Modified staging strategy in treatment of type C3 Pilon fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CHEN Yu ,  ZHANG Hui , LIU Xi , LI Yaxing , QIN Boquan , REN Yi , WU Shizhou , HUANG fuguo

Foot and Ankle Center of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

ZHANG Hui, Email: caesarzh@163.com

Keywords：

Type C3 Pilon fracture; staging operation; internal fixation; open reduction

DOI：

10.7507/1002-1892.201903100

Video：

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Objective To investigate the safety, feasibility, and effectiveness of modified staging strategy in treatment of type C3 Pilon fractures.Methods The clinical data of 23 patients with type C3 Pilon fractures treated with modified staging strategy between January 2012 and January 2018 was retrospectively analyzed. There were 14 males and 9 females with an average age of 47.9 years (range, 22-61 years). Twenty-three cases were high-energy injuries, including 11 cases of traffic accidents and 12 cases of falling from height. One case was an open fracture of Gustilo type ⅢA with no obvious sign of infection on the wound after early treatment. The remaining patients were closed fractures. The time from injury to admission was 3-40 hours with an average of 16.4 hours. The preoperative pain visual analogue scale (VAS) score was 7.22±1.17 and American Orthopaedic Foot and Ankle Society (AOFAS) score was 0. The flexion and plantar flexion activities of ankle joint were (1.13±0.26) and (4.79±0.93)°, respectively. Twenty-two patients had a tibiofibular fracture. In the first-stage operation, the posterior approach was used to reduce the posterior column fracture and the external stent was temporarily assisted. After the soft tissue crisis was removed, the final fracture reduction and internal fixation was performed through the anterior approach in the second-stage operation.Results All 23 patients were followed up 12-84 months with an average of 26.6 months. The waiting time before the first-stage operation was 4-47 hours with an average of 23.4 hours. The interval between the two stage operations was 6-11 days with an average of 7.9 days. The first-stage operation time was 60-90 minutes with an average of 67.8 minutes; the second-stage operation time was 110-160 minutes with an average of 124.1 minutes. The hospital stay was 15-28 days with an average of 23.5 days. One patient (4.35%) had a tourniquet paralysis symptom after the second-stage operation, and two patients (8.7%) had delayed anterior incision healing. The other patients had incision healing without early complications. The radiographic review showed that the quality of articular surface reduction was excellent in 19 cases, good in 2 cases, and poor in 2 cases, with an excellent and good rate of 91.3%. At last follow-up, the fractures healed with no bone nonunion and malunion; the different degrees of osteoarthritis occurred in 7 cases. At last follow-up, the VAS score was 0.89 ±0.88 and the AOFAS score was 81.3±7.8. The flexion and plantar flexion activities of ankle joint were (10.23±5.05) and (20.97±3.92)°, respectively, and the differences between pre- and post-operation were significant (P<0.05).Conclusion The midified staging strategy can not only provide a template for articular surface reduction for the second-stage anterior surgery, but also improve the quality of the reduction. It can also reduce the interval between the two operations and the operation time of the second-stage operation through the first-stage posterior fascial decompression, and can obtain satisfactory effectiveness.

Citation： CHEN Yu, ZHANG Hui, LIU Xi, LI Yaxing, QIN Boquan, REN Yi, WU Shizhou, HUANG fuguo. Modified staging strategy in treatment of type C3 Pilon fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(11): 1358-1362. doi: 10.7507/1002-1892.201903100 Copy

1.	Cui X, Chen H, Rui Y, et al. Two-stage open reduction and internal fixation versus limited internal fixation combined with external fixation: a meta-analysis of postoperative complications in patients with severe Pilon fractures. J Int Med Res, 2018, 46(7): 2525-2536.
2.	Duckworth AD, Jefferies JG, Clement ND, et al. Type C tibial pilon fractures: short- and long-term outcome following operative intervention. Bone Joint J, 2016, 98-B(8): 1106-1111.
3.	王磊, 刘欣, 吴志新, 等. Ruedi-Allgower Ⅲ型Pilon骨折中Tillaux骨块的处理. 中国修复重建外科杂志, 2018, 32(10): 1308-1312.
4.	Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma, 2004, 18(8 Suppl): S32-S38.
5.	Mauffrey C, Vasario G, Battiston B, et al. Tibial pilon fractures: a review of incidence, diagnosis, treatment, and complications. Acta Orthop Belg, 2011, 77(4): 432-440.
6.	龚晓峰, 许毅博, 吕艳伟, 等. 影响Pilon骨折手术疗效的相关因素分析. 中华骨科杂志, 2016, 36(21): 1380-1385.
7.	Ketz J, Sanders R. Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures. J Orthop Trauma, 2012, 26(6): 341-347.
8.	Zelle BA, Dang KH, Ornell SS. High-energy tibial pilon fractures: an instructional review. Int Orthop, 2019, 43(8): 1939-1950.
9.	Bear J, Rollick N, Helfet D. Evolution in management of tibial pilon fractures. Curr Rev Musculoskelet Med, 2018, 11(4): 537-545.
10.	Kottmeier SA, Madison RD, Divaris N. Pilon fracture: preventing complications. J Am Acad Orthop Surg, 2018, 26(18): 640-651.
11.	Mittlmeier T, Wichelhaus A. Treatment strategy and planning for pilon fractures. Unfallchirurg, 2017, 120(8): 640-647.
12.	White TO, Guy P, Cooke CJ, et al. The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study. J Orthop Trauma, 2010, 24(12): 757-763.
13.	Wang D, Xiang JP, Chen XH, et al. A meta-analysis for postoperative complications in tibial plafond fracture: open reduction and internal fixation versus limited internal fixation combined with external fixator. J Foot Ankle Surg, 2015, 54(4): 646-651.
14.	Bhattacharyya T, Crichlow R, Gobezie R, et al. Complications associated with the posterolateral approach for pilon fractures. J Orthop Trauma, 2006, 20(2): 104-107.
15.	Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma, 1999, 13(2): 85-91.
16.	Chan DS, Balthrop PM, White B, et al. Does a staged posterior approach have a negative effect on OTA 43C fracture outcomes? J Orthop Trauma, 2017, 31(2): 90-94.
17.	Dunbar RP, Barei DP, Kubiak EN, et al. Early limited internal fixation of diaphyseal extensions in select pilon fractures: upgrading AO/OTA type C fractures to AO/OTA type B. J Orthop Trauma, 2008, 22(6): 426-429.
18.	王明鑫, 刘德昌, 王坤, 等. 改良双切口治疗合并腓骨骨折的Pilon骨折疗效观察. 中国修复重建外科杂志, 2016, 30(12): 1483-1487.
19.	Howard JL, Agel J, Barei DP, et al. A prospective study evaluating incision placement and wound healing for tibial plafond fractures. J Orthop Trauma, 2008, 22(5): 299-306.
20.	Chen L, O'Shea K, Early JS. The use of medial and lateral surgical approaches for the treatment of tibial plafond fractures. J Orthop Trauma, 2007, 21(3): 207-211.
21.	Assal M, Ray A, Stern R. The extensile approach for the operative treatment of high-energy pilon fractures: surgical technique and soft-tissue healing. J Orthop Trauma, 2007, 21(3): 198-206.
22.	Tornetta P 3rd, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Relat Res, 1996, (323): 273-276.

1. Cui X, Chen H, Rui Y, et al. Two-stage open reduction and internal fixation versus limited internal fixation combined with external fixation: a meta-analysis of postoperative complications in patients with severe Pilon fractures. J Int Med Res, 2018, 46(7): 2525-2536.
2. Duckworth AD, Jefferies JG, Clement ND, et al. Type C tibial pilon fractures: short- and long-term outcome following operative intervention. Bone Joint J, 2016, 98-B(8): 1106-1111.
3. 王磊, 刘欣, 吴志新, 等. Ruedi-Allgower Ⅲ型Pilon骨折中Tillaux骨块的处理. 中国修复重建外科杂志, 2018, 32(10): 1308-1312.
4. Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma, 2004, 18(8 Suppl): S32-S38.
5. Mauffrey C, Vasario G, Battiston B, et al. Tibial pilon fractures: a review of incidence, diagnosis, treatment, and complications. Acta Orthop Belg, 2011, 77(4): 432-440.
6. 龚晓峰, 许毅博, 吕艳伟, 等. 影响Pilon骨折手术疗效的相关因素分析. 中华骨科杂志, 2016, 36(21): 1380-1385.
7. Ketz J, Sanders R. Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures. J Orthop Trauma, 2012, 26(6): 341-347.
8. Zelle BA, Dang KH, Ornell SS. High-energy tibial pilon fractures: an instructional review. Int Orthop, 2019, 43(8): 1939-1950.
9. Bear J, Rollick N, Helfet D. Evolution in management of tibial pilon fractures. Curr Rev Musculoskelet Med, 2018, 11(4): 537-545.
10. Kottmeier SA, Madison RD, Divaris N. Pilon fracture: preventing complications. J Am Acad Orthop Surg, 2018, 26(18): 640-651.
11. Mittlmeier T, Wichelhaus A. Treatment strategy and planning for pilon fractures. Unfallchirurg, 2017, 120(8): 640-647.
12. White TO, Guy P, Cooke CJ, et al. The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study. J Orthop Trauma, 2010, 24(12): 757-763.
13. Wang D, Xiang JP, Chen XH, et al. A meta-analysis for postoperative complications in tibial plafond fracture: open reduction and internal fixation versus limited internal fixation combined with external fixator. J Foot Ankle Surg, 2015, 54(4): 646-651.
14. Bhattacharyya T, Crichlow R, Gobezie R, et al. Complications associated with the posterolateral approach for pilon fractures. J Orthop Trauma, 2006, 20(2): 104-107.
15. Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma, 1999, 13(2): 85-91.
16. Chan DS, Balthrop PM, White B, et al. Does a staged posterior approach have a negative effect on OTA 43C fracture outcomes? J Orthop Trauma, 2017, 31(2): 90-94.
17. Dunbar RP, Barei DP, Kubiak EN, et al. Early limited internal fixation of diaphyseal extensions in select pilon fractures: upgrading AO/OTA type C fractures to AO/OTA type B. J Orthop Trauma, 2008, 22(6): 426-429.
18. 王明鑫, 刘德昌, 王坤, 等. 改良双切口治疗合并腓骨骨折的Pilon骨折疗效观察. 中国修复重建外科杂志, 2016, 30(12): 1483-1487.
19. Howard JL, Agel J, Barei DP, et al. A prospective study evaluating incision placement and wound healing for tibial plafond fractures. J Orthop Trauma, 2008, 22(5): 299-306.
20. Chen L, O'Shea K, Early JS. The use of medial and lateral surgical approaches for the treatment of tibial plafond fractures. J Orthop Trauma, 2007, 21(3): 207-211.
21. Assal M, Ray A, Stern R. The extensile approach for the operative treatment of high-energy pilon fractures: surgical technique and soft-tissue healing. J Orthop Trauma, 2007, 21(3): 198-206.
22. Tornetta P 3rd, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Relat Res, 1996, (323): 273-276.

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Modified staging strategy in treatment of type C3 Pilon fractures

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