Sat., 10/18/08 Foot & Ankle/Pediatrics, Paper #56, 11:09 am OTA-2008
Prospective Cohort Trial of External Fixation versus Internal Fixation of Distal Tibia Plafond Fractures
William T. Obremskey, MD, MPH (a-Synthes; e-Medtronic, Osteogenix);
The Southeast Fracture Consortium
Vanderbilt University, Nashville, Tennessee, USA
Purpose: The purpose of this study was to assess complications and outcomes of open reduction and internal fixation versus articular reduction and maintaining external fixation of distal tibia pilon fractures.
Methods: We prospectively enrolled 56 patients in a surgeon experienced-based trial of temporary external fixation and then formal articular reduction and fixation of distal tibia fracture versus temporary external fixation, articular reduction, and continuing bridging external fixation of distal tibia pilon fractures. 24 patients were enrolled in the definitive external fixation (XF) group. 32 patients were enrolled in the internal fixation (IF) group. The demographics, smoking history, comorbidities, fracture type, articular reduction, as well as complications and arthrosis scores, were assessed for all patients for at least 6 months. Articular reduction was assessed as good, fair, or poor as in Marsh and Dirschl (2003). Arthrosis was assessed at 6-month radiographs on a 0 to 3 scale as described by Domsic and Saltzman (1998).Functional outcomes were assessed with the Short Form-36 (SF-36), Short Musculoskeletal Functional Assessment (SMFA), and the Iowa Ankle Score.
Results: No differences were noted in either the XF or IF group in terms of patient age, smoking history, c-morbidities, or incidence of open fractures. The patients in the XF group were in an external fixator for a mean of 10 weeks (range, 7-17) versus 3.3 weeks (range, 0- 12) in the IF group. No difference was noted in articular reduction postoperatively between the groups (P = 0.42) or in arthrosis score at 6 months (P = 0.67). The patients in the IF group had 6 of 32 (19%) delayed unions or nonunions and the XF group had 10 of 24 (42%) delayed unions or nonunions. Deep infection was equally likely in either group. The most significant statistical predictor of a nonunion or deep infection was an open fracture. At 6 months, the IF group had improved functional outcome scores in the Iowa Ankle (P = 0.006), and the SMFA Dysfunction Index (P = 0.02) and SMFA Daily Activities (P = 0.007). The SMFA Mobility score was nearly significant (P = 0.06). No differences were seen in any SF-36 domains. At 12 months, no differences were seen in the Iowa Ankle, SMFA, or SF-36 scores.
Conclusions: Treatment of distal tibia pilon fractures continues to have a high complication rate. Patients who undergo external fixation with articular reduction and leaving the external fixator until bony union may be at increased risk of developing a nonunion, but seem to have no difference in evaluation of articular reduction immediately postoperatively. Functional outcomes were improved in the IF group at 6 months, but no differences were seen at 12 months.
Significance: Patients being treated for distal tibia pilon fractures should be counseled about high complication rates with any treatment method. Either internal fixation or external fixation can attain bony union with adequate articular reduction, but external fixation may be associated with a higher risk of delayed or nonunion. Patients may have improved early outcomes with IF versus XF.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.