Fri., 10/15/10 Foot & Ankle, Paper #51, 11:37 am OTA-2010
Staged Posterior Tibial Plating for the Treatment of OTA 43C2 & 43C3 Tibial Pilon Fractures
John Ketz, MD; Roy Sanders, MD;
Florida Orthopaedic Institute, Tampa, Florida, USA
Purpose: Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures.
Methods: From January 1, 2005 to December 31, 2008, 19 OTA 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by us. Five were open fractures, while 14 fractures had an associated fibula fracture. Nine patients were treated with posterior plating of the tibia (PP) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (AP) with indirect reduction of the posterior fragment. Quality of reduction was assessed using postoperative plain radiographs and CT. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination, and evaluation of the ankle using the American Orthopaedic Foot & Ankle Society ankle and hindfoot score (AHS) and Maryland Foot Score (MFS), as well as noting all complications.
Results: All 19 patients were available for follow-up at an average of 20 months (range, 14- 37 months). There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the AP group, 6 (60%) had at least 2 mm of joint incongruity at the posterior articular fracture edge compared with no patients in the PP group, as measured on postoperative CT scans. At latest follow-up, 5 patients (50%) in the AP group had radiographic evidence of joint-space narrowing compared to 1 (11%) in the PP group. Ankle range of motion for the AP group was 35.8° versus 34.2° for the PP group (not significant). There were 2 delayed wound-healing complications in each group with 1 deep infection in the PP group. Two patients in the AP group required arthrodesis procedures due to posttraumatic arthrosis compared to none in the PP group. No significant difference was seen in postoperative complications across both groups. The average MFS and AHS for the PP group were 86.8 and 84.8 compared to 67.5 and 76.5 for the AP group.
Conclusion: The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on CT scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in MFS and AHS for the PP group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.
Alphabetical Disclosure Listing (292K PDF)
• 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.