications, amputation, and pri - mary arthrodesis.

Resultados del manejo quirúrgico en fracturas parciales de la tibia proximal / Results of surgical management in proximal partial tibia fractures

Introducción: Las fracturas parciales articulares proximales de la tibia son un gran desafío para el ortopedista por la sintomatología y la complejidad de su manejo. Objetivo: Describir los resultados del tratamiento quirúrgico de las fracturas articulares proximales de la tibia. Material y métodos: Se realizó un estudio descriptivo en un Hospital de Tercer Nivel de Atención. Se incluyó a pacientes con fractura articular parcial proximal tibial (Müeller AO/ASIF 41-B), ambos géneros, evolución postquirúrgica a seis meses, con expediente clínico completo. La evaluación postquirúrgica fue mediante la escala Orfaly & Keating. Utilizamos estadística descriptiva con medidas de tendencia central y dispersión, prueba de Fischer para riesgo relativo y regresión logística. Resultados: Fueron 25 pacientes. Edad promedio 41.6, (16-81), DE 17.03 años; 15 (60%) hombres, 10 (40%) mujeres; 1 (4%) con DM2; el lado más afectado fue el izquierdo 17 (68%); todos manejados quirúrgicamente con osteosíntesis; hubo concordancia al 100% del diagnóstico preoperatorio con el postoperatorio (Kappa 1.0); la evolución fue satisfactoria en 76%, aceptable en 24% (Orfaly & Keating), 16% con deformidad angular en valgo y 12% rigidez articular; mujeres con RR 1.33 (IC 0.869-2.045) deformidad angular en valgo, RR 0.22 (IC 0.27-1.846) rigidez articular, la osteosíntesis con placa en palo de hockey RR 2.68, osteosíntesis mínima RR 1.088 (IC 95% 0.7-3.1) para escala Orfaly & Keating no satisfactoria. Conclusión: Existe riesgo relativo positivo del género femenino para deformidad angular en valgo y del tratamiento con placa en palo de hockey y osteosíntesis mínima para evolución no satisfactoria de acuerdo a la escala Orfaly & Keating seis meses después de realizado el tratamiento quirúrgico.

Introduction: Proximal partial articular tibia fractures represent a great challenge for orthopedic surgeons due to their symptoms and complex management. Objective: To describe the results of surgical treatment of proximal articular fractures of the tibia. Material and methods: Descriptive study conducted at a tertiary care hospital. We included patients with proximal partial articular tibia fracture (Müeller AO/ASIF 41-B), of both sexes, with a six-month postoperative follow-up and a complete clinical record. Postoperative assessment was conducted with the Orfaly & Keating scale. We used descriptive statistics with central trend and scatter measurements, Fischer test for the relative risk and logistic regression. Results: The total number of patients was 25. Mean age was 41.6 (16-81), SD was 17.03 years; 15 patients were males (60%) and 10 females (40%); 1 (4%) had type-2 diabetes mellitus; the left side was affected in 17 (68%) patients; all patients underwent surgery with osteosynthesis; there was 100% match between the preoperative and postoperative diagnoses (Kappa 1.0); patient course was appropriate in 76% and acceptable in 24% (Orfaly & Keating); 16% had angular valgus deformity and 12% had joint stiffness. Females with RR 1.33 (CI 0.869-2.045) had angular valgus deformity; those with RR 0.22 (CI 0.27-1.846) had joint stiffness, RR was 2.68 for hockey stick plate osteosynthesis, and RR was 1.088 (CI 95%, 0.7-3.1) for the unsatisfactory course according to the Orfaly & Keating scale. Conclusion: A positive relative risk was found among females for angular valgus deformity, and in hockey stick plate osteosynthesis and minimal osteosynthesis for an unsatisfactory course, according to the Orfaly & Keating scale, six months after surgical treatment.

Análise da capacidade funcional de indivíduos submetidos a tratamento cirúrgico após fratura do planalto tibial / Assessment of the functional capacity of individuals submitted to surgical treatment after tibial plateau fracture

As fraturas articulares são consideradas graves e ocasionam incapacidade, principalmente quando atingem uma articulação de carga, como o joelho. É necessário tratamento imediato a fim de obter estabilização dos fragmentos, evitando complicações secundárias. O objetivo do presente estudo foi analisar a capacidade funcional, durante as atividades de vida diária, de indivíduos que sofreram fraturas do planalto tibial e foram submetidos a tratamento cirúrgico entre os anos de 2002 a 2005. Foram analisados 20 pacientes com a aplicação do questionário ADLS (Activities of Daily Living Scale). Concluímos que 85 por cento dos indivíduos apresentaram capacidade funcional próximo ao normal, de acordo com a pontuação estabelecida pela escala utilizada.

Joint fractures are regarded as serious, causing disability, especially when involving a load joint, as the knee. Early treatment is required in order to get stabilization of fragments, preventing the occurrence of secondary complications. The present study was aimed at assessing functional capacity during daily life activities, on individuals who experienced tibial plateau fractures and submitted to surgical treatment between the years 2002 to 2005. Twenty patients were assessed by using the ADLS questionnaire (Activities of Daily Living Scale). We concluded that 85 percent of the individuals presented close-to-normal functional capacity, according to the scale's scoring system.

Fracturas de pilón tibial: evaluación de resultados con diferentes métodos terapéuticos / Tibial pilon fractures: evaluation of results with different therapeutic methods

Las fracturas de pilón tibial son infrecuentes (1 por ciento del miembro inferior), su correcta interpretación imagenológica y clasificación son dificultosas, son técnicamente demandantes para el cirujano debido a la complejidad de la cirugía y difíciles de manejar tanto en el pre como en el postoperatorio por la gran cantidad de complicaciones existentes en este tipo de fracturas. En este trabajo se realizó un estudio descriptivo de corte transversal en 24 pacientes con fractura de pilón tibial en un periodo de 2 años (febrero 2002 a enero 2004 incluido), con el objetivo de presentar nuestros resultados con diferentes metodologías terapéuticas, donde 16 pacientes fueron tratados quirúrgicamente y 7 en forma incruenta. De los primeros, 10 presentaron buenos resultados, 1 regular y 5 malos. De los segundos, 2 obtuvieron buenos resultados y 5 malos. Basándonos en la clasificación AO (Asociación de Osteosíntesis), el tratamiento fue diferente según el tipo de fractura, todas las A1, un caso B2 y un caso C3 se trataron con yeso inguinopédico; al resto se les realizó osteosíntesis. En 1 caso se tuvo que realizar amputación infrapatelar, siendo este caso excluido de la evaluación. Nuestros resultados se debieron a que es una patología poco frecuente, al tiempo de internación (promedio 46 días) y a la demora en la provisión de los implantes solicitados.

Complicaciones en las fracturas complejas de la meseta tibial y factores asociados / Complications in complex fractures of the tibial plateau and associated factors

Objetivo: identificar factores asociados a complicaciones con el manejo quirúrgico de las fracturas complejas de la meseta tibial. Material y métodos: estudio de casos y controles. Muestra integrada con expedientes de 56 pacientes diagnosticados con fractura compleja de la meseta tibial (tipos IV, V y VI de Schatzker), tiempo de seguimiento promedio de 12.9 ± 3.2 meses (8 a 18), y con uno o más de los siguientes factores de riesgo: edad mayor de 50 años, comorbilidad, tiempo de isquemia mayor de 60 minutos y fractura tipo IV, V o VI. Se consideró caso al paciente que presentara una o más complicaciones. Resultados: la edad promedio fue de 50.1 ± 15.7 años (17 a 87); 35 pacientes (62.5 %) pertenecieron al sexo masculino. Los pacientes con o sin complicaciones mostraron homogeneidad respecto a edad, sexo, lado, tipo de fractura y tiempo de seguimiento; 41.1 % presentó antecedentes patológicos. En todos los procedimientos se utilizó torniquete neumático. El tiempo promedio de cirugía fue de 91 ± 27.2 minutos (40 a 175). Los tratamientos empleados fueron placa más tornillos (53.6 %), fijadores externos más tornillos (35.7 %), doble placa y clavo centromedular. 37.5 % desarrolló complicaciones: infección superficial, 16.1 %; deformidades angulares residuales, 10.7 % (varo, 7.1 %); lesión del nervio peroneo, 5.4 %, pseudoartrosis, 3.5 %; trombosis venosa profunda, 1.8 %. Presentó más de una complicación, 22.2 %. Conclusiones: los factores de riesgo asociados significativamente a complicaciones con el manejo de la fractura compleja de la meseta tibial, fueron la edad mayor de 60 años y el tiempo de isquemia transoperatoria mayor de 120 minutos. Los pacientes en estas condiciones presentaron tres veces más riesgo para desarrollar complicaciones.

BACKGROUND: We undertook this study to identify factors associated with surgical complications of complex fractures of the tibial plateau. METHODS: We designed a case-control study with 56 patients with a diagnosis of complex fracture in the tibial plateau (IV-VI Schatzker) and with 12.9 +/- 3.2 (8-18) months of follow-up. Risk factor exposure was defined as having one or more of the following characteristics: age >60 years; co-morbidity (diabetes mellitus, systemic arterial hypertension); time of [quot ]Kidde[quot ] (>60, >90, >120 min) and fracture type IV, V or VI. A case was considered with one or more complications. Results: Mean age was 50.1 +/- 15.7 (17-87) years old; 35 patients (62.5%) were males. Homogeneity between groups was shown for age, sex, side effects, type of fracture and time of follow-up; 41.1% of patients had pathological history. All surgeries used pneumatic compression (Kidde) for 91 +/- 27.2 (40-175) min. The implants used were plate plus cancellous screws (53.6%), external fixators plus cancellous screws (35.7%), double plate and intramedullary nail. Complications appeared in 37.5% of all patients. Complications reported were superficial infection (16.1%), residual angular deformities (10.7%, varum [7.1%]), peroneal nerve injury (5.4%), non-union (3.5%) and deep venous thrombosis (1.8%); 22.2% of all patients presented more than one complication. CONCLUSIONS: Statistically significant risk factors were age >60 years and pneumatic compression >120 min. Patients with one of these characteristics had a three-times risk of complications. No association was demonstrated between type of fracture, surgical treatment, time between injury and the surgery, with development of complications.

Estudio retrospectivo de fracturas de tibia tratadas en el Hospital "Pérez de León" de Petare (1990-1995) / A retrospective study was done of tibial fractures treatment in the Hospital \"Perez of León\" od Petare (1990-1995)

En el presente trabajo se realizó un estudio retrospectivo de fracturas de tibia, tratadas en el servicio de traumatología del Hospital "Pérez de León" de Petare entre los años 1990-1995. Encontramos paridad entre el tratamiento quirúrgico y el tratamiento ortopédico, ambos con resultados satisfactorios similares. Se observaron en ambos tratamientos las complicaciones comunes en toda fractura de tibia: consolidación, pseudoartrosis y osteomielitis crónica