ABSTRACTS DE PUBLICACIONES SOBRE PILN TIBIAL

Clin Orthop Relat Res. 2004 Jun;(423):93-8.

Factors affecting outcome in tibial plafond

fractures.
Williams TM1, Nepola JV, DeCoster TA, Hurwitz SR, Dirschl DR, Marsh JL.

Author information
Abstract
To determine what fracture- and patient-specific variables affect outcome, 29 patients with
32 tibial plafond fractures were evaluated at a minimum of 2 years from the time of injury
(range, 24-129 months; average, 46.5 months). The rank order method was used to assess
severity of injury and accuracy of articular reduction on radiographs and agreement among
the five surgeons was excellent with intraclass correlation coefficients of 0.93 and 0.94.
Outcome was assessed by four independent measures: a radiographic arthrosis score, a
subjective ankle score, the Short Form-36 (SF-36), and the patient's ability to return to
work. The four outcome measures did not correlate with each other. Radiographic arthrosis
was predicted best by severity of injury and accuracy of reduction. However, these
variables did not show any significant relationship to the clinical ankle score, the SF-36, or
return to work. These outcome measures were more influenced by patient-specific
socioeconomic factors. Higher ankle scores were seen in patients with college degrees and
lower scores were seen in patients with a work-related injury. The ability to return to work
was affected by the patient's level of education. This study highlights the difficulties of
predicting patient outcome, after these severe articular fractures.

J Bone Joint Surg Am. 2004 May;86-A(5):988-93.

Extracapsular placement of distal tibial

transfixation wires.
Vora AM1, Haddad SL, Kadakia A, Lazarus ML, Merk BR.

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Abstract

BACKGROUND:

Treatment of tibial plafond fractures with external fixation may involve use of transfixation
wires within the periarticular region. Pin track infections that develop along wires placed
intracapsularly may lead to joint infection. To our knowledge, there have been no previous
investigations assessing the circumferential reflection of the ankle capsule or the potential
for communication between the distal tibiofibular joint and the tibiotalar joint. The purpose
of this study was to define these anatomic entities to provide guidelines for safe
extracapsular placement of distal tibial wires.
METHODS:

Twelve fresh-frozen cadaveric ankles and three ankles of living human volunteers were
utilized for this study. High-resolution magnetic resonance imaging was performed on each
ankle after pressurized distention of the joint capsule with gadolinium solution. The
perpendicular distance from the subchondral bone at the joint line to the capsular synovial
reflection was measured with use of a verified technique. The cadaveric ankles were
sectioned, the capsular synovial reflections were measured by investigators who were
blinded to the imaging results, and the corresponding measurements were compared.
RESULTS:

The anterolateral capsular synovial region displayed the most proximal reflection in all
specimens (mean, 9.3 mm; maximum, 12.2 mm). The anteromedial region displayed less
reflection (mean, 3.3 mm; maximum, 5.5 mm). All posteromedial and posterolateral
synovial reflections were <or=2 mm. Capsular synovial reflections proximal to the medial
and lateral malleoli were negligible. In all ankles, the distal tibiofibular joint communicated
with the tibiotalar joint and had a maximum proximal extension of 20.6 mm.
CONCLUSIONS:

Placement of distal tibial transfixation wires >12.2 mm from the subchondral surface of the
plafond avoids penetration of the capsule. The distal tibiofibular joint communicates with
the tibiotalar joint and thus should not be penetrated, to ensure extracapsular placement of
the wires.

Clin Orthop Relat Res. 2004 Oct;(427):57-62.

Infected fractures of the distal tibial

metaphysis and plafond: achievement of

limb salvage with free muscle flaps, bone

grafting, and ankle fusion.
Zalavras CG1, Patzakis MJ, Thordarson DB, Shah S, Sherman R, Holtom P.

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Abstract
Infection after fractures of the tibial plafond is a challenging problem that may even result
in amputation. The current study evaluates a limb salvage protocol and the associated long
term functional outcome in 6 patients (mean age 46 years) who were treated for infection
after a fracture of the distal tibial metaphysis and plafond. Our limb salvage protocol
included 3 stages: 1) radical debridement and stabilization of the ankle with a bridging
external fixator, 2) soft tissue coverage with free muscle flaps, and 3) ankle fusion using
iliac crest bone graft for filling the existing defects measuring 4.2 cm on average. At a mean
followup of 5.5 years (range, 2-10.5 years), limb-salvage and eradication of infection was
accomplished in all extremities. Fusion of the ankle joint was achieved in all patients, with
one patient requiring a supplemental bone grafting procedure for delayed healing of the
fusion site. All patients are able to walk without assistive devices and five of six patients
are pain free. Limb salvage with free muscle flaps, bone grafting, and ankle fusion is a
viable option for the treatment of infected tibial metaphysis and plafond fractures.

Iowa Orthop J. 2009;29:143-8.

The direct lateral approach to the distal

tibia and fibula: a single incision technique
for distal tibial and pilon fractures.
Femino JE1, Vaseenon T.

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Abstract
Distal tibia fractures remain difficult injuries to treat when fracture displacement precludes
non-operative treatment. Different methods of treatment including limited internal fixation
with external fixation, as well as open reduction and internal fixation have been
recommended. Open reduction and internal fixation is often favored for the improved

ability to anatomically reduce displaced fractures, particularly articular fractures. However,

wound complications due to the associated trauma to the fragile soft tissue envelope in this
region continue to be a significant concern.The authors present a surgical approach for open
reduction and fixation of distal tibia and fibula fractures through a single lateral incision,
which respects the angiosomes of the distal leg and ankle. This can, in some cases, resolve
the need to delay ORIF of the tibia since the incision is essentially the same as that used for
the immediate ORIF of fibula fractures, which is commonly used in the staged treatment of
distal tibial and plafond fractures. This approach can be extended proximally and distally to
allow treatment of other injuries about the ankle and hindfoot. Illustrative cases are
provided.

Arch Orthop Trauma Surg. 2010 Oct;130(10):1289-97. doi: 10.1007/s00402010-1075-6. Epub 2010 Feb 25.

Comparison of two-staged ORIF and

limited internal fixation with external
fixator for closed tibial plafond
fractures.
Wang C1, Li Y, Huang L, Wang M.

Author information
Abstract
OBJECTIVE:

To compare the results of two-staged open reduction and internal fixation (ORIF) and
limited internal fixation with external fixator (LIFEF) for closed tibial plafond fractures.
METHODS:

From January 2005 to June 2007, 56 patients with closed type B3 or C Pilon fractures were
randomly allocated into groups I and II. Two-staged ORIF was performed in group I and
LIFEF in group II. The outcome measures included bone union, nonunion, malunion, pintract infection, wound infection, osteomyelitis, ankle joint function, etc. These
postoperative data were analyzed with Statistical Package for Social Sciences (SPSS) 13.0.

RESULTS:

Incidence of superficial soft tissue infection (involved in wound infection or pin-tract

infection) in group I was lower than that in group II (P < 0.05), with significant difference.
Group I has significantly less radiation exposure (P < 0.001). Group II had higher rates of
malunion, delayed union, and arthritis symptoms, with no statistical significance. Both
groups resulted similar ankle joint function. Logistic regression analysis indicated that
smoking and fracture pattern were the two factors significantly influencing the final
outcomes.
CONCLUSIONS:

In the treatment of closed tibial plafond fractures, both two-staged ORIF and LIFEF offer
similar results. Patients undergo LIFEF carry significantly greater radiation exposure and
higher superficial soft tissue infection rate (usually occurs on pin tract and does not affect
the final outcomes).

J Orthop Trauma. 2010 Aug;24(8):499-504. doi:

10.1097/BOT.0b013e3181c8ad52.

The sequential recovery of health status

after tibial plafond fractures.
Marsh JL1, McKinley T, Dirschl D, Pick A, Haft G, Anderson DD, Brown T.

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Abstract
OBJECTIVES:

To assess the recovery of ankle function and general health status at multiple time points
during the first 24 months after an isolated tibial plafond fracture treated with jointspanning external fixation and to determine factors that affect a rapid versus a slow
recovery and factors that influence patient outcome at a minimum of 2 years after injury.
DESIGN:

Prospective observational study.

SETTING:

Two Level I trauma centers.

PATIENTS:

Forty-three patients (mean age, 42 years; range, 20-60 years) with unilateral fractures of the
tibial plafond were prospectively assessed. These 43 patients had a 24 month follow up and
were seen for at least three additional scheduled visits before the 24-month follow up.
INTERVENTION:

Spanning articulated external fixator and follow ups at defined time intervals after injury to
track the progress of the outcome measures over time.
MAIN OUTCOME MEASURES:

The Short Form Health Survey (SF-36) Medical Outcomes Study (MOS) version 2
Physical Component Summary Score (PCS) and Mental Component Summary Score
(MCS) and the Ankle Osteoarthritis (AOS) Pain and Disability Scales.
RESULTS:

Early after injury, the MCS was not as negatively affected as the PCS. By 6 months after
injury, the MCS had improved to be equivalent to age-matched norms and remained there
at 2 years after injury. The PCS was more severely compromised and did not level off until
the 12-month clinic visit. At 2 years, the PCS remained on average one standard deviation
below age-matched normal. Although not statistically significant, both the average pain and
disability AOS scales deteriorated between 6 and 12 months, suggesting some patients
actually perceived their ankle as being worse as they begin walking on their injured ankle.
Between 12 and 24 months, they trended toward improvement in both the pain and function
scales. However, their ankle continued to have dramatically increased pain and decreased
function compared with population-based norms.
CONCLUSIONS:

In patients recovering from a tibial plafond fracture that was treated with joint-spanning
external fixation, the MCS improves quickly and completely, whereas the PCS often takes
1 full year or longer to reach maximal improvement and does not completely recover,
because it remains on average one standard deviation below normal at 2 years after injury.
Changes in the AOS pain and disability scales between 6 and 12 months after injury were
not significantly different but at all time points, the patient's ankle pain and function
remains dramatically different than the normal population. These results can be used in
future studies for comparison with patients treated with alternate treatment techniques and
to assess the effect of important treatment variables such as stabilization techniques and
quality of reduction.

Rev Esp Cir Ortop Traumatol. 2013 Mar-Apr;57(2):117-22. doi:

10.1016/j.recot.2012.11.004. Epub 2013 Feb 22.

[Medial versus lateral plating in distal

tibial fractures: a prospective study of 40
fractures].
[Article in Spanish]
Encinas-Ulln CA1, Fernandez-Fernandez R, Rubio-Surez JC, Gil-Garay E.

Author information
Abstract
OBJECTIVE:

Tibial plafond fractures are one of the most challenging injuries in orthopaedic surgery.
Their results could be improved by following the new guidelines for the management, and
modern plating techniques. The results and complication rate between anteromedial and
anterolateral approach for open reduction and internal fixation of these fractures were
compared.
MATERIAL AND METHODS:

A study was conducted on 40 patients treated by open reduction an internal fixation

between 2007 and 2008. The surgical approach was selected by the surgeon in charge,
depending on fracture pattern and skin situation. Patients were evaluated clinically and
radiographically by an independent orthopaedic surgeon, not involved in the surgical
procedure, using clinical (American Orthopaedic Foot and Ankle Society score) and
radiological criteria at a minimum of two years. The appearance of complications after both
approaches was recorded.
RESULTS:

Forty patients were included. The mean age was 53 years, with 24 males and 16 females.
Seventeen of the injuries were of high energy, and there were 8 open fractures (3 of type i,
4 type ii and one type iii), and 12 of the closed injuries were grade ii or iii in the Tscherne
classification. Six patients (15%) had associated injuries. At final follow-up there were 33
(82%) excellent or good results. No statistical differences were found between either
surgical approach regarding time to bone union, rate of delayed union and infection rate.

Three plates of the anteromedial group and none of the anterolateral group needed to be
removed.
CONCLUSION:

Open reduction and internal fixation of distal tibia fractures produced reliable results, with
no statistical differences found between anteromedial and anterolateral surgical approaches.
Clinical and radiological results and complication rate were mainly related to the fracture
type.

Foot Ankle Spec. 2015 Jun;8(3):220-5. doi: 10.1177/1938640014548322. Epub

2014 Aug 24.

Early Tibiotalocalcaneal Arthrodesis

Intramedullary Nail for Treatment of a
Complex Tibial Pilon Fracture
(AO/OTA 43-C).
Hsu AR1, Szatkowski JP2.

Author information
Abstract
Management of severely comminuted, complete articular tibial pilon fractures (AO/OTA
43-C) remains a challenge, with few treatment options providing good clinical outcomes.
Open reduction and internal fixation of the tibial plafond, tibiotalar arthrodesis, and salvage
hindfoot reconstruction procedures are all associated with surgical complications and
functional limitations. In this report, we present a case of a complex pilon fracture in a
patient with multiple medical comorbidities and socioeconomic disadvantages that was
successfully and acutely treated with a retrograde tibiotalocalcaneal hindfoot arthrodesis
nail. At final follow-up examination, the patient had decreased pain, a stable plantigrade
foot, and could ambulate with normal shoes without any assistive devices.
LEVELS OF EVIDENCE:

Therapeutic, Level IV: Case series.

J Foot Ankle Surg. 2015 Jul-Aug;54(4):646-51. doi: 10.1053/j.jfas.2014.06.007. Epub 2014

Aug 12.

A Meta-Analysis for Postoperative

Complications in Tibial Plafond Fracture:
Open Reduction and Internal Fixation
Versus Limited Internal Fixation
Combined With External Fixator.
Wang D1, Xiang JP2, Chen XH3, Zhu QT1.

Author information
Abstract
The treatment of tibial plafond fractures is challenging to foot and ankle surgeons. Open
reduction and internal fixation and limited internal fixation combined with an external
fixator are 2 of the most commonly used methods of tibial plafond fracture repair.
However, conclusions regarding the superior choice remain controversial. The present
meta-analysis aimed to quantitatively compare the postoperative complications between
open reduction and internal fixation and limited internal fixation combined with an external
fixator for tibial plafond fractures. Nine studies with 498 fractures in 494 patients were
included in the present study. The meta-analysis found no significant differences in bone
healing complications (risk ratio [RR] 1.17, 95% confidence interval [CI] 0.68 to 2.01, p = .
58], nonunion (RR 1.09, 95% CI 0.51 to 2.36, p = .82), malunion or delayed union (RR
1.24, 95% CI 0.57 to 2.69, p = .59), superficial (RR 1.56, 95% CI 0.43 to 5.61, p = .50) and
deep (RR 1.89, 95% CI 0.62 to 5.80) infections, arthritis symptoms (RR 1.20, 95% CI 0.92
to 1.58, p = .18), or chronic osteomyelitis (RR 0.31, 95% CI 0.05 to 1.84, p = .20) between
the 2 groups.

Acta Chir Orthop Traumatol Cech. 2014;81(5):313-6.

The risk of neurovascular injury in

minimally invasive plate osteosynthesis

(MIPO) when using a distal tibia

anterolateral plate: a cadaver study.
Lidder S1, Masterson S, Grechenig C, Clement H, Gnsslen A, Grechenig S.

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Abstract
PURPOSE OF THE STUDY:

Percutaneous plating of the distal tibia via a limited incision is an accepted technique of
osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. The aim of
this study was to analyze structures that are at risk during this approach.
MATERIAL AND METHODS:

Thirteen unpaired adult lower limbs were used for this study. Thirteen, 15-hole LCP
anterolateral distal tibial plates were percutaneously inserted according to the recommended
technique. Dissection was performed to examine the relation of the superficial and deep
peroneal nerves and anterior tibial artery relative to the plate.
RESULTS:

The superficial peroneal nerve was found to cross the vertical limb of the LCP plate at a
mean distance of 63 mm (screw hole five) but with a wide range of 21 to 105 mm. The
neurovascular bundle (deep peroneal nerve and anterior tibial artery) crossed the plate at a
mean of 76 mm (screw hole six) but also with a wide range of 38 to 138 mm. The zone of
danger of the neurovascular structures ranges from 21 to 138 mm from the tibial plafond. In
one specimen, a significant branch of the deep peroneal nerve was found to be entrapped
under the plate.
CONCLUSION:

Caution is advised when using anterolateral minimally invasive technique for plate
insertion and screw placement in the distal tibia due to great variability in the neurovascular
structures that course distally in the lower leg and cross the ankle.

Injury. 2015 Jun 18. pii: S0020-1383(15)00353-8. doi:

10.1016/j.injury.2015.06.025. [Epub ahead of print]

Prognostic factors of health-related quality

of life in patients after tibial plafond
fracture. A pilot study.
Cutillas-Ybarra MB1, Lizaur-Utrilla A2, Lopez-Prats FA1.

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Abstract
BACKGROUND:

Tibial plafond fractures are a uncommon injury, and the outcomes described in literature
are generally poor. The purposes were to determine the effect of the tibial plafond fractures
on general health-related quality of life, and to examine the factors that influence these
outcomes.
METHODS:

Retrospective study of 43 patients with average age of 45.6 (range 18-69) years who were
also invited for a clinical and radiological reassessment. The primary outcome measure was
quality of life assessed by the Short Form-36 questionnaire. Visual analogue scale for pain,
and motion of both ankle and subtalar joints were also assessed. Radiological evaluation
was performed to assess bone healing, fracture reduction quality, and tibial alignment.
RESULTS:

The mean follow-up at last visit was 8.1 (range, 4-12) years. Patients who had suffered
plafond fracture had significantly poorer quality of life compared with age- and gendermatched general population of our country regardless of the treatment method used.
Multivariate analyses showed that the age had influence on the emotional outcomes,
educational level and fracture pattern on physical outcomes, and marital status, fracture
reduction quality, and ankle motion on both physical and mental component summaries.
CONCLUSION:

Tibial plafond fractures have a significant negative impact on general health-related quality
of life regardless of the operative treatment used which reflects injury severity. In addition,
psychosocial characteristics of patients may influence the outcomes.

J Bone Joint Surg Br. 2008 Jan;90(1):1-6.

External fixation devices in the treatment

of fractures of the tibial plafond: a
systematic review of the literature.
Papadokostakis G1, Kontakis G, Giannoudis P, Hadjipavlou A.

Author information
Abstract
We have compared the outcomes of the use of external fixation devices for spanning or
sparing the ankle joint in the treatment of fractures of the tibial plafond, focusing on the
complications and the rates of healing. We have devised a scoring system for the quality of
reporting of clinical outcomes, to determine the reliability of the results. We conducted a
search of publications in English between 1990 and 2006 using the Pubmed search engine.
The key words used were pilon, pylon, plafond fractures, external fixation. A total of 15
articles, which included 465 fractures, were eligible for final evaluation. There were no
statistically significant differences between spanning and sparing fixation systems
regarding the rates of infection, nonunion, and the time to union. Patients treated with
spanning frames had significantly greater incidence of malunion compared with patients
treated with sparing frames. In both groups, the outcome reporting score was very low;
60% of reports involving infection, nonunion or malunion scored 0 points.

J Orthop Sci. 2015 Jul;20(4):695-701. doi: 10.1007/s00776-015-0713-9. Epub

2015 Mar 21.

Intramedullary nailing versus minimally

invasive plate osteosynthesis for distal
extra-articular tibial fractures: a
prospective randomized clinical trial.
Polat A1, Kose O, Canbora K, Yank S, Guler F.

Author information
Abstract

PURPOSE:

The purpose of this randomized clinical trial is to compare intramedullary nailing (IMN)
versus minimally invasive plate osteosynthesis (MIPO) for the treatment of extra-articular
distal tibial shaft fractures.
MATERIALS AND METHODS:

Twenty-five consecutive patients with distal extra-articular tibial fractures which were
located between 4 and 12 cm from the tibial plafond (AO 42A1 and 43A1) were randomly
assigned into IMN (n: 10) or MIPO (n: 15) treatment groups. All patients were followed for
at least 1 year. Foot function index, time to weight bearing, union time, duration of
operation, length of incision, intra-operative blood loss, intra-operative fluoroscopy time,
rotational and angular malalignment, rate of infection, secondary interventions and
complications were compared between groups.
RESULTS:

All patients completed the trial and were followed with a mean of 23.1 9.4 months (range
12-52). Foot function index, weight bearing time, union time, rate of malunion, rate of
infection and rate of secondary interventions were all similar between groups (p = 0.807,
p = 0.177, p = 0.402, p = 0.358, p = 0.404, p = 0.404, respectively). Intra-operative blood
loss, length of surgical incision, radiation time and rotational malalignment were higher in
the IMN group (p = 0.012, p = 0.019, p = 0.004 and p = 0.027, respectively).
CONCLUSIONS:

Results of our study showed that both treatment methods have similar therapeutic efficacy
regarding functional outcomes and can be used safely for extra-articular distal tibial shaft
fractures, and none of the techniques had a major advantage over the other.

J Orthop Trauma. 2015 Sep;29(9):424-7. doi: 10.1097/BOT.0000000000000304.

Does the Fibula Need to be Fixed in

Complex Pilon Fractures?
Kurylo JC1, Datta N, Iskander KN, Tornetta P 3rd.

Author information
Abstract

OBJECTIVES:

To review a series of patients with complex plafond injuries with a metadiaphyseal

dissociation who did not have the fibula fixed and compare with patients who had their
fibula fixed using patients without a fibula fracture as a control group.
DESIGN:

Retrospective case-control study.

SETTING:

Level 1 Trauma center at a university hospital.

PATIENTS/PARTICIPANTS:

Skeletally mature patients with a complete metadiaphyseal plafond fracture, and adequate
presentation, postreduction, and healed radiographs to measure varus and valgus alignment.
INTERVENTION:

Surgical treatment [external fixator or open reduction internal fixation (ORIF)] of high
energy pilon fractures.
MAIN OUTCOME MEASUREMENTS:

Metaphyseal alignment at the time of presentation, after fixation, and at union, surgical
procedures performed, and complications.
METHODS:

From 364 patients with plafond fractures, 111 had high energy injuries with metadiaphyseal
dissociation and form the basis of the study. Radiographs and charts were reviewed for
fracture characteristics, metaphyseal alignment at the time of presentation, after fixation,
and at union, surgical procedures performed, and complications.
RESULTS:

Of the 111 study patients, 93 patients were treated definitively with ORIF of the tibia and
18 patients were treated definitively in an external fixator. Within the 93 patients treated
definitively with ORIF of the tibia, we identified 3 groups of patients those with a fibula
fracture that was fixed (26 patients), those with a fibula fracture that was not fixed (37
patients), and those without a fibula fracture acting as the control group (30 patients).
Between the 2 groups having a fibula fracture treated with ORIF of the tibia, there was no
difference in fibula fracture pattern or location. For the 26 patients who had fibular fixation,
it was performed in 11 patients at an average of 17 days for inability to hold length and

alignment and in 15 patients to augment fixation in poor bone stock or to aid in the
reduction. Patients with initial valgus deformity were more likely to have their fibula fixed.
There was no difference in the postoperative or final alignment between the patients with
fibula fractures (with or without fixation) and those without fibula fractures (P = 0.92).
When comparing the 3 groups, the only statistical finding between the 2 groups was that
those with fibula fixation required plate removal (P < 0.0001).
CONCLUSIONS:

Fibular fixation is not a necessary step in the reconstruction of pilon fractures, although it
may be helpful in specific cases to aid in tibial plafond reduction or augment external
fixation. We found a higher rate of plate removal if the fibula was fixed.
LEVEL OF EVIDENCE:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of
evidence.