The outcomes of the management of complex distal tibia and ankle fractures in elderly with tibiotalocalcaneal nail in a minimum 12-month follow-up period.

PURPOSE: To evaluate the clinical outcomes of the use of tibiotalocalcaneal nail for the treatment of complex distal tibia and ankle fractures in elderly people, in a major trauma centre. METHODS: Elderly patients (age > 65) with distal tibia or ankle fractures that underwent stabilization with a tibiotalocalcaneal nail were eligible to participate. Exclusion criteria were patients that died or were lost to follow-up and cases in which the nail was used in a chronic setting, such as malunion and non-union. Main parameters evaluated were fracture union, complications and functional outcomes. The functional outcome was assessed using the Olerud-Molander Ankle Score (OMAS). The minimum follow-up was 12 months. RESULTS: Thirty-two consecutive patients (12 males) with a mean age of 80.2 years (range 66-98) met the inclusion criteria and formed the basis of this study. Fracture union was achieved in 93.8% of the cases at a mean time of 3.9 months (range 2-8). Two patients developed surgical site infections and underwent reoperation before union. The overall complication rate was 25.1%, while the respective reintervention rate was 18.8%. In terms of functional outcomes, the mean OMAS score was 45, ranging from 20 to 70. CONCLUSION: Tibiotalocalcaneal nailing can be considered as an acceptable less invasive option with good functional outcomes for the treatment of complex distal tibia and ankle fractures in frail patients with problematic local soft tissues.

Three-Dimensional Heat Map: The OTA/AO Type 43C Pilon Fracture Lines Distribution.

Background: This study aimed to create three-dimensional heat map and study the characteristic of fracture lines and represented fragments of OTA/AO type 43C pilon fractures. Methods: CT scan was performed in105 fractures diagnosed with OTA/AO type 43C pilon fractures between January 2017 and December 2022. Three-dimensional pilon fracture maps were created and converted into fracture heat maps. CT scan graphic parameters including the fracture line height, α angle, ß angle, the ratio of the area and size of bone fragment represented by the fracture line to the total articular surface were measured. Results: The study included 105 patients with 91 males and 14 females. The fractures included C1 (n=16), C2 (n=23), and C3 (n=66). There was no statistically different among the most parameters except in the fracture-line height of the anterior fracture line (p=0.03) and the sagittal fracture line (p=0.02) between C2 and C3 pilon fractures. The average size of the anterolateral fragment, occupied approximately 13.5% of the articular surface area, was (11.5±2.8) mm × (20.5±6.3) mm with the average height of 29.8 mm. The average size of the posterolateral fragment, occupied approximately 13.0% of the articular surface area, was (15.7±4.6) mm × (19.3±4.0) mm with the average height of 19.1 mm. Conclusion: This study demonstrates that the articular surface fracture lines in the C type pilon fracture are formed by fixed main fracture lines. The understand of morphological and distribution characteristics of the fracture lines and size of fragments in OTA/AO type 43C pilon fractures would help the surgeons take suitable approach and fixation.

Evaluation of Functional Outcome in Surgically Managed Tibial Pilon Fractures.

Background Pilon fractures are infrequent and among the most challenging to manage. One reason is the extensive soft tissue injury surrounding the distal tibia. Second, the articular surface of the distal tibia with a complex fracture pattern needs anatomic reduction. These fractures occur due to high energy impaction of the talus into the distal tibia. The fracture patterns and extent of soft tissue involvement vary based on the intensity of the impact's energy. The management needs to be patient-specific to prevent complications. Proper pre-operative planning with the help of computer tomography scans aids in choosing the approach and proper reduction. Either single-stage early definitive fixation or two-staged protocols involving the application of spanning external fixation to maintain length and allow soft tissue healing followed by definitive open reduction and internal fixation is done. However, complications still remain inevitable in a significant subset of patients. Objective To evaluate the functional outcome in surgically managed tibial pilon fractures using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. Methods This prospective observational study included 20 patients who underwent surgery for pilon fractures of the tibia at Nizam's Institute of Medical Sciences between November 2020 and September 2022. The patients were between 18 and 65 years old and consented to participate in the study group. After undergoing patient-specific surgical management, all patients are followed for a minimum of six months. Their functional outcome is evaluated after fracture union and scheduled physiotherapy sessions every four weeks using the AOFAS scoring system. Ankle range of motion (ROM) is also evaluated. Results The average age of the patients was 40 years, and male predominance was present. Most of the patients (60%) underwent internal fixation. According to the AOFAS scoring system, six patients had an excellent outcome, 11 had a good outcome, and three had a fair outcome. Most of the patients (11 patients) had excellent to good ankle ROM. Complications were encountered in two patients with ankle stiffness and one with wound dehiscence. Conclusion Pilon fractures are more common in young adults due to road traffic accidents. The most common type of pilon fracture is a closed fracture, which can be treated with definitive internal fixation after the soft tissue has healed. Definitive internal fixation has shown excellent and good functional outcomes (according to the AOFAS score) with improved ankle ROM and no complications when compared to external fixation, which can result in ankle stiffness and delayed union.

Symmetry of the left and right tibial plafond; a comparison of 75 distal tibia pairs.

PURPOSE: Tibia plafond or pilon fractures present a high level of complexity, making their surgical management challenging. Three-Dimensional Virtual Planning (3DVP) can assist in preoperative planning to achieve optimal fracture reduction. This study aimed to assess the symmetry of the left and right tibial plafond and whether left-right mirroring can reliably be used. METHODS: Bilateral CT scans of the lower limbs of 75 patients without ankle problems or prior fractures of the lower limb were included. The CT images were segmented to create 3D surface models of the tibia. Subsequently, the left tibial models were mirrored and superimposed onto the right tibia models using a Coherent Point Drift surface matching algorithm. The tibias were then cut to create bone models of the distal tibia with a height of 30 mm, and correspondence points were established. The Euclidean distance was calculated between correspondence points and visualized in a boxplot and heatmaps. The articulating surface was selected as a region of interest. RESULTS: The median left-right difference was 0.57 mm (IQR, 0.38 - 0.85 mm) of the entire tibial plafond and 0.53 mm (IQR, 0.37 - 0.76 mm) of the articulating surface. The area with the greatest left-right differences were the medial malleoli and the anterior tubercle of the tibial plafond. CONCLUSION: The tibial plafond exhibits a high degree of bilateral symmetry. Therefore, the mirrored unfractured tibial plafond may be used as a template to optimize preoperative surgical reduction using 3DVP techniques in patients with pilon fractures.

Treatment of Klammer type Ⅲ posterior pilon fracture via the posterolateral combined posteromedial approach / 中华创伤骨科杂志

Objective:To investigate the therapeutic effects of internal fixation via the posterolateral combined posteromedial approach in the treatment of posterior pilon fracture (Klammer type Ⅲ).Methods:A retrospective study was performed to analyze the 69 posterior pilon fractures (Klammer type Ⅲ) which had been treated by internal fixation with hollow screws or a buttress plate at Department of Orthopaedic Trauma, Yantai Shan Hospital from January 2015 to January 2020. There were 36 males and 33 females with an age of (45.3±10.0) years and duration from injury to surgery of (6.0±1.5) d. They were assigned into 2 groups according to different surgical approaches. The observation group (41 cases) was treated through the posterolateral combined posteromedial approach while the control group (28 cases) through the posterolateral approach alone. The therapeutic effects were evaluated by comparing the 2 groups in terms of incision length, intraoperative bleeding, operation time, fracture union time, fracture reduction (evaluated by the Burrwell-Charnley radiological score), the ankle-hindfoot score of American Orthopaedic Foot and Ankle Society (AOFAS) and complications.Results:There was no significant difference in the preoperative general data between the 2 groups, showing comparability ( P>0.05). All the 69 cases were followed up for (16.9±4.0) months, revealing primary healing of all the incisions and no vascular injury or wound infection. The incision length [(11.2±1.8) cm] and operation time [(76.0±6.6) min] in the observation group were significantly shorter than those in the control group [(12.4±1.9) cm and (79.7±6.8) min], the excellent and good rate of reduction in the observation group (97.6%, 40/41) was significantly higher than that in the control group (89.3%, 25/28), and the ankle-hindfoot scores of AOFAS at 1, 3 and 12 months after operation in the observation group [(78.4±5.6), (79.5±2.8) and (86.9±2.1)] were significantly higher than those in the control group [(75.2±5.5), (78.0±3.2) and (85.8±2.3)] (all P<0.05). There was no significant difference in the intraoperative bleeding between the 2 groups ( P>0.05). In the control group, 2 patients developed numbness in the dorsum of foot, which gradually disappeared after 3 months of treatment, but no other complications like persistent pain or flexor contracture within 1 year after operation. Conclusion:In the treatment of Klammer type Ⅲ posterior pilon fracture, the posterolateral combined posteromedial approach can result in satisfactory therapeutic effects, because the surgical approach can fully expose the fracture and facilitate better reduction.

Epidemiological characteristics of patients with tibial pilon fracture / 中华创伤骨科杂志

Objective:To explore the epidemiological characteristics of inpatients with tibial pilon fracture in The Third Hospital of Hebei Medical University from 2016 to 2019.Methods:The data of all the patients who had been hospitalized for pilon fracture from January 2016 to December 2019 in The Third Hospital of Hebei Medical University were collected using the medical image computer archiving and transmission system and the medical record query system. The patients' age, gender, occupation, residence, season, cause of injury, Rüedi-Allg?wer classification, and AO classification were analyzed.Results:A total of 234 inpatients with tibial pilon fracture were collected, including 179 males and 55 females, with a ratio of male to female of 3.3∶ 1. The prevalence age ranged from 41 to 50 years in male patients (31.3%, 56/179) and from 51 to 60 years in female patients (25.5%, 14/55). In the 234 patients, farmers (101 cases, 43.2%), rural area (166 cases, 70.9%) and spring season (77 cases, 32.9%) accounted for a higher proportion. The proportions of high-altitude falling (41.0%, 96/234) and high-energy injury (61.5%, 144/234) were the highest. Of the 234 patients by the Rüedi-Allg?wer classification, 23 (9.8%) had type Ⅰ fracture, 90 (38.5%) type Ⅱ fracture, and 121 (51.7%) type Ⅲ fracture, with type Ⅲ fracture prevalent in males (58.1%, 104/179) and type Ⅱ fracture prevalent in females (16.4%, 9/55). Of the 234 patients by the AO classification, 131 (56.0%) had type 43B fracture and 103 (44.0%) type 43C fracture, with a higher proportion of type 43B fractures in women (67.3%, 37/55) than in men (52.5%, 94/179). In type 43B fractures, type 43B3 (43.5%, 57/131) and type 43B3.3 (75.4%, 43/57) were the most common; in type 43C fractures, type 43C3 (74.8%, 77/103) and type 43C3.3 (51.9%, 40/77) were the most common.Conclusions:In the recent 4 years in The Third Hospital of Hebei Medical University, pilon fractures increased year by year and occurred more frequently in spring. They were more common in farmers and in the rural areas. They prevailed in the patients aged from 41 to 50 years. The Rüedi-Allg?wer type Ⅲ fractures and the AO type 43B fractures were the most common.

Minimally invasive single locking plate combined with multiple planar screw internal fixation for pilon fracture / 中华创伤杂志

Objective To investigate the clinical effect of minimally invasive single locking plate combined with multiplanar screw internal fixation on pilon fracture of distal tibia. Methods A retrospective case control study was conducted to analyze the clinical data of 51 patients with pilon fracture involving distal tibial articular surface admitted to 81th Group Military Hospital of the Army from January 2013 to August 2017. Among the patients, 20 patients including 15 males and five females, aged (37. 5 ± 9. 9)years were treated with closed traction reduction or open joint reduction through minimally invasive incision and single main locking plate combined with multiplanar screw placement ( study group) . There were 13 patients with type II and seven patients with type III according to Ru edi-Allgwer classification of fracture. In addition, 31 patients were treated with open reduction and multi-plate internal fixation (control group), including 25 males and six females, aged (43. 4 ± 11. 3) years. There were 20 patients with type II and 11 with type III according to Ru edi-Allgwer classification. The operation time, fracture healing time, postoperative complications were compared between the two groups. Burwell-Charnley imaging evaluation criteria were used to assess the quality of fracture reduction. At the last follow-up, ankle function was assessed by the American Orthopedic Foot and Ankle Society ( AOFAS) ankle-hind foot functional score. Results All 51 patients were followed up for 6-24 months, with an average of 16 months. The operation time was (82. 5 ± 19. 2)minutes in the study group and (127. 7 ± 40. 8)minutes in the control group (P<0. 05). The fracture healing time was (10. 8 ± 1. 6)weeks in the study group and (11.0 ±1.5) weeks in the control group (P>0.05). Local skin necrosis (not above the plate) occurred in two patients in the study group and in three patients in the control group, with the wounds being healed within 3 months after dressing change and vacuum sealing drainage ( VSD) . In the control group, one patient had severe infection and recovered after treatment of steel plate removal, debridement and irrigation, and external fixator fixation. Three patients in the control group had skin necrosis resulting in plate exposure, who received transferred skin flaps to cover the wound. The incidence of postoperative complications were 10％ (2/20) and 23％ in the study group and the control group, respectively (7/31) (P >0. 05), with the incidence of severe complications for 0 and 13％(4/31)(P<0. 05), respectively. According to Burwell-Charnley imaging evaluation criteria, 18 patients obtained anatomical reduction in the study group, one had unsatisfactory reduction and one had poor reduction, with satisfaction rate of 90％. In the control group, 29 patients obtained anatomical reduction and two had unsatisfactory reduction, with satisfaction rate of 94％ (P>0. 05). At the last follow-up, AOFAS ankle-hind foot function scores were excellent in 12 patients, good in five patients, fair in two patients and poor in one patient in the study group with excellence rate of 85％, while the scores were excellent in 20 patients, good in six patients, fair in three patients and poor in two patients in the control group, with excellence rate of 84％ (P>0. 05). Conclusion For pilon fracture of distal tibia, both minimally invasive single locking plate combined with multi-plate screw internal fixation and open reduction combined with multi-plate internal fixation have good reduction effect and satisfactory recovery of ankle function, but the former can significantly shorten the operation time and reduce the incidence of serious complications after operation.

Extra-articular distal tibial fractures, is interlocking nailing an option? A prospective study of 147 cases / 中华创伤杂志(英文版)

PURPOSE@#Distal tibia fractures comprise about 7%-10% of lower extremity trauma. Because of the peculiarity of the soft tissue and subcutaneous location of the bone there are many controversies in the ideal treatment of distal tibia fractures especially extra articular pilon fractures. Plating is fraught with complications of wound dehiscence and infection. There are limited studies which document outcomes in such cases using intramedullary interlocking nail. We intend to study the outcome and complications of extra articular distal tibial fractures treated with interlocking nailing.@*METHODS@#This is a prospective study conducted in a tertiary care orthopaedic hospital in southern India. There are 147 patients of distal tibia extra-articular fractures managed by IM nailing with follow up of more than one year were included in this study. Only cases with fresh injury (less than 1 week), fracture below the isthmus, closed and open Gustilo Anderson type 1 and 2 fractures were included in the study. Patients were reviewed at 3, 6, 12 and 24 weeks after surgery and thereafter at one year and were assessed for clinical and radiological signs of healing, any complications, time to union and functional outcome.@*RESULTS@#There were 102 males and 45 females (male/female ratio is 2.3:1) with a mean age of 38.96 (range 23-65) years. According to AO classification, there were 78 cases (53.06%) of 43-A1, 39 cases (26.53%) of 43-A2 and 30 cases of 43-A3 constituting 20.40%. The fracture united in all the patients at an average of 18 weeks (range 16-22 weeks), none of the patient in our series had a delayed or non-union. Two patients (1.47%) had the fracture united in mild valgus but it was well within the acceptable limits (<5°). The functional outcome was assessed in all the patients at final follow up using Olerud and Molander score all the patients fared an excellent to good score, there were no cases with poor score.@*CONCLUSION@#Intramedullary nailing is a viable option to treat distal tibial fractures with excellent outcome. Wound complications related to plating can be avoided but meticulous surgical technique is key to avoid malunion.

Treatment of Pilon fractures complicated with soft tissue injury by plate and lag screw fixation via posterolateral approach / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the clinical effects of plate and lag screw fixation for treatment of Pilon fractures complicated with soft tissue injury via posterolateral approach.</p><p><b>METHODS</b>From May 2013 to June 2016, 25 patients with Pilon fractures complicated with soft tissue injury underwent open reduction and internal fixation via posterolateral approach. There were 15 males and 10 females, aged from 25 to 61 years old with an average of(39.6±0.2) years. Plate and lag screw fixation were used in operation. Healing of soft tissue contusion and abrasions in the ankle wounds and injuries were observed after operation. The Burwell-Charnley standard was applied to assess the quality of fracture reduction and the AOFAS Ankle foot scoring system(total score 100 points) was used to evaluate the clinical effects.</p><p><b>RESULTS</b>All the patients were followed up from 6 to 24 months with an average of 12 months. All operative wounds and soft tissue injuries were healed. According to the Burwell-Charnley standard, 22 cases obtained excellent results with anatomic reduction, while 2 cases were dissatisfied, and 1 case poor. The AOFAS ankle foot scores were 90.2±7.5 on average, with 20 cases of excellent results, 3 good, 2 fair.</p><p><b>CONCLUSIONS</b>Plate and lag screw fixation by posterolateral approach in treating Pilon fracture complicated with soft tissue injury shows advantage of avoiding injury to the anteromedial skin and soft tissue, provides forceful fixation without further injury.</p>

Simple external skin expansion technique in treatment of skin necrosis defect after the surgery for Pilon fracture / 天津医药

Objective To evaluate the clinical effects of simple external skin expansion technique in treatment of skin necrosis defect after the surgery for Pilon fracture.Methods Data of 12 patients with skin necrosis defect after the surgery for Pilon fracture treated with simple external skin expansion technique in our hospital from May 2015 to January 2017 were retrospectively analyzed.There were 10 males and 2 females in the 12 patients with age 32-58 years old(average 45.30± 8.91 years old).There were 4 cases with open fractures and 8 cases with closed fractures.The defect area was about 9.1 cm long and 3.9 cm wide.There were 3 cases with skin necrosis of open fractures and 9 cases with postoperative skin necrosis of incision site. After completely debridement and removing infection from the skin necrosis areas, kirschner needle wired intermittented through the skin,the kirschner wire was around a sterile silicone rubber tube at both ends and the kirschner wire was connected to the both ends of the Kirschner on the opposite side.After giving moderate tensile force,which showed that the skin on both sides was still bleeding,no obvious pale color on skin,two ends of rubber tube were fixed with forceps. Using the ductility of skin and the tensile force of sterile silicone rubber tube to gradually extend the skin and to gradually narrow and close the suturing wound.All patients were followed up for 3-6 months to observe the effect of surgery.Results All of the 12 cases were healed in 2-4 weeks,average(2.50±0.59)weeks.The patients were sutured directly after simple external skin expansion,and 4 patients were sutured with the surface of the external plate or tendon,and parts of wound were delayed healed after the re-suture.The skin color,lustre,hair growth and elasticity were normal,no bloated,and tenderness was normal after simple external skin expansion.Conclusion The simple external skin expansion technique in treatment of skin necrosis defect after the surgery for Pilon fracture is a simple,effective and economic method,which is worthy of clinical promotion.

Limited open reduction combined with percutaneous medial locking plate for treatment of Rüedi-Allg(o)wer type Ⅱ and Ⅲ closed tibial pilon fractures / 中华创伤杂志

Objective To evaluate the clinical efficacy of limited open reduction combined with percutaneous medial locking plate in treatment of Rüedi-Allg(o)wer type Ⅱ and Ⅲ closed tibial pilon fractures.Methods A retrospective case-control analysis was made on 45 cases of closed tibial pilon fractures treated surgically between June 2008 and December 2015.There were 33 males and 12 females,aged from 26-66 years (mean,44.6 years).All cases were unilateral tibial pilon fractures,among which 18 were on the left while 27 were on the right.Thirty-four cases were combined with fibular fractures.There were 14 cases of type Ⅱ fractures and 31 type Ⅲ fractures according to the Rüedi-Allg(o)wer classification.Using the Tscheme-Gotzen system to evaluate soft tissue injury,two patients were in grade 1,29 patients in grade 2,and five patients in grade 3.On the basis of surgical methods,the cases were divided into Group A,limited open reduction with percutaneous medial locking plate and Group B,conventional open reduction.The operation time,reduction quality,fracture healing time,American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale at final follow-up visit and complications were recorded and compared between the two groups.Results The operation time of Group A was shorter than that of Group B (P ＜ 0.05).All patients had been followed up for 12-24 months,among which Group A was 22.5 months and Group B was 20.0 months (P ＞ 0.05).Compared with Group B,Group A was superior in fracture healing time (P ＜ 0.05) and AOFAS ankle-hindfoot scale(P ＜0.05),but was inferior in reduction quality (P ＜ 0.05).Poor wound healing was observed in two cases in each group,yet there was no nonunion in all cases.Conclusion Compared with conventional open reduction,the limited open reduction combined with percutaneous medial locking plate has more advantages in operation time and fracture healing,which can achieve better ankle functions for closed tibial pilon fractures.

Clinical efficacy and safety of limited internal fixation combined with external fixation for Pilon fracture: A systematic review and meta-analysis / 中华创伤杂志(英文版)

<p><b>PURPOSE</b>To compare the clinical efficacy and complications of limited internal fixation combined with external fixation (LIFEF) and open reduction and internal fixation (ORIF) in the treatment of Pilon fracture.</p><p><b>METHODS</b>We searched databases including Pubmed, Embase, Web of science, Cochrane Library and China Biology Medicine disc for the studies comparing clinical efficacy and complications of LIFEF and ORIF in the treatment of Pilon fracture. The clinical efficacy was evaluated by the rate of nonunion, malunion/delayed union and the excellent/good rate assessed by Mazur ankle score. The complications including infections and arthritis symptoms after surgery were also investigated.</p><p><b>RESULTS</b>Nine trials including 498 pilon fractures of 494 patients were identified. The meta-analysis found no significant differences in nonunion rate (RR = 1.60, 95% CI: 0.66 to 3.86, p = 0.30), and the excellent/good rate (RR = 0.95, 95% CI: 0.86 to 1.04, p = 0.28) between LIFEF group and ORIF group. For assessment of infections, there were significant differences in the rate of deep infection (RR = 2.18, 95% CI: 1.34 to 3.55, p = 0.002), and the rate of arthritis (RR = 1.26, 95% CI: 1.03 to 1.53, p = 0.02) between LIFEF group and ORIF group.</p><p><b>CONCLUSION</b>LIFEF has similar effect as ORIF in the treatment of pilon fractures, however, LIFEF group has significantly higher risk of complications than ORIF group does. So LIFEF is not recommended in the treatment of pilon fracture.</p>

Preoperative full reset combined with minimally invasive treatment of extreme distal pilon fractures / 中华创伤杂志

Objective To investigate the clinical efficacy of preoperative full reset combined with minimally invasive treatment of extreme distal pilon fractures.Methods A retrospective analysis was made on 34 patients (35 ankles) with tibial fractures extremely close to the distal articular surface treated surgically between January 2011 and January 2015.There were 21 mnales and 13 females,aged 20-71 years (mean,36.2 years).Injury resulted from traffic accidents in 32 patients and high falls in two.Using the AO/OTA fracture classification system,type 43-B3 was noted in three patients,43-C1 in five patients,43-C2 in 18 patients and 43-C3 in eight patients.Calcaneal traction combined with manipulative reduction was used to correct fracture displacement preoperatively.All fractures were stabilized by minimally invasive percutaneous plate osteosynthesis (MIPPO) through single or combined medial,anteromedial and anterolateral approaches while minimizing damage to bone attachment and continuity of soft tissue,after soft tissue swelling subsided.For the patients with articular surface collapsing with severe comminution,a series of procedures were done under direct vision including using the talus articular surface as a mold,stable fixation with fine Kirschner (1-1.5 mm) and thin screws (2.1-2.7 mm series) and impaction bone grafting below subchondral bone.Thereafter,distal tibia anatomical short multi-directional locking plate fixation,distal nail support and early ankle joint functional exercise were done.Burwell-Charnley radiological evaluation system was used for radiological assessment,and TeenyWiss scoring system for ankle clinical symptoms and function.Postoperative complications were recorded.Results Follow-up lasted for 11-38 months (mean,16.6 months).No infection,wound disunion,or plate exposure occurred.Burwell-Charnley radiological evaluation system showed anatomic reduction in 32 patients,unsatisfactory reduction in one,and poor reduction in one.According to the Teeny-Wiss scoring system,the results were excellent in 31 patients,good in two and poor in one,with the excellentgood rate of 97％.Three patients suffered traumatic arthritis after operation and alleviated after oral administration of painkiller.Conclusion With use of full reset combined with manipulative reduction to correct fracture displacement,minimally invasive locking plate,distal row of nails,impaction bone grafting and limited fixation,the patients with extremely distal tibial pilon fractures achieve satisfactory reduction,stable fixation,and early functional exercise.

Application of rapid prototype and 3D printing in therapy of complex pilon fractures / 中华创伤骨科杂志

Objective To investigate the value of 3D rapid prototype technology in therapy of complex pilon fractures.Methods In this study,60 patients with pilon fracture who had been hospitalized during January 2013 to May 2014 were randomly and equally divided into a 3D group and a control group according to their hospitalization order.The 3D group:21 males and 9 females,an average age of 34.8 ±6.0 years,13 cases of AO type C2 and 17 ones of AO type C3.The control group:21 males and 9 females,an average age of 35.8 ±6.2 years,12 cases of AO type C2 and 18 ones of AO type C3.The 3D group received surgery aided by rapid prototype and 3D printing while the control group underwent conventional surgery with open reduction and internal fixation.In the 3D group,the distal tibia models were manufactured by 3D rapid prototyping technology based on the 3D reconstructions which were accomplished by computer aided technology.The diagnosis,classification and preoperative plan were then conducted using the models.The 2 groups were compared in terms of operation time,postoperative skin necrosis and infection,and Maryland foot function scoring at the last follow-up.The 2 groups were compatible in preoperative demographic data (P ＞ 0.05).Results There were significant differences between the 3D and control groups in operation time (65.1 ±4.8 minutes versus 80.5 ± 3.6 minutes) and rate of postoperative complications [6.7％ (2/30) versus 16.7％ (5/30)] (P ＜0.05).There was no significant difference between the 2 groups in the excellent to good rate by Maryland foot function scoring at the last follow-up [76.7％ (23/30) versus 73.3％ (22/30)] (P ＞ 0.05).Conclusion Since rapid prototype and 3D printing technology can display the morphology of pilon fracture intuitively and stereoscopically,it helps surgeons with accurate assessment of the fracture.3D printed models of the pilon fracture pre-operatively raise the accuracy of reduction,reduce both operation time and incision complications,and facilitate functional recovery.

Osteosíntesis mininvasiva con placas bloqueadas en fracturas metafisarias distales de tibia. Comparación de resultados entre fracturas AO 43A y AO 43C / Minimally invasive plate osteosynthesis in distal metaphyseal fractures of tibia. Comparison of results between AO 43A and 43C fractures

Introducción: Las fracturas distales de tibia son un desafío terapéutico debido a la escasa cobertura y la particular vascularización. Los objetivos de este estudio son analizar los resultados clínicos y funcionales de los pacientes con fractura de tibia distal, tratados con técnica MIPO con placas bloqueadas; comparar los resultados del grupo de fracturas AO 43A con el de fracturas AO 43C1-C2; y comparar los resultados de la técnica MIPO con el tratamiento abierto convencional. Materiales y Métodos: Entre 2004 y 2012, se evaluaron 32 fracturas de tibia distal tratadas con la técnica MIPO. El 59,4% tenía fracturas AO 43A y el 40,6%, AO 43C. Seguimiento promedio: 39.6 meses, mediante la escala de la AOFAS y radiología. Se consignaron las complicaciones. Se compararon los resultados de los grupos AO A y AO C. Resultados: El grupo AO A: media de 95,89 puntos en la escala AOFAS, en el posoperatorio. El grupo AO C1-2: media de 92,15 puntos en el posoperatorio. Carga del peso corporal: a las 8.7 semanas promedio. Comparación entre AO 43A y AO 43C: p = 0,46 (no significativa). Retorno a la actividad previa a la lesión: 9.3 meses promedio. Comparación entre tipo A y tipo C: p = 0,16 (no significativa). Se detectaron complicaciones en el 18,75% y se retiró la osteosíntesis en 14 casos. Conclusiones: La osteosíntesis mínimamente invasiva con placa y tornillos es una buena opción para las fracturas de tibia distal; con buena evolución clínico-funcional y escasas complicaciones cuando se la compara con la cirugía abierta. Las fracturas 43A presentan menos complicaciones mayores que las 43C, tratadas con la técnica MIPO. Nivel de evidencia: IV.

Introduction: Distal tibial fractures are a therapeutic challenge due to the limited coverage and specific vascularization. The aims of this study are to analyze the clinical outcome and functional results in patients with tibial fracture treated with MIPO technique with locked plates, and to compare AO 43A and AO 43C1-C2 fracture results, and conventional open treatment with MIPO technique. Methods: Between 2004 and 2012, 32 distal tibial fractures treated with MIPO technique were evaluated. The 59.4% were AO 43A fractures and 40.6% were AO 43C. Mean follow-up: 39.6 months using AOFAS Score and X-rays. Complications were recorded. Results in AO A and AO C groups were compared. Results: Mean postoperative AOFAS score was 95.89 and 92.15 in AO A fracture and AO C1-2 fractures respectively. The mean time of weight bearing was 8.7 weeks. The mean time to return to activities was 9.3 months. Complications were detected in the 18.75% and removal of the hardware was necessary in 14 cases. Conclusions: Minimally invasive plate osteosynthesis is a good choice for tibial distal fractures, clinical and functional outcomes are good, and there are fewer complications in comparison to open surgery. AO 43A fractures have less complications than AO 43C with this technique. Level of evidence: IV.

Clinical effect analysis of primary bone graft and VSD for open and complex pilon fractures / 国际外科学杂志

Objective To investigate the clinical effect of primary bone graft and VSD for open and complex Pilon fractures.Methods Fifty-six cases with open and complex Pilon fractures admitted in Dongfeng general hospital between January 2010 and January 2011 were treated with primary bone graft and VSD,the clinical datum were collected,for example soft tissue union,fracture union,incidence rate of traumatic arthritis,ankle article function scores.Results Fracture healed,no soft tissue infection happened,according to Helfer scores criteria,there were 22 excellent,21 good,8 fair,5 poor,excellent and good rate were 76.8％.Conclusions The method of primary bone graft and VSD resolved many questions simultaneously,for example fracture fixation,bone defect and soft tissue coverage,which has feature of simpler operation,lower infection incidence rate,better fracture union and article function than conventional methods.

Short-term efficacy of double operative approaches for severe Pilon fractures / 中华创伤杂志

Objective To investigate surgical exposure,reduction and fixation of the severe Pilon fractures. Methods A total of 11 patients with severe Pilon fractures (Rüedi-Allgwer type Ⅲ or AO/OT type C3 ) were managed by anteriormedial malleolar approach in combination with transfibular fracture or fibular osteotomy approach to reveal the tibiotalar joint.Reduction was performed under direct vision and then the tibia was fixed followed by fibula fixation. Results All patients obtained satisfactory bone reduction including nine patients with Ⅰ stage wound healing and two with Ⅱ stage wound healing.No sclerotin infection occurred.The fractures as well as the osteotomy sites were healed. Conclusions The double operative approaches can completely expose the tibiotalar joint,favor the reduction and fixation of the displaced bone fragments and attain satisfactory short-term reduction and fixation effects in the treatment of severe Pilon fractures.

Surgical treatment strategy for tibial pilon fracture / 中华创伤杂志

Objective To explore the surgical treatment strategy for tibial pilon fractures.Methods Forty-seven patients with tibial pilon fractures surgically treated in our hospital from May 2005 to March 2008 were retrospectively studied. There were 37 males and ten females, at mean age of 42 years (range 23-46 years). There were 51 sides of tibial pilon fractures, for four patients were with bilateral tibial pilon fractures. Injury causes included traffic accidents in 34 patients, fall from height in 12 and bruise by heavy objects in five. Open fractures were determined in seven patients and close fractures in 44 patients. According to Ruedi-Allgower classification, there were six sides of type Ⅰ fractures, 28 type Ⅱ fractures and 17 type Ⅲ fractures. According to Tscherna-Grotzen tissue injuries classification,open fractures were determined as 1° in two patients, 2° in three and 3° in two; close injuries were defined as 0° in two patients, 1° in 27 and 2° in 15. Distal tibia was partitioned as anterolateral column,anteromedial column and posterior column in order to select reasonable internal fixation. Eighteen fractures were treated with DePuy T plate, 10 with AO cloverleaf pattern plate, two with AO small T plate,two with locking plate, four with Link anterolateral anatomic plates and 15 with Orthofix overtake-anklejoint outside-fixed frame combined with limited internal fixation. Results The patients were followed up for a mean time of 23 months (range 12-44 months). According to Mazur ankle evaluation grading system, 29 patients were graded as excellent, 13 good, seven fair and two poor, with an excellence rate of 82.4%. Conclusions Correct operation time and treatment plans on the basis of Ruedi-Allgower classification and Tscherne-Gotzen classifications of soft tissues and reasonable internal fixation according to the condition of the involved three column in distal tibia can decrease postoperative complications and achieve good and satisfactory clinical effect.

Arthroscopically Assisted Limited Open Reduction and Ilizarov External Fixation of Tibial Pilon Fractures

PURPOSE: To evaluate the clinical results of the pilon fractures treated with arthroscopically assisted limited open reduction and Ilizarov external fixation. MATERIALS AND METHODS: This is a retrospective study of the clinical result, bone union, complication and postoperative ankle function of 22 pilon fractures treated with arthroscopically assisted limited open reduction and Ilizarov external fixation between January 1999 to March 2004. RESULTS: Clinical follow up averaged 16 months, with an average age of 39.2. All patients with type 1 and 2 fracture had excellent or good score by Ovadia and Beals criteria. Closed fractures healed within 13 weeks and open fractures within 16 weeks after surgery in average. Average range of motion of the ankle was 12o dorsiflexion (0~20 degree) and 25o plantar flexion (15~35 degree). CONCLUSION: Minimal soft tissue dissection and anatomical reduction are very important factor for minimizing complication and satisfactory ankle function. So, arthroscopically assisted limited open reduction and Ilizarov external fixation is an effective treatment option for tibial pilon fractures.

Total Knee Arthroplasty in Charcot's Joints / 대한정형외과학회잡지

Four total knee arthroplasties were performed in 3 patients with the diagnosis of classical Charcot's joints associated with syphilis during past 4 years from 1985 to 1988. All patients had positive reaction in serology test(VDRL, TPHA). We corrected the bone loss and severe joint instability with allograft or autogenous bone grafting and ligament balancing. The knee score was increased from preoperative 37 points to postoperative 87.3 points. We expect that total knee arthroplasty may be the alternative treatment to the conservative treatment or knee arthrodesis in Charcots joints.