Staged procedure protocol based on the four-column concept in the treatment of AO/OTA type 43-C3.3 pilon fractures

Abstract

Objective: We herein introduce a staged management protocol for AO/OTA type 43-C3.3 pilon fractures based on the four-column theory designed to protect the soft tissue.

Methods: Twenty-three patients with 25 type C3.3 pilon fractures underwent a staged procedure with four-column osteosynthesis from April 2014 to December 2016. The first stage involved immediate calcaneal traction or external fixation to span the ankle joint. When the soft tissue swelling decreased, the posterolateral approach was used to restore the lateral column and initially fix the posterior column. After 10 to 12 days, the third stage involved treatment of the anterior and medial columns through the anterior approach. Charts and radiographs were reviewed, and the American Orthopaedic Foot and Ankle Society (AOFAS) evaluation system was used to evaluate the postoperative outcomes.

Results: All fractures achieved union after a mean of 3.3 months (range, 2.0-5.7 months) after the third stage. A good or acceptable reduction rate was observed in 85.7% of the patients. Results from the AOFAS evaluation system indicated excellent or good postoperative ankle function in 81.0% of the patients.

Conclusion: This staged procedure protocol combined with the four-column theory is a feasible way to protect the soft tissue and reduce the fracture.

Keywords: Pilon; ankle; four-column concept; fracture; soft tissue; staged procedure.

Figure 1.

Schematic layout of four-column classification of tibial plafond. (a) Axial view of tibial plafond. (b) Anterior view of distal tibia. (c) Posterior view of distal tibia.

Figure 2.

External fixator was used in the first stage. (a, a’) Coronal and sagittal computed tomography scan of a left type C3.3 pilon fracture. (b, b’) Three-dimensional reconstruction view. (c, c’) Radiograph 2 days after the first-stage surgery.

Figure 3.

(a, a’) Radiograph of a pilon injury in the left ankle of a 42-year-old man. (b, b’) Three-dimensional reconstruction view. (c, c’) Radiograph 2 days after the second-stage procedure. (d, d’) Radiograph 2 days after the final surgery.

Figure 4.

(a, a’) Radiograph of a pilon injury in the left ankle of a 45-year-old man. (b, b’) Coronal and sagittal computed tomography scan of the pilon fracture. (c, c’) Three-dimensional reconstruction view. (d, d’) Radiograph 2 years after the final fixation. (e, e’) Coronal and sagittal computed tomography scan 2 years after the final surgery.

Figure 5.

(a, a’) Radiograph of a pilon injury in the right ankle of a 45-year-old man. (b, b’) Coronal and sagittal computed tomography scan of the pilon fracture. (c, c’) Three-dimensional reconstruction view. (d, d’) Radiograph 2 years after the final fixation. (e, e’) Coronal and sagittal computed tomography scan 2 years after the final surgery. (f, f’) Clinical outcome 2 years after the final surgery.