External fixator supplemented with screw fixation versus staged open reduction and internal fixation tibial pilon fracture

INTRODUCTION

Tibial plafond fractures are life-changing events that affect the patient's life. It keeps a unique place as an ideal opposing traumatic injury to each orthopedist. The main goals in treating such injuries are to reconstruct the articular surface that should be repaired conveniently and modulary, along with stable fixation that allows for an early range of motion to avoid stiffness. All these goals must be taken into account regarding the state of the soft tissues as it is the mostly affected injury site. The main intent is to avoid complications such as infection, wound dehiscence, and osteomyelitis that may lead to amputation, which is the frustrating end. ³      Fractures of the tibia due to either low-energy rotational injury or high-energy axial compression mechanisms. The higher energy mechanism is associated with further crushing and large soft tissue injury. Due to the axial injury mechanism, the exclusion of concomitant injuries is very important from the ipsilateral foot to

the lumbar spine. Companionship between compartment syndrome and pilon is low ( occurs in 0% to 5% of cases) in contrast to the more proximal tibial ones. ⁸

Soft tissue management is the primary determinant of fracture healing and restoration of affected limb function. Of the skin delicate inspection of abrasions, open wounds and blisters should be performed on the association with a complete vascular evaluation of the affected limb. It is imperative to realize that many concurrent comorbidities can affect definitive treatment of open fractures as well as soft tissue injuries. Thus, having a history of the concurrent diseases of the patient (diabetes, and ischemic disorders, chronic venous insufficiency, and nutritional deficiencies, autoimmune connective tissue disorders), the use of nicotine (peripheral vascular disease) is of great value.^16,29

It is interesting to note that some of the key factors purposefully lead to poor outcomes as published by Pollack et al. In his retrospective analysis of 103 patients who underwent surgical treatment for pilon fractures, they proposed that those who had two or more accompanying chronic diseases, married, annual compensation of less than $ 25,000, and had no high school diploma obtained unsatisfactory outcome. ^29,28

Ruedi & Allgower suggested ²⁹ surgical tactics to help facing such injuries. They emphasized the importance of ideal restoration of fibular length with ideal reduction and fixation as it is considered the lateral column to help correct the distal tibial valgus deformity with subsequent anatomical restoration of articular surface with metaphyseal grafting associated with medial tibial buttressing to neutralize rotational forces and prevent varus angulation.. ²⁴

Careful planning for the usage of exhaustive investigations like CT is mandatory for best outcomes it can provide a thorough picture of injury pattern that facilitates confronting the problem., Classically it is best to use it after interim stabilization to delineate the fragmentation pattern  extension . ¹²

Lateral column or fibular fixation remains a surgeon preference issue. Fibular length and rotation must be ideally retained with careful stabilization tactic as these injuries are more complicated than the other simpler malleolar patterns. ¹

The final tibial fixation method is multifactorial and predictable based on the experience of the surgeon, the extent of fragmentation, and the degree of soft tissue damage. Bearing in mind that each surgical procedure owns favors and disfavors, Pilon fractures can be permanently repaired with an external fixator of the Ilizarov type or hybrid ring, or minimally invasive tactic, or LCP, or a combination thereof. ¹

It is crucial to recognize that such injuries has evermore accompanied with perspicuous metaphyseal & articular fragmentation, extensive displacement, articular cartilage impaction, with articular debris are usually seen. Dual staged protocol involve interim external fixator construct that aids ideal ankle alignment with subsequent resolution of attacked soft tissues gathered with ideal restoration of ankle joint dimensions to facilitate final surgery. Angular distortions in either the sagittal or coronal direction must be corrected using external tibia construct, and early fixation of the fibula may help make this more predictable. Skin vitality with potential damage due to stress from displaced bony fragments should be considered and corrected to avoid future complications and skin necrosis. ¹⁴

Eventual fixation of pilon fractures with external fixators has been described by several surgeons. Several authors described multiple studies using different types of external fixators, and many proposed the results to nearly identical to staged open fixation. ²⁵ These methods have typically been associated with mini-invasive tactic to deal with joint surface. ²⁵ Plafond fractures are evidently different from the more commonly noticed malleoli fractures caused by weaker influencing forces on the ankle. Health outcomes and quality of life are among the most important elements to consider in management for such injuries. ⁶

PATIENTS AND METHODS

Patients selected from orthopedic casualty. Those who matched completely with inclusion criteria were included until fully gaining required sample size.

Patients selection was according to certain criteria:-

1-Pilon fractures are types 43 (B&C1, C2, C3)OTA Classification of distal tibial fractures.

2-Primary surgery.

3-Age group was between18-60 years old.

Exclusion criteria:

1-Patients with two or more comorbidities (Malnutrition, Alcoholism, Diabetes, Neuropathy, , Peripheral Vascular Disease and Osteoporosis, long term steroid use)

2-Pathological fractures.

3-Mangled foot injury with transection of the posterior tibial nerve.

4-OTA types 43 A (1,2,3) distal tibial fractures.

The patients ' ages ranged between 2^nd &6^th decades with an average age of 40.6 years , 11 ladies (18%) And 49 male patients (81.6%) included. 28 patients were enrolled with the right leg affected (46.6%) While the remaining 32 patients were left sided (53.3%). Relying on OTA , AO classification system (Figure 1) this study included one patient with 43B1 , And ten Patients with 43B2 , And four patients, type 43B3 And twenty-three patients of type 43C2. Finally, 22 patients were of type 43C3.

Fig 1: Simplified schematic representation of AO/OTA classification of distal tibial fractures where (A) is extra articular,( B )is partial articular injury and( C )is complete articular injury.

Methods:

I- Life support and general management of polytrauma patients(ATLS protocol).

II- Preoperative assessment: Patient evaluation, Radiographic Evaluation, and Planning and time of surgery.

III- Surgical technique.

Surgical steps: Reduction of the pilon fracture was either through open approach or closed techniques, starting usually with fixation of the lateral malleolus followed by tibial pilon. In some cases that fibular fracture is stable with no shortening or rotation fixation of fibula not done.

Reduction techniques:

Operative procedure using external fixator aided with screws maneuver:

  Done Closed mainly with percutaneously reducing the major articular parts , And fixation by supplementary internal fixation with either percutaneous screws Or wires Under the image intensifier, or through open reduction and fixation With screws then we fixed the hinged block to the shaft and the Metaphyseal area, then an external fixation framework is applied with the aim of preserving Reduction. When an open reduction is required, we begin with the grinded portion to change the fracture into a more stable pattern (Figures. 2,3,4).

Fig 2: Preoperative, a: skin condition, b: preoperative x rays AP, c: lateral View,  d & e, C.T. scan axial, f: C.T. coronal, g: C.T. scan sagittal.

Fig 3: a & b: post operative with external fixator., AP view& lateral view, c & d: Postoperative after frame removal, e & f,: after full union AP view& lateral View

Fig 4: After complete union, range of ankle motion. a, Planter Flexion., b: Dorsiflexion, c: bilateral dorsiflexion, d: plantarflexion, and e: During standing, and walking.

Operative procedure using staged fixation maneuvers:

The long-term consequences of Pilon fractures are primarily influenced by the concomitant soft tissue conditions. Aid in the evolution of orthopedic concepts for damage control innovated the idea of maneuvers that aid in early care of a fracture without compromising severely injured soft tissues. These injured structures are allowed to heal while the patient prepares for another procedure that helps rebuild deformed fractured bones.

Timing of surgery:

The condition of affected soft tissues is the main factor in predicting the time of surgery, the presumed optimal surgical tactic. Injured limb initially is deformed, shortened and swollen due to formed hematoma. After 8-12 hours, interstitial edema is the main cause of swelling and is the most important factor in controlling successful wound healing. Poor outcome should be anticipated and so delicate careful inspection of marked soft tissue injury markers as skin and subcutaneous fat contusion with skin blisters and deep abrasions associated with pronounced oedema should be taken into consideration. Blisters filled with blood are a bad sign of complete detachment of the skin, which often indicates poor wound healing, so the skin should be avoided in this area by planning the incision. In some cases, the affected soft tissue area has a wide area of ​​transmission that extends away from the fracture site. Moreover, ischemia develops in the affected area and becomes a maximum of 24 hours and usually develops within 3 to 6 days, so planning needs to be done. The surgeon crucially obliged to consider all these disturbing events to avoid disastrous results.

Surgical steps:

Initially, we start with the external fixator application for the first 24 hours as a damage control measure. We begin with the oscalcis pin insertion (half a pin is inserted when planning the medial delta frame) with the proximal pins closely inserted into the tibia with additional pin inserted into the1st. metatarsal to avoid equinus and finally to form the simplest shape of the delta frame gathered with correcting any sagittal, coronal or transitional distortions and then Maintain reduction by using an external stabilizer. fibular fixation was performed in some cases but was delayed in most cases with final fixation (Figures 5,6)

Fig 5: preoperative x rays, a: Lateral X-rays, b: X-rays AP , c: Coronal Computed tomography , d, axial , e: Three-dimensional, f: Sagittal computed tomography , g & h: immediate  post fixation with external fixator.

Fig 6: a & b post operative with external fixator., AP view& lateral view, c & d, Postoperative after frame removal, e & f,  after full union AP view& lateral View.

IV- Postoperative management and follow up.

Follow up using AAOS foot and ankle outcome questionnaire with added SF36 (figure 7) health survey. The American Academy of Orthopedic Surgeons (AAOS) foot and ankle questionnaire ^{(12, 13)} is a foot and ankle-related disability score (0-100). Higher scores indicate better foot function.

Fig 7: Early after ORIF, a & b: AP.& Lateral respectively . c  d: completely healed fracture AP& LAT. Respectively. e, f & g: range of motion of ankle joint, Dorsiflexion, , Plantarflexion & walking respectively.

RESULTS

In this study, we've got A study showed excellent results in every outcome measure. The current study compared the two study groups according to different variables,: There was a notable difference between the variables in the two groups. Group B showed a higher score than Group A. The AAOS questionnaire includes the Baseline Foot and Ankle Score (20 items) and the Footwear Comfort Scale (five items)^19,26. This score is scored on a scale from 0-100 with a high score representing better results. The score for the AAOS foot and ankle was 76.13 ± 16.04 in group B and 67.57 ± 20.71 in group (A). There was a difference in the mean standard measurement of the ankle core and foot AAOS in the two groups. Group B showed the mean standardized foot and ankle score of AAOS higher than Group A. There was a notable difference in the Normative score of AAOS Foot and Ankle in the two groups. Group B showed the score higher than Group A. Group B showed a higher score regarding standardized mean and normative scores for shoe comfort than group A. Regarding the mean SF36% physical performance in the two groups. Group B showed a higher physical performance of SF36% than Group A.

 In group A; 15 (50.0%) of cases had no complications. 15 (50.0%) of cases had complications: 2 (6.7%) of cases were Nonunuion. 4 (13.3%) of the cases were Malunion. 7 (23.3%) of the cases had a wound problem. 3 (10.0%) of the cases were profound infection. 10 (33.3%) of the cases had ankle joint osteoarthritis. 1 (3.3%) of the cases were CRPS. 4 (13.3%) of the cases was loss of reduction. 1 (3.3%) of the cases were tibiofibular fusion. In group B; 13 (43.3%) of cases had no complications. 17 (56.7%) of cases had complications: 3 (10.0%) of cases were Nonunion. 2 (6.7%) of the cases were Malunion. 3 (10.0%) of the cases had a wound problem. 4 (13.3%) of the cases were profoundly infected. 8 (26.7%) of the cases were ankle joint arthritis. 3 (10.0%) cases were CRPS.1 (3.3%) of cases was the loss of reduction. 1 (3.3%) of the cases were tibiotalar fusion, 1 (3.3%) of the cases were amputations and 1 (3.3%) of the cases were tibiofibular fusion(Figure 8). In this study, Group A showed a shorter period of time from exposure to fixation compared to Group B. No dissimilarity was noted in the average period of time until the Union in the two groups . There was no dissimilarity- between the two groups with regard to complications.

There is a negative relation between Age (years) and AAOS foot and ankle core scale standardized mean in group B. There is a negative correlation between Time interval from injury till fixation and AAOS foot and ankle core scale standardized mean in group B (Tables 1,2,3,4,5).

Fig 8: Comparison between the two studied groups according to complication.

Table 1: Comparison between the two studied groups according to AO classification (c²: Chi-square test, MC: Monte Carl^; p: p-value for comparing between the studied groups).

Table 2: Comparison between the two studied groups according to fibular fixation (c²: Chi-square test, MC: Monte Carl^; p: p-value for comparing between the studied groups).

Table 3: Comparison between the two studied groups according to AAOS foot and ankle core scale standardized mean, AAOS Foot and Ankle core normative score, Shoe comfort standardized score, Shoe comfort normative score, SF36 physical functioning%, SF36role limitation due physical health%, SF36role limitation due emotional problem%, SF36 energy fatigue%, SF36 emotional well-being%, SF36 social functioning%, SF36 pain%, SF36 general health%, and SF36 health changes% (U: Mann Whitney test)

Table 4: Correlation between different parameters in group A (n= 30) (r_s: Spearman coefficient; *: Statistically significant at p ≤ 0.0).

Table 5: Correlation between different parameters in group B (n= 30) (r_s: Spearman coefficient; *: Statistically significant at p ≤ 0.0).