Objective To explore the effectiveness of staged treatment of open Pilon fracture combined with soft tissue defect. Methods Between June 2007 and December 2012, 18 cases of open Pilon fracture combined with soft tissue defect were treated. There were 14 males and 4 females with an average age of 35 years (range, 19-55 years). The causes of injury included falling from height in 12 cases, traffic accident in 4 cases, and crushing by machine in 2 cases. According to AO classification, 1 case was classified as type B2 fracture, 3 cases as type B3 fracture, 5 cases as type C1 fracture, 5 cases as type C2 fracture, and 4 cases as type C3 fracture. Sixteen cases accompanied by fibular fracture (14 cases of simple fibular fracture and 2 cases of communicated fibular fracture). According to Gustilo classification, the soft tissue injuries were all type IIIB. In first stage, debridement and vaccum sealing drainage combined with external fixation were performed; open reduction and internal fixation of simple fibular fracture were used. In second stage, open reduction and internal fixation of Pilon fracture and communicated fibular fracture were performed, and the flaps of 6 cm × 5 cm to 18 cm × 14 cm were applied to repair soft tissue defect at the same time. The donor site was repaired by skin graft. Results Partial necrosis occurred in 2 flaps, the other 16 flaps survived completely. The incisions of donor sites healed by first intention, the skin graft survived completely. The average follow-up interval was 12 months (range, 6-24 months). The X-ray films showed that the bone healing time ranged from 5 to 8 months (mean, 6 months). No internal fixation failure was found. At last follow-up, the average range of motion of the ankle joint was 37° (range, 26-57°). According to the American Orthopedic Foot and Ankle Society (AOFAS) scale, the average score was 80.2 (range, 72-86). Traumatic arthritis occurred in 2 cases (11%). Conclusion The staged treatment has the advantages of accurate evaluation of soft tissue injury, shortened cure time, good reduction of the articular surface, and reduced incidence of infection, so it is an optimal method to treat open Pilon fracture combined with soft tissue defect.
ObjectiveTo evaluate the effectiveness of very low profile/variable angle locking plate (VLP) internal fixation for posterior Pilon fractures extending to the medial malleolus by posteromedial approach. MethodsA retrospective analysis was made on the clinical data from 13 patients with posterior Pilon fractures extending to the medial malleolus between December 2011 and August 2012. There were 4 males and 9 females with an average age of 48.9 years (range, 23-68 years). Fractures were caused by falling in 9 cases and by traffic accident in 4 cases. The locations were the left ankle in 6 cases and the right ankle in 7 cases. According to the Orthopedic Trauma Association (OTA) classification, 6 cases were rated as type 43B1, 4 cases as type 43B2, and 3 cases as type 43B3. Twelve cases had fibular fractures, including 11 cases of Denis-Weber type B, 1 case of Denis-Weber type C. The interval of injury and operation was 7-14 days (mean, 11.4 days). Open reduction was performed and VLP internal fixation was used for posterior malleolar fracture by posteromedial approach. ResultsPrimary healing of incision was obtained in all patients. Tibial nerve palsy was observed in 2 cases, and was cured after oral administration of mecobalamin. Twelve cases were followed up 12-18 months (mean, 14.5 months). According to the Burwell-Charnley's radiological evaluation system, 11 cases achieved anatomical reduction, 1 case achieved fair reduction. The fracture union time was 3-6 months (mean, 3.7 months). No loosening or breakage of internal fixation occurred during follow-up. According to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, the results were excellent in 7 cases, good in 4, and fair in 1; the excellent and good rate was 91.7%. ConclusionVLP internal fixation for posterior Pilon fractures extending to the medial malleolus by posteromedial approach can achieve good short-term effectiveness. The high quality of reduction is acquired under direct vision with low rate of soft tissue complications.
Objective To investigate the effectiveness and biomechanical analysis of 3 fixation methods of screw anterior-posterior fixation (SAPF), screw posterior-anterior fixation (SPAF), and buttress plate fixation (BPF) in treatment of posterior Pilon fractures. Methods Fifteen fresh-frozen skeleto-ligamentous lower leg specimens were harvested to establish the models of posterior Pilon fracture, and then fracture was fixed with BPF (n=5), SAPF (n=5), and SPAF (n=5). Vertical force was loaded to internal fixation failure in a speed of 1 cm/minute with servohydraulic testing machine. The instantaneous loads of 1 mm and 2 mm steps and the failure modes were recorded. Between May 2008 and December 2011, 56 patients with posterior Pilon fracture were treated with SAPF (SAPF group) in 11 cases, or SPAF (SPAF group) in 26 cases, or BPF (BPF group) in 19 cases. There was no significant difference in age, gender, injury cause, side, disease duration, and complications among groups (P gt; 0.05). Clinical and radiographic examinations were used to assess the reduction and healing of fracture; the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS) were used to evaluate the functional outcomes. Results No breaking or bending was observed in all specimens, fixation failure was caused by cancellous bone compression. The instantaneous loads of 1 mm and 2 mm steps were the largest in BPF group, larger in SPAF group, and smallest in SAPF group, showing significant differences among 3 groups (P lt; 0.05). A total of 47 cases were followed up 16-54 months (9 in SAPF group, 22 in SPAF group, and 16 in BPF group), with a mean time of 35.2 months. Fixation failure was found in 2 cases of SAPF group; the other cases obtain bony union within 3 to 4 months (mean, 3.2 months) with no fixation failure. The AOFAS score was significantly lower in SAPF group than in SPAF and BPF groups (P lt; 0.05), but no significant difference was found between SPAF and BPF groups (P gt; 0.05). The VAS score was significantly higher in SAPF group than in SPAF and BPF groups (P lt; 0.05), but no significant difference was found between SPAF and BPF groups (P gt; 0.05). Conclusion SAPF could not reach enough fixation strength for the posterior Pilon fracture; both SPAF and BPF could reach rigid fixation, and have good effectiveness. And from the biomechanical points, BPF could reach better fixation strength than screw fixations.
Objective To investigate the clinical effect of the reverse transposition of pedicled soleus muscle flap in repairing soft tissue defects after Pilon fracture fixation. Methods From May 2002 to June 2006, 14 patients (11 males, 3 females; aging 2050 years) with soft tissue defects afterPilon fracture fixationunderwent repairing operations with the reverse soleus muscle flaps. The soft tissue defects ranged from 7.0 cm×3.5 cm to 100 cm×60 cm. Of the patients, Pilon fractures were treated by internal fixations in 9 cases, open Pilon fractures weretreated by external fixations in 5 cases. The area of muscle flap ranged from 8.5 cm×5.5 cm to 12.5 cm×7.5 cm. Results All patients achieved primary healings, and the grafting skin survived. Twelve flaps survived completely but 2 flapshad mildinfection, which survived after dressing change. Eleven patients were followed up for 3 to 26 months, averaged 15 months. The flap appearances were good and smooth without ulceration. The dorsiflexion ranges of ankle joint were 10-25°, and plantar flexion ranges were 15-40°. The gait was normal. Conclusion The reverse soleus muscle flap is no need to reveal blood vessel pedicle and has constant position of anatomy. It has big muscle belly, convenient to move and circuitation 180°. It is profitable to reduce infection rate and to promote wound healing to raise local osteotylus.
ObjectiveTo observe the effectiveness of 360° internal fixation by anteromedial and posterior-lateral approaches for high-energy closed Pilon fractures. MethodsBetween February 2013 and February 2015, 18 cases of high-energy closed Pilon fractures were treated. There were 11 males and 7 females with an average age of 40.5 years (range, 20-65 years). The causes were falling injury in 10 cases and traffic accident injury in 8 cases. All fractures were RüediAllgower type Ⅲ Pilon fracture combined with ipsilateral fibula fracture. The average interval from injury to operation was 8 days (range, 5-13 days). Reduction of fracture was performed by anteromedial and posterior-lateral approaches and the fracture fragments were fixed by 360° internal fixation. The effectiveness was assessed by ankle X-ray film and Mazur score at last follow-up. ResultsTwo cases had skin necrosis and received flap surgery, the other cases obtained primary healing of incision. All the cases were followed up 11.2 months on average (range, 3-27 months). X-ray film showed that all fractures healed at 3-4 months after operation (mean, 3.6 months). No deep infection or plate exposure occurred. According to Mazur score, the results were excellent in 8 cases, good in 7 cases, fair in 2 cases, and poor in 1 case, and the excellent and good rate was 83.3%. ConclusionThe effectiveness of the 360° internal fixation for treatment of high-energy closed Pilon fractures has the advantages of reliable fixation, early functional exercise, and good functional recovery of the ankle joint.
ObjectiveTo investigate the application value of three-dimensional reconstruction and virtual pre-operative planning for Pilon fractures. MethodsBetween July 2010 and June 2014, 16 patients with closed Pilon fracture were treated, including 12 males and 4 females with an average age of 36.5 years (range, 22-53 years) and a mean disease duration of 10.2 days (range, 6-14 days). According to AO/Orthopaedic Trauma Association (AO/OTA) typing, 2 cases were rated as 43.B2 type, 3 cases as 43.B3 type, 3 cases as 43.C1 type, 2 cases as 43.C2 type, and 6 cases as 43.C3 type. The preoperative CT data from 16 patients were imported into Mimics10.01 software to establish the detailed fracture three-dimensional digital models. Virtual operation of fracture reduction and implanting internal fixation was performed on the models, and the optional surgical planning was made. Based on the virtual preoperative planning, operations were performed. ResultsEstablished detailed three-dimensional Pilon fracture digital models could perfectly reflect the fracture characteristics, could be observed at any direction, and aided for fracture classification accurately. Virtual fracture operations of reduction, internal fixation and other could be performed to simulate the clinical operation, which could assist the surgeon better preoperative planning in achieving visual presentation and improving the communication. The operation time was 70-130 minutes (mean, 87.8 minutes); intraoperative blood loss volume was 30-150 mL (mean, 71.9 mL). The wounds healed by first intension in all patients. The mean follow-up time was 11.6 months (range, 8-18 months). Postoperative radiological results at 3 groups showed good anatomic reduction according to the Burwell-Charnley criteria, and the fracture healing time was 3-6 months (mean, 3.7 months). There was no complication of internal fixation loosening or breakage during follow-up. The American Orthopedic Foot and Ankle Society (AOFAS) score was 71-100(mean, 92.3); the results were excellent in 10 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 93.8% at last follow-up. No loss of fracture reduction was observed on the X-ray film. ConclusionThe clinical feasibility of virtual reconstruction preoperative planning is good in the treatment of Pilon fractures, which helps surgeons better understanding Pilon fracure and making the surgical planning.
Objective To explore an improved method of surgical operation for reposition of the articular surface with Type Ⅲ Pilon fractures. Methods From January 1999 to December 2005, 20 patients (22 sides) with Type Ⅲ Pilon fractures were treated with the delayed open reduction and the internal fixation, which took the superior articular surface of the talus as a templet so as to reposition the lower articular surface of the tibia, strengthen the bone transplantation, fasten the internal fixation, and make an early functional exercise possible. Complete data were obtained from 16 of the patients with 18 sides (13 males,15 sides; 3 females, 3 sides; age, 14-48 years). The injury due to a fallingaccident was found in 12 patients (14 sides), and due to a traffic accident in 4patients (4 sides). Results The healing of the first intention was achieved in 14 sides, the delayed healing in 3 sides, and the infection in 1 side. The follow-up of all the 16 patients for 971 months (average, 22 months) including the X-ray examinations revealed that no screw for the internal fixation entering the articular cavity. According to the Teeny’s judging standards of radiology evaluating the result of the surgery for Pilon fractures, the anatomical reduction of the related articular surface was found in 77.8% of the sides (14/18) and thehealing of the first intention (stage Ⅰ) in 94.4% (17/18). According to the Mazur’s criteria, an excellent result was obtained in 5 sides, good in 7, fair in 5, and poor in 1. The excellent and good result was 66.7%. Conclusion Propermanagement of the injured soft tissues, prompt recovery of the tibial distant plateau height, and accurate reposition of the articular surface, enough transplant bone for the solid support, b internal fixation for the distant tibial anatomical structure, and early functional exercise are the key points to the successful operation.
ObjectiveTo explore the clinical outcomes of open reduction and internal fixation by posterolateral and posteromedial approaches for treating posterior Pilon fractures in elderly patients. MethodsBetween August 2009 and August 2014, 20 elderly patients with posterior Pilon fractures were treated with open reduction and internal fixation by posterolateral and posteromedial approaches. There were 14 males and 6 females, aged from 66 to 83 years (mean, 72.7 years). The causes were falling injury in 11 cases and traffic accident injury in 9 cases. All the patients had lateral malleolus and medial malleolus fractures. The time from injury to operation was 7-14 days (mean, 8.6 days). The posterolateral incision was made to expose the posterolateral bone fragments of posterior malleolus and lateral malleolus fracture, and the posteromedial incision was made to expose the posteromedial fracture fragments of posterior malleolus and medial malleolus fracture. After reduction, fracture was fixed with locking plate or cannulated screw. All the patients began to functional exercise at 1 day after operation. ResultsThe operation time was 60-110 minutes (mean, 92 minutes). The incisions healed primarily in all patients. There were no complications of incision dehiscence, infection, implant exposure, and nerve damage. No irritation sign of tendon was observed. All 20 cases were followed up for 12-18 months (mean, 13 months). The X-ray films showed that fracture healed at 3-9 months, with an average of 5.2 months. During follow-up period, no loosening or breakage of the implant was observed. The other patients could walk normally except 2 patients (over 80 years old) who could walk with crutch. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the results were excellent in 12 cases, good in 4 cases, and fair in 4 cases; the excellent and good rate was 80%. ConclusionA combination of posterolateral approach and posteromedial approach for open reduction and fixation of posterior Pilon fractures can achieve satisfactory effect in elderly patients. It has the advantages of protecting ankle blood supply and avoiding the soft tissue necrosis and implants exposure.
ObjectiveTo analyze the importance and effectiveness of Tillaux bone block in Ruedi-Allgower type Ⅲ of Pilon fracture surgery.MethodsTwenty-one patients with Pilon fractures with Tillaux dislocation were treated between February 2010 and September 2013. There were 17 males and 4 females, aged from 28 to 68 years with an average age of 42.9 years. The causes of injury included falling from height in 13 cases, falls injury in 4 cases, crush injury in 2 cases, and sprained injury in 2 cases. X-ray film and CT examination showed that all 21 patients had fibula fracture and Tillaux bone block had obvious displacement. According to AO/OTA classification, there were 3 cases of type C1.2, 1 case of type C1.3, 10 cases of type C2, and 7 cases of type C3. The duration from injury to operation ranged from 4 to 31 days, with an average of 10 days. All cases of Pilon fracture were treated with open reduction and plate internal fixation. Steel plate or screw was used to fixation for Tillaux block; allograft bone graft was selected for compression of fracture.ResultsThere were 2 cases of skin necrosis at the corner of wound after operation, and the wound healed after corresponding treatment; the wound healed at first intention in the other 19 cases. The effect of surgical reduction was evaluated by Burwell-Chamley imaging scoring system within 72 hours after operation, there were 19 cases of anatomical reduction and 2 cases of general reduction. All the 21 patients were followed up 18-48 months, with an average of 24.9 months. No complication such as nerve injury, loosening of internal fixation, or periprosthetic fracture was found during follow-up. All fractures obtained bone healing, which lasted from 4 to 8 months, with an average of 6 months. The ankle and hindfoot scores of the American Orthopaedic Foot and Ankle Society (AOFAS) were used to evaluate the ankle and hindfoot function at 1 year after operation or at last follow-up, the results were excellent in 13 cases, good in 6 cases, and fair in 2 cases, with an excellent and good rate of 90.5%. Internal fixator was removed from 19 patients at 15-19 months after operation. There were 17 cases of joint hyperplasia and 4 cases of osteoarthritis. All joint mobility was restored. The functional recovery of the ankle joint was evaluated according to the Olerud-Molander ankle fracture score standard, the results were good in 6 cases, fair in 8 cases, and poor in 7 cases at postoperative full weight training; and after 1 year of full weight training, the results were excellent in 10 cases, good in 3 cases, fair in 6 cases, and poor in 2 cases.ConclusionThe Tillaux bone block is a reliable marker for the reduction of complex Pilon fractures. The reconstruction of the Tillaux can improve the effectiveness of complex Pilon fractures.
ObjectiveTo investigate the effectiveness of the nose ring drain (NRD) technique combined with Ilizarov circular external fixation in treatment of Gustilo ⅢA Pilon fracture.MethodsBetween March 2017 and December 2019, 17 patients with Gustilo ⅢA Pilon fractures were admitted and treated with NRD technique combined with Ilizarov circular external fixation. Among them, there were 11 males and 6 females; the age ranged from 24 to 63 years, with an average of 38.2 years. There were 3 cases of traffic accident injury, 13 cases of falling injury, and 1 case of penetrating injury. There were 13 cases of emergency admittance and 4 cases of wound infection after surgical treatment. Furthermore, there were 2 cases of fibula fractures and 3 cases of lateral malleolus fractures. ResultsAll patients were followed up 8-12 months, with an average of 9.9 months. All wounds healed by first intention, and 4 patients with preoperative infection had no recurrence during the follow-up. The external fixator was removed after fracture healing in 17 patients at 3-7 months after operation (mean, 4.5 months). At last follow-up, the pain score of the ankle joint Kofoe score was 40-50, with an average of 44; the functional score was 17-27, with an average of 25; the mobility score was 8-18, with an average of 14; and the effectiveness was rated as excellent in 8 cases, good in 7 cases, and poor in 1 case.ConclusionFor Gustilo ⅢA Pilon fractures, the NRD technique combined with Ilizarov circular external fixation has advantages of good fracture fixation and drainage effects, which greatly reduces the complications of traditional treatment options and the number of operations.