TYPE-C FRACTURES OF THE TIBIAL PYLON - CO MPARISON OF DIFFERENT METHODS OF SURGICAL-MANAGEMENT

Between 1982 and 1992, 79 pylon fractures were treated with internal f ixation as the primary treatment at the trauma department of the Hanno ver Medical School. In a retrospective study 71 patients were evaluate d, and 51 of them were re-examined clinically and radiographically an average of 68 months after injury. The purpose of this study was to co mpare these different forms of surgical management concerning their lo ng-term results: 1. Minimal invasive internal fixation for reconstruct ion of the joint with external transfixation of the ankle joint and/or plaster cast until bony healing occurred. 2. Primary internal fixatio n with plating of tibia and fibula following the AO techniques. 3. Int ernal fixation with a plate applied in a second step after initial rec onstruction of the joint with minimal internal fixation and short-term external transfixation. Evaluation was based on the infection rate, t he development of posttraumatic arthritis and the range of motion in t he ankle joint as objective criteria. Subjective criteria were pain, s welling, and restrictions of working or leisure activities. Although o nly closed fractures were treated primarily by internal fixation with plating no significant differences between the three groups were found in the classification of fractures and soft tissue damage. All but 4 fractures were type-C lesions according to the AO classification, and 19 patients sustained open injuries. The infection rate for minimal in vasive internal fixation was significantly lower with a two-step proce dure (group 3) than with the one-step procedure according to a suitabl e statistic test (P<0.01). No significant correlation was detected eit her between the soft tissue damage and the degree of arthritis or betw een type of management and extent of post-traumatic arthritis. In 23% of all cases a secondary arthrodesis was necessary, but none had been needed in group 3 by the time of follow-up. Comparison of the function in the different groups revealed that the range of motion was much le ss restricted after minimal invasive internal fixation. These patients also had less pain and more of them were able to go to work and take part in leisure activities. These differences were not statistically s ignificant, however. In view of these results, a two-step procedure wi th primary reconstruction and internal fixation of the joint with as f ew implants as possible, external transfixation of the ankle joint and internal plate fixation of the tibia in a second step after soft tiss ue consolidation is recommended for the treatment of severe tibial pyl on fractures with extensive soft tissue damage.