Results of pilon fracture treatment depend on fixation choice
By Peter Pollack
Intra-articular fractures of the tibia plafond can be among the most challenging problems faced by orthopaedists. Researchers for poster exhibit P465 found that two-staged internal fixations and hybrid fixations with small arthrotomy were equally effective in achieving bony union without losing range of motion in the ankle. Patients undergoing external fixation with ankle spanning had a higher rate of delayed union and reduced activities.
In this study, patients who were treated with two-staged internal fixation achieved union in an average of 5.1 months and all were able to maintain their activity levels. On the other hand, patients who received a half-pin external fixator with ankle spanning took an average of 6.9 months until union and more than a third of patients (7 of 20) reduced their activity levels.
This comparison of the functional outcomes of surgically treated distal tibia fractures using three different fixation methods (two external and one internal) involved a retrospective review of preoperative data and a prospective evaluation of functional outcomes.
The study was randomized-by-surgeon and included 55 patients with pilon fractures. There were 24 open fractures and 31 closed fractures; 36 fractures were type C and 19 were type B fractures.
Patients were grouped according to three surgical protocols. Group A consisted of 20 patients who received a half-pin external fixator with ankle spanning. The mean age of patients in Group A was 42 years old (range: 22 years to 74 years). Mean follow-up for Group A was 77.7 months (range: 38 months to 132 months).
Group B consisted of 22 patients treated with a single ankle sparring ring hybrid external fixator under a small arthrotomy. The mean age of patients in Group B was 48.4 years (range: 28 years to 76 years), and the mean follow-up was 67.9 months (range 36 months to 132 months).
Group C consisted of 13 patients treated with a two-staged internal fixation. The mean age of patients in Group C was 45.6 years (range: 30 years to 66 years), and the mean follow-up was 78.6 months (range: 55 months to 132 months).
“The study groups had similar demographics for baseline covariates: age, gender, fracture type (closed/open) and severity of soft-tissue injury,” notedthe authors. “We addressed the dissimilarity of the type of fracture in each group by performing supplementary stratified analyses within each fracture type group.”
Patients in Groups B and C had better outcomes than patients in Group A. In general, they healed faster, maintained their activity levels better and had better ankle motion. In addition, fewer patients in Groups B and C developed posttraumatic arthritis. Patients with type C fractures had higher rates of infection (p < 0.001), higher rate of limitation of motion (p < 0.001) and higher rate of activities reduction (p = 0.026).
Patients in Group A took an average of 6.9 months (range: 4 months to 11 months; standard deviation [SD] = 2.4) to achieve union. In comparison, patients in Group B took an average of only 5.6 months (range: 4 months to 9 months; SD = 1.1) to union and those in Group C averaged 5.1 months (range: 4 months to 6 months; SD = 0.5) (p = 0.009) to union.
Six of the patients in Group A had limited ankle motion, compared to two patients in Group B and only one patient in Group C (p = 0.47). Four patients in Group A developed posttraumatic arthritis, compared to only one patient in each of Groups B and C (p = 0.25). In addition, seven patients in Group A reduced their activities, while all the patients in groups B and C maintained their activity level.
“Type C pilon fractures are very demanding injuries that require meticulous preoperative planning,” said the authors. “Two-staged plating provides good results regarding union and range of motion.
“In addition, the ring hybrid fixator with ankle sparring using a mini arthrotomy to have direct visualization to the fragments is also useful for type C fractures. The patients should be strictly followed during the postoperative period as there is a tendency to lose the reduction.”
The lead researcher is Panagiotis S Koulouvaris, MD, PhD; additional researchers include Kosmas Stafylas, MD; Grigoris Mitsionis, MD; Marios Vekris, MD; Alexandros Mavrodontidis, MD, and Theodoros Xenakis, MD—all of Ioannina, Greece. The authors report no conflicts of interest.