Intra‐Articular Distal Tibia (Pilon/Plafond) Fractures


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Intra‐Articular Distal Tibia (Pilon/Plafond) Fractures


Luc Rubinger MD1, Seper Ekhtiari MD MSc1, and Peter J. O’Brien MD2


1Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada


2Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC, Canada


Clinical scenario



  • A 30‐year‐old man who was involved in a motor vehicle accident comes in as a trauma team activation. He has been cleared on primary and secondary survey. He has suffered an isolated injury to his right ankle. His chief complaint is pain, swelling, and inability to weightbear on his right lower extremity. He is diagnosed with a distal tibia intra‐articular fracture (i.e. pilon or plafond) on x‐ray.
  • On physical examination, there are no open wounds, there are intact dorsalis pedis and posterior tibial pulses with only moderate swelling. Computed tomography (CT) scan confirms an intra‐articular multifragmentary distal tibia fracture with proximal displacement of the talus, an AO43 type C fracture.1
  • As the most responsible physician caring for this patient, you consider the most appropriate management plan in terms of operative approach, immediate versus delayed fixation, and the use of external fixator in the treatment for pilon fractures.

Top three questions



  1. In patients undergoing operative management for distal tibia intra‐articular fractures, does staged open reduction and internal fixation (ORIF) result in better clinical and postsurgical outcomes compared to acute fracture management?
  2. In patients undergoing operative management for distal tibia intra‐articular fractures, does definitive management with limited internal fixation with external fixation result in better clinical and postsurgical outcomes compared to ORIF (early or delayed)?
  3. In patients undergoing operative management for distal tibia intra‐articular fractures, does any specific surgical exposure result in better clinical and postsurgical outcomes compared to other exposures?

Question 1: In patients undergoing operative management for distal tibia intra‐articular fractures, does staged open reduction and internal fixation (ORIF) result in better clinical and postsurgical outcomes compared to acute fracture management?


Rationale


Intuitively, ORIF is easiest to perform immediately after injury and before the development of organizing hematoma, soft tissue contraction, callus formation, and inflammatory osteopenia. However, the timing of definitive surgery depends on soft tissue integrity. Appropriate surgical timing decreases the risk of wound complications, including skin slough and superficial and deep infection.


Clinical comment


The decision on when to operate depends on multiple factors such as age, general and current health, soft tissue integrity, and other injuries that influence the safe administration of anesthesia.2


Surgical intervention during maximal soft tissue swelling will lead to a higher risk of wound necrosis and infection. Early surgical intervention or delayed surgery as part of two‐stage management is carried out when the soft tissue envelope is favorable. Specific clinical signs that help the surgeon decide if the soft tissue is ready include resolution of edema and fracture blisters and the return of skin wrinkling.


Available literature and quality of the evidence


Overall, there is limited high‐quality evidence on the topic of acute versus delayed management of pilon fractures. There is one prospective cohort study (level II) and two retrospective cohort studies (level III) that specifically seek to answer this question.


Tang et al. retrospectively compared a cohort of 46 patients with closed type C pilon fractures who underwent surgery either within 36 hours of injury or had delayed treatment (level III).3 Sajjadi et al. retrospectively studied 41 closed tibial pilon fractures, half of which were treated definitively within 24 hours, and the other half of which were treated with an external fixator within 24 hours then subsequent ORIF once soft tissues were amenable (level III).4 In a prospective cohort study, Conroy et al. reported the results of early ORIF in 32 patients who suffered from open type B (21 patients) and type C pilon fractures (11 patients) (level II).5 They followed a fix and flap protocol by managing pilon fractures with early bone stabilization and flap coverage at the same time. In this study 28 patients were managed with early ORIF and early coverage using free muscle flaps and split skin graft, and four patients were managed with application of external fixation.


Findings


In their retrospective cohort (level III), Tang et al. found that there was no significant difference between groups regarding the rate of soft tissue complications, fracture union, and final functional outcome score. Further, the early fixation group had a significantly shorter mean time to fracture union and hospital stay.3 Sajjadi et al. (level III) reported no significant difference in rate of infection (superficial or deep infection, osteomyelitis), malunion/nonunion, and patients’ satisfaction with American Orthopaedic Foot and Ankle Society (AOFAS) score. Similar to Tang’s study, Saijadi et al. reported significantly decreased length of stay with early ORIF.4 In their study, Conroy et al. (level II) reported two amputations (6.2%), two deep infections (6.2%), and three malunions (9.3%).5 After exclusion of the two amputees, all 30 remaining patients progressed to clinical and radiological union. They concluded their aggressive protocol showed excellent union rate, low rate of infection, and good functional outcome.


At least two major differences can be identified between the studies above that endorse the use of early ORIF, and the lower‐quality studies that historically reported much higher complication rates6–9: the mechanism of injury and status of the soft tissues. In the more recent, higher‐quality evidence, when soft tissue integrity and fracture type are taken into account, early ORIF represents a reasonable and comparable option to delayed fixation.

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May 14, 2023 | Posted by in Uncategorized | Comments Off on Intra‐Articular Distal Tibia (Pilon/Plafond) Fractures

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