Session IX - Foot & Ankle
The Treatment of 100 Tibia/Fibula, Distal Segment (43) Fractures with Circular Tensioned Wire Fixators
James J. Hutson, Jr, MD; Gregory A. Zych, DO, University of Miami School of Medicine, Miami, FL
Purpose: To evaluate the treatment of 100 distal tibia/fibula fractures in 96 patients treated prospectively over a 9-year period (1991-1999) at an urban level I trauma center with circular tensioned wire fixation.
Methods: Twenty-seven Type A fractures (A1, 3; A2, 3; A3, 21) and 73 Type C3 fractures (C1,4; C2,16; C3, 53) were treated with circular fixators. Thirty-nine percent were open (GI, 3; GII, 21; GIIIA, 4; GIIIB,11). Four patients with fractures had leg and foot compartment syndromes, and one patient with a fracture had a foot syndrome. Forty-six fractures were stabilized with percutaneous reductions and frames not extending past the ankle. Fifty-four patients had bridging ankle frames, 20 had percutaneous reductions, and 34 had limited open reductions. Autologous bone graft was used in treating 7 fractures, cancellous allograft in 7 fractures, proximal bone transport in 6 fractures, and acute shortening in 3 fractures to reconstruct bone loss. Forty-five fractures were treated with limited external fixation with screws or free Steinmann pins. Fibular fixation of fractures was done in 24 patients; 10 tubular plates and 14 intramedullary pins were used. The bridging foot frame was removed 6 weeks after surgery to start ankle motion except for 4 acute arthrodesis and 6 bone transports to close defects. Frame removal was done when the fracture was healed and the patient could walk with full weight bearing with the frame loosened.
Results: Ninety fractures healed primarily. Four fractures had nonunion; 2 healed with fracture bracing and 2 required a revision circular frame for healing. Four fractures were treated by acute arthrodesis: 2 for severe comminution and 2 for comminution and infection. Two fracture patients were lost to follow up. Average ankle motion was 5° dorsiflexion to 25° plantar flexion. Average frame time was 23 weeks (6-78). Average follow-up was 12 months (6-96 months).
Complications included 10 pin tract infections, 6 deep infections, 1 septic arthritis, and 2 valgus malunion at 10°. Thirteen infectious complications were treated successfully with intravenous antibiotics, and 3 fractures required debridement and ankle arthrodesis. Two fractures have had late arthrodesis for traumatic arthritis. No nonunion or deep infection was associated with fibular fixation. No internal fixation screw was associated with infection. All deep infections occurred in C3 fractures. No patient had a wound dehiscence or required free flaps. No fracture reduction was lost due to loss of fixation by the circular fixator.
Discussion: Ninety-eight fractures healed or had arthrodesis as an outcome. One fracture patient has a chronic osteomyelitis. Nonunion and varus has been observed at a high percentage in some series using hybrid fixators. It is our opinion that circular fixators offer technical advantages over hybrid fixators in manipulating and stabilizing distal tibia fractures and can incorporate acute shortening and bone transport to achieve union. The average frame time in our series was longer (23 weeks) because the fixator was not removed until clinical and radiographic union. Higher nonunion rates are associated with reduced fixation time. It is our opinion that the greatest drawback to circular wire fixation is the infection problem with wires, (17%) which requires the aggressive use of intravenous antibiotics and may have long-term repercussions not yet identified.
Conclusion: Circular wire fixation is an effective method for treatment of distal tibia periarticular fractures with a fracture union rate of more than 90%. Infections from wires can be treated successfully, but it is the major drawback to the method. The incidence of soft tissue complication such as wound necrosis, dehiscence and need for free tissue transfer is minimal.