Session VII - Foot / Ankle

Sat., 10/12/13 Foot/Ankle, PAPER #76, 10:06 am OTA 2013

Combined Approaches Increase Nonunion in Tibial Pilon Fractures

Paul M. Balthrop, MD1; Daniel S. Chan, MD1; Brian White, MD, David Glassman, MD2;
Roy Sanders, MD1;
1Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, Florida, USA;
2Naval Medical Center, Portsmouth, Virginia, USA

Background/Purpose: Staged fixation of tibial pilon fractures has become commonplace. There is very little literature, however, discussing the staged fixation of the tibia through separate incisions. Recent evidence has suggested that a staged approach to the posterior tibia may offer improved articular reductions at the time of anterior fixation. To date, no large series of patients with staged posterior fixation has been compared with isolated anterior fixation to determine if this improvement in reduction holds true.

Methods: From January 1, 2005 to December 31, 2011, all records of patients treated for 43C fractures of the distal tibia were reviewed. Patients in this retrospective clinical cohort were grouped according to posterior-anterior and anterior-alone approaches. Medical charts and surgical documentation were reviewed and postoperative CT scans were examined for residual articular displacement and quantified. Ultimate union rate was correlated with approach strategy. Articular reduction was subdivided into three groups (<1 mm, 1-2 mm, >2 mm).

Results: 116 patients were identified as having had 43C fractures treated surgically with postoperative CT scans completed. 26 fractures presented as an open injury. Of these 116 patients, 35 underwent staged fixation of the posterior malleolus at an average of 10 days postinjury, followed by delayed anterior fixation at an average of 16 days postinjury. The remaining 81 patients underwent anterior fixation alone. 21 patients were lost to follow-up prior to 6 months. Of the 95 patients with sufficient follow-up, there were 24 nonunions. There was a statistically significant association of nonunion with staged posterior approach (40% vs 19%, P = 0.015). CT reduction for staged-posterior versus anterior-alone approach was not significantly different for any of the three categories (63% vs 57% <1 mm, 31% vs 26% 1-2 mm, 6% vs 17% >2 mm).

Conclusion: There is no statistically proven benefit to combined surgical approaches to tibial pilon fractures. It appears from this investigation that there is a significantly higher risk of nonunion with no demonstrable benefit to articular reduction. While articular reduction is of paramount importance, aggressive approaches to direct reduction and fixation of all fragments may lead to further complications.

Alphabetical Disclosure Listing

• 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.