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Med. J. Cairo Univ., Vol. 77, No. 4, June: 101-108, 2009
www.medicaljournalofcairouniversity.com
Management of Comminuted Tibial Pilon Fractures by Ilizarov
External Fixation
AHMED KHOLEIF, M.D.
The Department of Orthopedics, Faculty of Medicine, Cairo University.
Abstract
Various types of external fixators have been used to treat
Ruedi and Allgöwer Type III pilon fractures, as serious complications can occur using conventional treatment princi-ples. However, insufficient reduction and loss of reduction are the two main disadvantages of external fixator treatments.
This is a case series involving 15 patients with comminuted
closed fractures of the distal tibia (Ruedi type III) treated
using cross ankle external fixators. Five patients underwent
closed reduction, while the others required open reduction
using minimal incision techniques. The reduction score, reduction loss, early and late complications, and ankle symp-toms and functions were evaluated.
The mean duration of external fixation was 15.9 ±3.7 weeks. The patients were followed for an average of 20.1 ±4.1 months (range: 12-26 months). We achieved excellent to good
articular reduction in 66.7% of the patients. Fracture union
was achieved in all patients with only one case of malunion at 16º of varus encountered. Superficial wound infection
developed in one case. Pin tract infection was the most commonly encountered complication (60%) but all cases
responded well to antibiotic therapy.
In conclusion, treatment of pilon fractures by external fixation, using Ilizarov fixators, is a reliable method for
stabilization and healing of high-energy distal tibial intra-articular fractures with acceptable frequency of soft tissue
complications.
Key Words: Ilizarov – External – Fixation – Pilon –
Fracture – Tibia.
Introduction
PILON fractures represent a challenging area of
fracture surgery. These fractures can result from
a high-energy axial compression mechanism caused
by falls or motor vehicle accidents or lower-energy torsional mechanisms [1-3] . The high-energy mech-anisms have proved to be more challenging, with worse outcomes. Several strategies were suggested
to avoid the risk of soft-tissue complications in these cases [4-6] . Soft tissue component is consid-ered the main limitation to treatment, and hence
may be the primary determinant of the outcome
especially in open fractures [7] .
Several methods have been proposed for the
treatment of pilon fractures of the tibia [8,9] . Open reduction and internal fixation was used initially
but it is now known that open reduction increases
the risk of complications after high-energy trauma [10,11] . To minimize the risk of postoperative com-plications, methods combining external fixation with minimally invasive fixation materials were developed. Today, various external fixation meth-ods such as circular, unilateral, and hybrid frames
exist [8,9,12,13] . External fixation aims to reduce
fractures by ligamentotaxis but it is difficult for
an external fixator to reduce the tibial articular
surface alone [12,13] .
The Ilizarov fixator does not violate the soft tissues, hence it can suite intra-articular commi-nuted fractures of the tibial pilon with questionable soft tissue integrity. It can also help achieve arthro-diastasis. This study presents a case series of Ilizarov treatment of complex tibial pilon fractures
to analyze its clinical and radiological outcome as
well as complications encountered.
Methods
This study involved 15 patients with complex tibial pilon fractures of type III according to the Ruedi and Allgöwer classification [10] . We treated them with percutaneous reduction and fixation with the Ilizarov fixator from July 2005 to Decem-ber 2007. All of the fractures were closed; open
injuries were not included. Nine injuries were the
results of traffic accidents, and the other six were
falls from heights. Four patients had additional injuries: two had vertebral fractures, one a femur
fracture, and one a contralateral tibial diaphysis
fracture.
101
102 Management of Comminuted Tibial Pilon Fractures
On the day of admission, all patients were put in below knee posterior slab with elevation of the
lower limb over a Bohler-Braun splint, and mea-sures were taken to avoid edema. Anteroposterior
and lateral radiographs were carefully analyzed. Operations were delayed for an average of 3-5
days to allow tissue swelling to subside.
Early complications, the reduction score of the articular surface, reduction loss, symptomatic and
functional evaluation of the ankle, and osteoarthro-sis findings were reported for the patients. The
quality of the operative reduction was based on the initial postoperative roentgenograms and the criteria proposed by Ovadia and Beals [14] and modified by Teeny and Wiss [15] . The quality of reduction, in a variety of aspects, was rated numer-ically: widening of the mortise, tilt or displacement of the talus, fibular shortening, and gaps in the articular surface (Table 1).
Table (1): Scoring criteria for quality of reduction according
to Teeny and Wiss [15] .
Anatomical site Quality of reduction
Score
1 2 3
Lateral malleolus displacement
0-1 mm 2-5 mm 5 mm
Medial malleolus displacement
0-1 mm 2-5 mm 5 mm
Posterior malleolus displacement
0-0.5 mm 0.5-2 mm 2 mm
Mortise widening 0-0.5 mm 0.5-2 mm 2 mm
Fibular widening 0-0.5 mm 0.5-2 mm 2 mm
Talar tilt 0-0.5 mm 0.5-2 mm 2 mm
Articular gap 0-2 mm 2-4 mm 4 mm
Surgical technique: The limb was positioned on the table, and closed
reduction of the fracture by traction and manipu-lation was attempted in all the patients. If the
fibular length could not be restored by traction, an open reduction and plate osteosynthesis of the
fibula was carried out. Fibular plating was required in 3 patients. The uppermost Ilizarov ring was placed at the level of the fibular head. Four rods
were then placed with an attached ring approxi-mately 2 cm proximal to the fracture. Four rods
were then attached to the third ring just proximal
to the ankle joint. No wires were placed in the second or third rings at this stage. A calcaneal wire was then placed and attached to the fourth most
distal ring. The construct consisted of 3 proximal full rings along the shaft of the tibia with the most
proximal ring tensioned with wires, connected to
the tensioned calcaneal half-ring. Traction was
applied manually to the calcaneal half-ring, and
the bolts were secured. Reduction of the large
metaphyseal unreduced fracture fragments was
attempted using the olive wires through two meta-physeal rings. This usually resulted in a well-aligned fracture pattern. The decision on whether to use limited internal reduction with fixation was
now determined based on the intraarticular fracture
pattern. Generally, less than 2 mm was considered acceptable. If limited internal reduction with fixa-tion was needed, the limb was elevated and the tourniquet inflated before a small incision necessary to elevate the depressed fragments was made. This was needed in nine patients were mini open fixa-tions were done mainly by using interfragmentary
screws. In three patients with large metaphyseal
bone defects and articular depression, elevation and ipsilateral autogenous iliac crest cancellous
bone grafting was performed through a medial metaphyseal cortical window. For definitive treat-ment, attention was directed to rings 2 and 3. Under
direct fluoroscopic guidance, with previously de-termined fracture pattern awareness, olive wires
were placed to reduce and "squeeze" the fracture
pattern in a very methodical way. Generally, two
wires were placed proximal to the fracture, with
three wires placed in the distal fracture just above and parallel to the ankle joint. Care was taken to
prevent tethering of muscles or tendons by exten-sion or flexion of the foot as indicated.
Postoperative management: Intravenous antibiotics (a third generation ceph-
alosporin) were given for 48 hours postoperatively.
Antibiotic prophylaxis was prolonged until wound
closure. Intramuscular NSAID injections (diclofen-ac 75 mg) were usually needed in the first few
days postoperatively. Intravenous anticoagulants
were ensued when associated injuries prevented
early ambulation.
All patients started gentle ROM exercises of the knee on the second to the fifth postoperative
day. With most frames, the patient can achieve 90 ° of flexion while the circular frame is in place.
The half-ring was removed at the first follow-up after 6 weeks on an outpatient basis. The calca-neal half-ring used for joint distraction helped to
prevent equinus contracture of the ankle.
Active and passive ankle mobilization was then started, and the non-weight-bearing crutch-walking
was continued for 3 months postoperatively. At
the end of 3 months, the patients were allowed to
Ahmed Kholeif 103
start gradually increasing weight-bearing using a
single crutch with the Ilizarov in position.
Follow-up radiographs were done at 1, 3, 6, 9, and 12 weeks postoperatively. Any displacement, angulation or malalignment discovered postopera-tively or during follow up visits was readily cor-rected by adding plates or hinges in the outpatient
setting. Fixators were removed after clinical and
radiographic evidence of fracture healing. Before
the fixator pins were taken out, loosening of the frame or removal of the connecting rods were done,
then fracture consolidation was tested manually
or the patient was asked to walk. Absence of spring-ing on manipulation or pain on walking indicates full clinical union.
Outcome measures: The primary outcome was measured using a
modification 16 of the system proposed by Mazur
[17] at the last follow-up. Clinical results were
graded as excellent, good, fair, or poor (Table 2).
Osteoarthrosis was graded according to the criteria
of Marsh et al. [18] : Grade 0 indicated no evidence of arthrosis; grade 1, small spurs but no joint space
narrowing; grade 2, osteophytes and some joint-space narrowing; and grade 3, complete loss of the
joint space. Ankle instability was diagnosed by
way of joint space opening on stress radiographs.
Ankle arthritis was diagnosed by painful restriction
of all movements with or without crepitus with radiological evidence of reduced joint space.
Table (2): Modified Mazur classification: Clinical rating.
Rating Results
Excellent (> 92 points)
No pain, normal gait, normal ROM, no swelling
Good (87-92 points) Minimal pain, 3/4 normal ROM, normal gait, trivial swelling
Fair (65-86 points) Aching with use, 1/2 normal motion, normal gait, NSAID mild swelling
Poor (< 65 points) Pain with walking, or rest, 1/2 normal motion, limp, swelling
ROM
: Range of motion. NSAID
: Nonsteroidal anti-inflammatory drugs
Results
Table (3) shows the detailed characteristics of the 15 patients involved in the study. The age of the studied group ranged between 19 and 56 years with a mean of 35.9 ± 11.6 years. Only 2 females (13.3%) were included.
Table (3): Details of the characteristics of the 15 studied cases.
Case Age Sex Injury
mechanism Reduction
type Reduction
score Duration
of fixation Follow-up
(month) Osteoarthrosis
grade Ankle score
1 34 M Fall Closed Good 14 24 1 Good 2 46 M MCA Mini-open Good 12 19 1 Poor 3 19 M Fall Closed Good 21 12 1 Good 4 22 M MCA Mini-open Anatomic 12 26 0 Excellent 5 50 M Fall Closed Fair 18 16 3 Fair 6 48 M MCA Mini-open Poor 15 22 3 Poor 7 30 F Fall Closed Fair 16 18 1 Good 8 27 M MCA Mini-open Good 14 20 2 Fair 9 56 M MCA Mini-open Good 24 14 1 Fair 10 39 M Fall Mini-open Fair 12 24 3 Good 11 32 M MCA Closed Good 14 20 1 Good 12 25 M MCA Mini-open Good 20 18 1 Excellent 13 23 F MCA Closed Fair 18 24 3 Good 14 46 M MCA Mini-open Good 16 25 3 Good 15 42 M Fall Mini-open Good 12 20 3 Good
MCA: Motor car accident.
The mean duration of external fixation was 15.9±3.7 weeks, and the mean follow-up time was
20.1 ±4.1 months (range: 12-26 months). Reduction
of the fracture was either mini-open (60%) or
closed (40%). The articular reduction was consid-ered excellent or good in 10 ankles (66.7%), fair
in 3 and poor in 2 (Fig. 1).
Fracture union was achieved in all patients;
secondary bone grafting was not needed. No neu-rovascular injuries occurred due to Ilizarov fixation.
The patients achieved full weight-bearing walk-ing without crutches within an average of 21 ±4.4 weeks (range 18-26 weeks). One of our patients
Good 53.3%
Poor 13.3% Excellent
13.3% Fair
20.0%
104 Management of Comminuted Tibial Pilon Fractures
had loss of fixation of the medial articular fragment,
leading to fracture malunion in 16 ° of varus. Al-though nine patients had 1-2 mm articular depres-sion, only four developed ankle arthritis.
The movements of the ankle ranged from 5 ° to 15° of dorsiflexion and from 5 ° to 35 ° of plantar flexion (Fig. 2 and Fig. 3). The range of motion is
shown in Table (4) recorded for all patients. Three patients had symptoms or signs of mediolateral
instability. Osteoarthrosis grade in the 15 patients is shown in Table (5). Using the modified Mazur classification, the procedure resulted in excellent
and good outcome in 10 cases representing 66.7%.
Ten patients (66.7%) faced minor complications;
9 (60%) had pin tract infection; that was treated
with oral antibiotics and dressings. One patients
developed wound infection; the infection was controlled with parenteral antibiotics. No cases of
serious infection were recorded.
Fig. (1): Grading of the reduction score of the 15 cases.
Fig. (2): A case of 30 years old female with highly comminuted pilon fracture after fall from 4 th floor.
Fig. (2-A): Preoperative AP & Lat x-rays. Fig. (2-B): Post operative x-rays.
Fig. (2-C): X-rays at final follow up.
Fig. (3-A): Preoperative AP & Lat x-rays. Fig. (3-D): Range of motion at follow-up.
Fig. (3-B): Post operative x-rays.
Fig. (2-D): Range of motion at follow-up.
Fig. (3): Showing comminuted Pilon fracture in a 46 years old male after MCA.
Fig. (3-C): X-rays at final follow-up.
Ahmed Kholeif 105
106 Management of Comminuted Tibial Pilon Fractures
Table (4): Mean values of Range of motion for all patients.
Treated side Contralateral side
Dorsiflexion 11.2° 24° Plantar flexion averaged 19.5° 36° Inversion 4.4° 10.5° Eversion 4.7° 13 °
Table (5): Outcome of the procedure in the 15 studied cases.
Number Percent
Osteoarthritis grade:
0 1 6.7 1 7 46.7 2 1 6.7 3 6 40.0
Ankle score: Excellent 2 13.3 Good 8 53.3 Fair 3 20.0 Poor 2 13.3
Complications 10 66.7
Discussion
The most important principle to be considered for the successful treatment of tibial plafond frac-tures is the anatomic reduction of the joint surface [15,19-23] . Three decades ago, Ruedi et al. [10] re-ported that the anatomic restoration of the joint
surface could only be achieved through open re-duction and internal fixation. However, this ap-proach can result in serious complications owing to the nature and complexity of this type of fracture.
Minimally invasive techniques for reduction
of the articular fragments combined with stable fixation through an external device have been employed in more recent years [12,13,19,24-26] .
In this study, we treated our patients with per-cutaneous reduction and external fixation with Ilizarov apparatus. Circular frames with tension wires, like Ilizarov fixator, provide better stabili-zation especially in comminuted lesions and control
the fracture in all three planes of the reduction [26- 31] . External fixation techniques preserve soft tis-sues and the periosteum and yet provide stable
reduction. Ilizarov fixators, being very economical,
are suitable for patients of the developing countries
as in Egyptian population.
In a prospective randomized trial of plating versus external fixation of tibial pilon fractures,
Wyrsch et al. [32] concluded that external fixation of these fractures is associated with clinical out-comes similar to those obtained with traditional
methods of open reduction and internal fixation
but with significantly fewer complications. Simi-larly, Watson et al. [33] showed that there is a significantly higher complication rate with the use
of open plating techniques in fractures of the distal
tibia, and this is probably related to the amount of
dissection and stripping of soft tissues needed to
achieve reduction and plate fixation. Conroy et al. [34] reported good functional outcome and reduced
rates of amputation and infection after early internal fixation and soft tissue cover with vascularized
muscle flap.
We achieved excellent or good articular reduc-tion in 66.7% of patients. Using external fixators,
previous studies reported variable degrees of suc-cess from 69% [35] and 71.4% [36] to 90% [19] and 95% [13] . Vidyadhara and Rao [37] reported excel-lent or good functional results in 76% of 21 patients
with complex tibial type B and C pilon fractures.
Bonar and Marsh [38] treated a group of 49 patients by with trans-articular external fixation
and used limited surgical exposures to accomplish a small degree of internal osteosynthesis. They described an anatomic reduction in none, a good
reduction in 69%, fair in 20% and poor in 11%.
Barbieri et al. [19] also treated 37 fractures in 36 patients with external fixation and minimal internal
osteosynthesis.
On the other hand, Teeny [15] reported anatomic reduction in only 30% type III fractures using open reduction and internal fixation, while success rates were 77% for Ovaida and Beals [14] and 50% for Etter and Ganz [21] .
Similar to our results, many authors have re-ported satisfactory results using the two-staged protocol and shown a decrease in soft-tissue com-plications [4,25] . Patterson and Cole6 retrospectively
reported the outcomes of 22 cases of type C3 pilon
fractures with 77% good results, 14% fair results,
and 9% poor results. They had no infections or
soft-tissue complications.
In this series, 66.7% of patients had pin tract, while only one case developed wound infection. All patients responded well to antibiotic therapy.
Soft tissue complications and deep infections are
not frequent when external fixation is combined
with minimally invasive surgery: Wyrsch [32] had infections in 5%, Tornetta [12] in 1 out of 17 cases, Barbieri [19] in 3 out of 37 cases.
Ahmed Kholeif 107
Sirkin et al. [39] reported partial skin necrosis
that healed with local wound care in 5 of 34 patients
(15%) with closed fractures, in addition to one patient who developed a chronic draining sinus
from osteomyelitis that resolved after fracture
healing. In a retrospective study [25] of 37 type II and III pilon fractures, infection occurred in only
8% of patients. They achieved good to excellent outcomes in 81% of patients.
Harris et al. [40] reported an overall complication rate of 14%, including 2.5% wound complication,
4% infection, 2.5% nonunion, 5.1% malunion, and 39% posttraumatic arthritis in 79 high-energy type
C3 fractures.
The risk of non union and malunion in presence
of instability is higher. In a report by Dillin and Slabaugh [11] , there was 55% infection and 36% wound dehiscence rate with unstable internal fix-ation.
In conclusion, treatment of pilon fractures by
external fixation, using Ilizarov fixators, is a reliable
method for stabilization and healing of high-energy
distal tibial intra-articular fractures with acceptable
frequency of soft tissue complications.
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