Session VII - Foot / Ankle

Sat., 10/12/13 Foot/Ankle, PAPER #77, 10:12 am OTA 2013

Long-Term Follow-up of High-Energy Pilon Fractures: A Prospective Comparison of Locked Plates Versus Nonlocked Plates

Theodore T. Le, MD; Albert d’Heurle, MD; Namdar Kazemi, MD;
Michael T. Archdeacon, MD, MSE; John D. Wyrick, MD;
University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA

Purpose: This study was undertaken to compare the clinical and radiographic outcomes of patients treated with either locking plates or conventional nonlocking plates in the management of high-energy pilon fractures. Our null hypothesis is that there would be no significant difference in the incidence of loss of reduction or functional outcomes between nonlocked and locked plates in the treatment of high-energy pilon fractures.

Methods: A prospective treatment protocol on patients with high-energy pilon fractures treated at a Level I trauma center between December 2005 and December 2008 was established and followed. Patients were randomized to either locking or nonlocking devices according to their medical record number. Radiographic outcomes were assessed with at least 6-month follow-up. Mortise/AP and lateral radiographs of the ankle were evaluated at the latest follow-up to assess for loss of reduction compared to radiographs at the time of surgery. This was defined as an angle measurement change ≥5°. Ankle hindfoot scores and Short Musculoskeletal Function Assessment (SMFA) functional outcome scores were collected on all patients with at least 1-year follow-up.

Results: From December 2005 through December 2008, 58 patients were randomized to receiving either a locked or a nonlocked plate for the treatment of high-energy pilon fractures. Radiographic measurements at a minimum of 6 months were available for 34 fractures (33 patients). There were 19 fractures in Group Nonlock and 15 in Group Lock. The average follow up was 30.6 ± 15.7 months (range, 8-67). Fracture classification included 25 OTA 43-C3, five 43-C2, two 43-C1, and two 43-B3 fractures. Mechanisms of injury included 11 falls from a height greater than 10 feet, 12 falls from standing, 7 motor vehicle accidents, and 3 other injuries. On the mortise view, 2 of 15 (13%) fractures in Group Nonlock demonstrated loss of reduction >5° compared to 3 of 19 (16%) in Group Lock (P = 0.999). There were no soft-tissue complications that required surgical intervention. In terms of complications, Group Lock had 1 patient with a deep infection, 2 nonunions, and 2 hardware failures. Group Nonlock had 1 hardware failure and 1 infected nonunion. Functional outcome scores were available for 18 patients (31%), 8 patients in Group Lock and 10 in Group Nonlock, with an average follow-up of 35.6 ± 16.0 months (range, 13-67). There was no significant difference between the ankle hindfoot scores (Lock: 71.75 ± 71.75; Nonlock: 66.1 ± 23.8; P = 0.625), the SMFA-BI (bother index) scores (Lock: 7175 ± 25.4; Nonlock: 66.1±23.8; P = 0.625), or the SMFA-FI (function index) scores (Lock: 32.9 ±36.2; Nonlock: 25.7 ± 20.2; P = 0.587).

Conclusion: The staged protocol for the treatment of high-energy pilon fractures has overcome the soft-tissue complications previously encountered. However, our data demonstrated that locking constructs have not improved the overall outcome of high-energy pilon fractures in terms of maintaining reduction or functional outcomes. However, given the low incidence of reduction lost in this study, the possibility of a type II error must be considered.

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.