Session IX - Foot & Ankle
*Tibial Plafond Fractures - Do These Ankles Function Over Time?
J. L. Marsh, MD; Dennis Weigel, MD; Douglas Dirschl, MD, University of Iowa Hospitals and Clinics, Iowa City, IA (all authors - a,b-EBI Medical)
Introduction: Many recent studies report the short term results of tibial plafond fractures treated with external fixation, but there is no data on how these ankles function at longer follow-up. The purpose of this study was to assess the pain, function, health-related quality of life, and the development of arthrosis at a minimum five years after injury in a group of patients treated with a uniform technique of external fixation and limited internal fixation, and when available compare those results to those obtained at an earlier follow-up.
Methods: Between 1989 and 1994 we treated 52 patients with tibial plafond fractures using this technique. Thirty-five ankles in 31 patients were located, contacted and agreed to return for a physical examination, patient questionnaire, SF-36, SMFA, Ankle Osteoarthrosis Score, and weight bearing ankle radiographs. Injury radiographs were classified according to AO/OTA and ranked for injury severity. Reduction was graded according to Burwell and Charnley and ranked on a 1-10 scale. Arthrosis was assessed on follow-up radiographs using a four grade scale. An Iowa Ankle Score was calculated and compared to a previously recorded score in nine ankles.
Results: The average duration of follow-up was 79 months (range 60-169) and the average age at follow-up was 44 (27-70). Twelve were open fractures (2-I, 2-II, 8-III). There were 10 B fractures (1-B1, 1-B2, 8-B3) and 25 C fractures (3-C1, 10-C2, 12-C3). The reduction was good-16, fair-14, poor-5. The average Iowa ankle score was 78 (28-96). Of the nine with previously recorded Iowa ankle scores, all had improved at recent follow-up. Average ankle range of motion was 10° dorsiflexion to 29o plantar flexion and subtalar motion was 10o of inversion and 9o of eversion. The majority of ankles had radiographic arthrosis (Grade 0-5, I-5, II-20, III-5). Eleven patients were laborers, ten were nonlaborers, seven considered themselves disabled, and one was not working. Fourteen patients changed occupation because of their ankle injury. On average, patients had poorer scores than age matched controls for SF-36 and SMFA. Patients reported a prolonged time to maximal healing (average 2.4 years). Injury severity and quality of reduction predicted the development of radiographic OA. However, there was no correlation between radiographic OA and clinical measures of function and health related quality of life.
Conclusion: Fractures of the tibial plafond have a long term effect on ankle function, patient pain, and health related quality of life. Despite this, the clinical results do not deteriorate over time, and most patients actually percieve that they improve for a long time. Arthrosis is present in the majority of patients, but does not correlate with clinical outcome. Fracture pattern, reduction or patient demographics did not have a statistically significant effect on clinical outcome measures.