Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques.

OBJECTIVE: To determine whether long-term results of one of three different management protocols for severe tibial pilon fractures offer advantages over the other two.
DESIGN: In a retrospective study, patients were examined clinically and radiologically after internal fixation of severe tibial plafond fractures (i.e., 92 percent Type C fractures according to the AO-ASIF classification).
SETTING: Department of Traumatology, Hanover Medical School. Level I trauma center. PATIENTS: Fifty-one of seventy-seven patients treated between 1982 and 1992 were examined clinically and radiologically at an average of sixty-eight months (range 13 to 130 months) after injury.
INTERVENTIONS: The patients were treated in three different ways: primary internal fixation with a plate following the AO-ASIF principles (n = 15), which was reserved for patients with closed fractures without severe soft tissue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least four weeks (n = 28); and a two-stage procedure entailing primary reduction and reconstruction of the articular surface with minimally invasive osteosynthesis and short-term transarticular external fixation of the ankle joint followed by secondary medial stabilization with a plate using a technique requiring only limited skin incisions (a reduced invasive technique) (n = 8). MAIN OUTCOME MEASUREMENTS: Objective evaluation criteria were infection rate, amount of posttraumatic arthritis, range of ankle movement, and number of arthrodeses. Subjective criteria were pain, swelling, and restriction of work or leisure activities.
RESULTS: Because only closed fractures were treated by primary internal fixation with a plate, there was a statistically significant difference (p < 0.005) in the distribution of open fractures between the three treatment groups. Fracture classification in these groups were not significantly different. All but four fractures were classified as Type C lesions according to the AO-ASIF system. The soft tissue was closed in 63 percent (n = 32) and open in 37 percent (n = 19). No significant relationship could be found between the soft tissue damage and degree of arthritis or between the type of surgical treatment and extent of posttraumatic arthritis. However, none of the patients who required secondary arthrodesis (23 percent of all cases) were in the group who had undergone two-step surgery (p < 0.05). The range of ankle movement was much greater in the two-step group than in the others; these patients also had less pain, more frequently continued working in their previous profession, and had fewer limitations in their leisure activities. These differences did not reach statistical significance. The incidence of wound infection did not differ significantly among the three groups.
CONCLUSIONS: On the basis of our results, we now prefer a two-step procedure for the treatment of severe tibial pilon fractures with extensive soft tissue damage. In the first stage, primary reduction and internal fixation of the articular surface is performed using stab incisions, screws, and K-wires. Temporary external fixation is applied across the ankle joint. After recovery of the soft tissues, the second stage entails internal fixation with a medial plate using a reduced invasive technique.