Analysis of the variables affecting outcome in fractures of the tibial pilon treated by open reduction and internal fixation

Abstract

Objective: To assess variables that could be related to outcomes in fractures of the tibial pilon treated by open reduction and internal fixation (ORIF).

Design: Retrospective.

Setting: University Hospital.

Patients: A total 92 fractures of the tibial pilon treated by ORIF in a 5-year period. The minimum follow-up was 1 year (mean: 3.3 years; range: 1-5).

Intervention: ORIF with LCP-LISS plate.

Primary outcome measurements: Age, sex, side, type of fracture, energy of the injury, provisional external fixation (EF), time until ORIF, stages of treatment (one or two), surgical approach, type of bone fixation, quality of reduction, bone graft, hardware removal, associated fractures (fibula and others), functional results (AOFAS scale), rates of infection, skin necrosis, flap coverage, non-union, and early posttraumatic ankle osteoarthritis (AOA).

Results: According to AOFAS scale 30.5% of results were excellent, 46.7% good, 13.1% fair and 9.7% poor. Overall, the rate of infection was 13.04%, The rate of non-union was 10.86%. The rate of skin necrosis was 7.6% and the rate of flap coverage was 13.04%. The rate of early posttraumatic AOA was 13.04%. Type 43C3 fractures of the AO classification had a higher rate of skin necrosis and flap coverage. Open fractures were related to a higher prevalence of nonunion and flap coverage. The use of a bone graft was associated with a higher rate of nonunion and poor results. Infection was related to a higher prevalence of fair and poor results. EF was associated with a higher need for flap coverage. A suboptimal anatomic reduction was related to a higher rate of fair and poor results. The anteromedial approach was associated with a higher prevalence of skin necrosis and early posttraumatic AOA than the anterolateral approach. The use of an medial plate was related to a higher rate of nonunion than the use of a lateral plate.

Conclusions: The anteromedial approach was associated with a higher rate of skin necrosis and posttraumatic AOA than the anterolateral approach. Medial plating had a higher prevalence of nonunion than lateral plating.

Level of evidence: IV (case series).

Keywords: Complications; Fractures; Osteosynthesis; Outcomes; Tibial pilon.

Fig. 1

(A–K) Open tibial pilon fracture. A 44-year-old man suffered an accident with trauma to his right ankle. An external fixator (EF) was implanted in the emergency department. Fifteen days later days the definitive open reduction and internal fixation (ORIF) was carried out. The result was good: (A) AP radiograph of the tibial pilon fracture. (B) Lateral view of the fracture. (C) AP radiograph after the implantation of the EF. (D) Lateral radiograph with the EF. (E) Axial view of the postoperative CT scan performed. (F) Saggital view of the postoperative CT scan. (G) Coronal view of the postoperative CT scan. (H) AP postoperative radiograph. (I) Lateral postoperative radiograph. (J) AP radiograph 5 years later. (K) Lateral radiograph at 5 years follow-up.

Fig. 2

(A–M) Closed tibial pilon fracture. A 54 year-old male suffered a fall from 7 m high with blunt trauma to his right ankle. An external fixator (EF) was implanted in the emergency department. Nine days later days the definitive open reduction and internal fixation (ORIF) was carried out. The result was poor, with early posttraumatic ankle (AOA) osteoarthritis that required an early ankle fusion 15 months after the initial injury: (A) AP radiograph showed a closed fracture (type 43C3) of the tibial pilon. (B) Lateral view of the fracture. (C) AP radiograph after the implantation of the EF. (D) Lateral radiograph with the EF. (E) 3-D CT scan showing the fracture. Note gap and step-off. (F) AP radiograph after open reduction and internal fixation (ORIF) of the tibia that was carried out with two plates (anteromedial and anterolateral). Reduction was not satisfactory (note the step-off). (G) Lateral radiograph after ORIF. (H) AP radiograph 15 months later showing early posttraumatic AOA. (I) Lateral radiograph 15 months later showing early posttraumatic AOA. Ankle fusion was indicated. (J) AP radiograph after ankle fusion. (K) Lateral radiograph after ankle fusion. (L) AP radiograph 2 years after ankle fusion. (M) Lateral radiograph 2 years after ankle fusion.