Session V - Foot and Ankle

The Functional Outcomes of Type C3 Tibial Plafond Fractures with Use of a Staged Protocol

Dolfi Herscovici, Jr., DO; Scott Devinney, DO; Mark A. Jenkins, DO; Thomas G. DiPasquale, DO; Anthony F. Infante, DO; Roy W. Sanders, MD; Florida Orthopaedic Institute, Tampa, Florida, USA

Purpose: Fractures of the tibial plafond have been associated with high rates of infection, malalignment, nonunion, and arthrosis. Although staged treatment protocols have decreased wound complications, the question remains whether the ability to perform formal reductions of the joint has resulted in improved patient outcomes. The purpose of this study was to evaluate patients who sustained AO/OTA type 43 C3 tibial plafond fractures that were managed with a staged protocol to determine whether a formal open reduction internal fixation (ORIF) of the joint improved functional outcomes.

Methods: From 1994 through 1999, 807 ankle fractures were surgically managed, 71 of which were identified as injuries of the tibial plafond (AO/OTA 43 A-C). The inclusion criteria for this study were patients who presented with 43 C3 patterns who also underwent a staged treatment for this injury. We identified 34 patients with 36 fractures. Stage 1 consisted of an ORIF of the fibula and the application of a transarticular external fixator across the ankle joint on admission, and stage 2 was a formal reconstruction of the plafond when the soft tissue swelling subsided. Radiographs were used to evaluate the joint reduction. Postoperative regimes consisted of immobilization for 1 to 2 weeks followed by therapy and non-weightbearing for the first 3 months. At follow-up, a chart review was performed, complications were noted, patients were examined, weight bearing radiographs were obtained to determine healing rate, and the presence of degenerative changes (Kellegren and Moore) were noted. All patients were evaluated using SF-36 and AOFAS Ankle Hindfoot Scores.

Results: Eight patients were lost to follow-up, leaving 26 patients with 28 fractures available for evaluation. The average age of patients was 39.6 years and follow-up averaged 43 months. Nine fractures were open (4 II, 3 IIIA, 2 IIIB). The mechanisms of injury included 15 from motor vehicle accidents, 9 from falls, and 2 from motor cycle injuries, resulting in 17 associated injuries. Stage 1 treatment was performed within 24 hours of the injury in 24 fractures, and stage 2 was performed an average of 16 days (range, 4 to 33) later. Complete union was identified in 26 fractures (93%) at an average of 3.2 months. Postoperative radiographs identified an anatomic reduction in 26 fractures and no malalignment more than 5° in any fracture. Overall, there were nine complications. A wound necrosis developed in three fractures, treated with local wound care and oral antibiotics. Deep infection requiring serial debridement and intravenous antibiotics developed in four fractures, and two patients had nonunions requiring a revision. Radiographic arthrosis was defined as moderate or severe in 12 fractures, of which 5 were treated with an ankle arthrodesis. The average AOFAS Ankle Hindfoot Score was 69 (range, 27 to 94), and SF-36 health outcome scores averaged 40.1.

Discussion: Because significant comminution is coupled with soft tissue injury, pilon fractures can be difficult to manage. In this series of 43 C3 fractures, managed by three experienced traumatologists with use of a staged treatment protocol, only 4 of 28 fractures (14%) developed a deep infection (two open injuries: one IIIB, one IIIA), and only 5 of 28 (18%) required an ankle arthrodesis. Not unexpectedly however, given the severity of injury and despite meticulous technique, 12 of 28 fractures (43%) developed moderate to severe arthroses with low SF-36 and AOFAS scores indicating the presence of long-term problems.

Conclusion: These 43 C3 plafond injuries are exceedingly difficult to treat and frequently result in a poor outcome. Although our techniques have largely eliminated soft tissue complications even in these severe injuries, outcomes for these complex fractures may still be poor, despite excellent articular reductions, largely due to cartilage damage at the time of impact. Patients must be made aware of the limitations of surgical intervention based on the severity of their injury.