Surgical options for the treatment of severe tibial pilon fractures: A study of three techniques

Objective: To determine whether long-term results of one of three different management protocols for severe tibial pilon fractures offer advantages ov er the other two. Design: In a retrospective study, patients were examined clinically and rad iologically after internal fixation of severe tibial plafond fractures (i.e ., 92 percent Type C fractures according to the AO-ASIF classification). Setting: Department of Traumatology, Hanover Medical School. Level I trauma center. Patients: Fifty-one of seventy-seven patients treated between 1982 and 1992 were examined clinically and radiologically at an average of sixty-eight m onths (range 13 to 130 months) after injury. Interventions: The patients were treated in three different ways: primary i nternal fixation with a plate following the AO-ASIF principles (n = 15), wh ich was reserved for patients with closed fractures without severe soft tis sue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least four weeks (n = 28); and a two-stage procedure enta iling primary reduction and reconstruction of the articular surface with mi nimally invasive osteosynthesis and short-term transarticular external fixa tion of the ankle joint followed by secondary medial stabilization with a p late using a technique requiring only limited skin incisions (a reduced inv asive technique) (II = 8). Main Outcome Measurements: Objective evaluation criteria were infection rat e, amount of posttraumatic arthritis, range of ankle movement, and number o f arthrodeses. Subjective criteria were pain, swelling, and restriction of work or leisure ac-ria were pain, swelling, activities. Results: Because only closed fractures were treated by primary internal fix ation with a plate, there was a statistically significant difference (p < 0 .005) in the distribution of open fractures between the three treatment gro ups. Fracture classification in these groups were not significantly differe nt. All but four fractures were classified as Type C lesions according to t he AO-ASIF system. The soft tissue was closed in 63 percent (n = 32) and op en in 37 percent (n = 19). No significant relationship could be found betwe en the soft tissue damage and degree of arthritis or between the type of su rgical treatment and extent of posttraumatic arthritis. However, none of th e patients who required secondary arthrodesis (23 percent of all cases) wer e in the group who had undergone two-step surgery (p < 0.05). The range of ankle movement was much greater in the two-step group than in the others; t hese patients also had less pain, more frequently continued working in thei r previous profession, and had fewer limitations in their leisure activitie s. These differences did not reach statistical significance. The incidence of wound infection did not differ significantly among the three groups. Conclusions: On the basis of our results, we now prefer a two-step procedur e for the treatment of severe tibial pilon fractures with extensive soft ti ssue damage. In the first stage, primary reduction and internal fixation of the articular surface is performed using stab incisions, screws, and K-wir es. Temporary external fixation is applied across the ankle joint. After re covery of the soft tissues, the second stage entails internal fixation with a medial plate using a reduced invasive technique.