High en ergy pilon frac tures pres ent a uniquechal lenge to the pa tient and or tho pae dic sur geon.Care for the soft tis sue en ve lope is as im por tantas man age ment of this ar tic u lar frac ture. This ar -ti cle pres ent long term re sults of pa tients suf -fered type C pilon frac tures treated with themethod of ex ter nal fix a tion with min i mal in va sive ap proach,. We ob serve a to tal of fifty five pa -

tients, be tween Au gust 2008 and Jan u ary 2015, un der -went ex ter nal fix a tion of type C pilon frac tures withmin i mal in va sive ap proach at Clinic of Or tho pae dicand Traumatology, Clin i cal cen ter Niš, Ser bia. In fec -tious com pli ca tions sec ond ary to wound heal ing prob -lems are a ma jor con cern af ter open sur gery for pilonfrac ture. There fore, soft-tis sue man age ment is crit i cal for suc cess ful op er a tive treat ment of these frac tures.Ac cord ing to our long term re sults in the pres entstudy, it seems that ex ter nal fix a tion rep re sent a ra -tio nal ap proach to ob tain and main tain align ment ofthe dis tal tibia through ligamentotaxis, thereby avoid -ing for mal open re duc tion for treat ment of the pa -tient with se vere pilon frac ture.

Key words: pilon frac ture, high en ergy frac tures,ex ter nal fix a tion

IN TRO DUC TION

The soft tis sues around the an kle and dis tal tibia areeas ily com pro mised by trauma and sub se quent op er a -

tive frac ture treat ment1,2. Sal vage of these chal leng ingprob lems more of ten than not re quires a staged treat mentbased on thor ough debridement(s), an ti bi otic treat mentun til in fec tion is elim i nated fol lowed by re con struc tion3-10. The ini tial debridement should in clude re moval of all failed hard ware. The re sult ing in sta bil ity will com pro -mise the erad i ca tion of in fec tion. To pre vent this, pri -mary fix a tion of com plex type C pilon afractures can beachieved by method of ex ter nal fix a tion with min i mal

invasive ap proach around a joint in or der to reach ar tic u -lar sur face re con struc tion.

Set ting the ap pa ra tus for ex ter nal fication in the ap pro -pri ate po si tion with the pins placed in safe zones, ob -tained align ment of dis tal tibia due to ligamentotaxis.Ad di tional fication of ar tic u lar sruface, if nec es sary, canbe achieved by min i mal in va sive ap proach. In this way is achieved a stgable fication and pres er va tion of the softtis sue en ve lope.

MA TE RIAL AND METH ODS

55 pa tients with 55 tibia pilon frac tures were treated atour clinic. The in di ca tions for an op er a tion in cluded un -ac cept able align ment of the frac ture with in con gru ity ofthe ar tic u lar sur face of more than 2 mm or an open frac -ture. The mech a nism of in jury was ve hi cle ac ci dents in33 pa tients (60%), high-en ergy falls in 13 pa tients(23.6%) and sports in ju ries in nine pa tients (16.4%). Themean age was 45.4 years (22–76) SD 12.6 and the meanfol low-up 76 months (36–132) SD 86.4. Thirty-two pa -tients (58.1%) were ru ral work ers. Three op er a tive pro ce -dures were per formed: ex ter nal fix a tion with an kle span -ning, ex ter nal fix a tion with an kle spar ring or two stagedin ter nal fix a tion. All the pa tients were man aged by one of three sur geons who were on call. Each sur geon per -formed one treat ment pro to col only. Each sur geon hadthe same num ber of calls ev ery month. All the sur geonswere trained in trauma. All the pa tients were pro spec -tively con tacted and asked to re turn to the hos pi tal for as -sess ment of long-term out come. Dur ing this last eval u a -tion, they were ex am ined clin i cally and ra dio graph i cally.All the pa tients un der went a range of mo tion mea sure -ments and ra dio graphic eval u a tion. Frac tures classifedac cord ing the AO-ASIF sys tem. Sixty-five per cent (n =36) were Type C in ju ries (14 Type C1, 16 Type C2 and 6 Type C3), and 35% (n = 19) were Type B (15 Type B2and 4 Type B3). In all pa tients, there was a con com i tantfrac ture of the fib ula that was clas si fied ac cord ing to

.........................................

Treat ment of high-en ergy pilon frac tures with ex ter nal fix a tion as a method of min i mal in va sive ap proach -long term re sults

Igor M. Kosti}, Mi lan M. Mitkovi}, Milorad B. Mitrovi}Clinic for Or tho pae dic Sur gery and Traumatology, Clin i cal Cen tre Ni{,Uni ver sity of Ni{, Ser bia

/STRU^NI RAD

UDK 616.718.5-001.5-089.2DOI 10.2298/ACI1501057K

emizer

Weber clas si fi ca tion (45 Type B and 10 Type C). Therewere 24 open and 31 closed frac tures. Closed soft tis suewas clas si fied in the man ner de scribed by Tscherne11 andopen soft tis sue dam age was graded ac cord ing to Gustiloand An der son ref er ences. All the pa tients were ini tiallyeval u ated in the emer gency room. Plain ra dio graphs were taken and CT scan was used in all Type C frac tures.Forty pa tients un der went pri mary sur gery within 24 h ofin jury. The re main ing had sur gery af ter soft tis sue re cov -ery within 10–12 days from injury.

Open frac tures were treated with im me di ate debride -ment and sta bi li za tion, ei ther tem po rary or def i nite. Allthe pa tients re ceived pre op er a tively an ti bi ot ics. All thepa tients were seen af ter the exit of the hos pi tal at 1 week, at 1 month, monthly for 12 months and then an nu ally.Each pa tient un der went a range of mo tion mea sure ment,stair-step ping abil ity and ra dio graphic eval u a tion.

Frac ture un ion was de fined as hav ing three cor ti cesbridg ing on the plain ra dio graphs for a pa tient who wasable to bear full weight. Non union was de fined as a frac -ture that did not heal within a year. Malunion was de -fined as the in con gru ity of the ar tic u lar sur face of more

than 2 mm or malalignment greater than 10° in anyplane. Three sur gi cal pro to cols were used.

In 20 pa tients, Group A (7 Type B, 13 Type C, 2 IIIa- 2 II-five I) with mean age 42.0 years (22.0–74.0) SD 14.1and mean fol low-up 77.7 months (38.0–132.0) SD 25.4,a half pin ex ter nal fixator with an kle span ning was per -formed (Fig. 1). The ex ter nal fix a tion was ap plied on thecalcaneus. Af ter ra dio graphic ap pear ance of un ion, thehard ware was re placed with par tial weight-bear ing castfor 10 days. The fib ula frac ture was al ways in ter nallyfixed with a plate.

In 22 pa tients, Group B (4 type B, 18 Type C, 5 I-twoII) with mean age 48.4 years (28.0–76.0), SD 12.4 andmean fol low-up 67.9 months (36.0–132.0), SD 27.8, asin gle an kle spar ring ring hy brid ex ter nal fixator withtensioned wires was per formed (Fig. 2). Af ter pri mary re -duc tion and plat ing of the fib ula, reconstructon of the ar -tic u lar sur face of the tibia was per formed through a small an te rior arthrotomy. Af ter the sur gery the pa tients used asplint for 2 weeks. In both Groups A and B, the pa tientswere not al lowed to bear weight un til the frac ture had ad -e quately con sol i dated.

58 I.M.Kostic et al. ACI Vol.LXII

FIG URE 1TYPE C PILON FRAC TURE TREATED WITH METHOD OF EX TER NAL FIX A TION COM BINED WITH ORIF OF FIB U LARFRAC TURE IN 60 YEARS OLD FE MALE PA TIENTS -TECH NIQUES OF LIGAMENTOTAXIS

FIG URE 2TYPE C PILON FRAC TURE TREATED WITH METHOD OF HY BRID FIX A TION WITH MINI ARTHROTOMY FOR RE DUC -TION OF AR TIC U LAR SUR FACE IN 45 YEARS OLD MALE PATIENT

In 13 pa tients, Group C (eight Type B, five Type C,five I-three IIIa) with mean age 45.69 years (30–66), SD9.76 and mean fol low-up 78.62 months (55–132), SD25.47 a two-staged in ter nal fix a tion was per formed withan periarticular plat ing sys tem ac cord ing to the AOASIFprin ci ples (Fig. 3).

All the pa tients un der went im me di ate fib u lar fix a tionand place ment of a me dial span ning ex ter nal fixator. Af -ter, on an av er age, 12 days (11–16), the pa tients un der -went re moval of the ex ter nal fixator and in ter nal fix a tionof the frac tures. Via a short dis tal skin in ci sion, the plateis in tro duced sub cu ta ne ously, pushed prox i mally andfixed by screws in serted via stab in ci sions. The hard warewas re moved 2 years af ter the pri mary sur gery. The de -mo graphic data are shown in Ta bles 1, 2, 3.

RE SULTS

MECH A NISM OF IN JURY

There were 16 pa tients in group A who were in volvedin traf fic ac ci dents, three who had fallen and one whowas in volved in a sports in jury. In group B, ten pa tientswere in volved in traf fic ac ci dents, nine had fallen andthree were in volved in sports in jury. In group C, sevenpa tients were in volved in trafic ac ci dent, one had fallenand five were in volved in sports in jury.

FRAC TURE PAT TERN

There was sig nif i cant re la tion ship be tween the type offrac tures - 77.8% type C from traf fic ac ci dents and themech a nism of in jury (x2 = 15.07; P = 0.001). When themech a nism of in jury was traf fic ac ci dents, the most com -

Br. 1 Treat ment of high-en ergy pilon frac tures with ex ter nal fix a tion as a method of 59min i mal in va sive ap proach

FIG URE 3TYPE C PILON FRAC TURE TREATED WITH TWO STAGED PRO TO COL IN 58 YEARS OLD FE MALE PATIENT

TABLE 1

THE THREE SURGICAL METHODS AND THE TYPE OF FRACTURES -AO-SIF CLASSIFICATION

Method of fixationTYPE#T

TotalB2 B3 C1 C2 C3

1 External 4 3 1 10 2 20

2 Internal 8 0 0 5 0 13

3 Hybrid 3 1 13 1 4 22

Total 15 4 14 16 6 55

mon frac ture was type C, while type B frac tures weremore com mon in sports in ju ries.

There was a sta tis ti cally sig nif i cant diference (P <0.003) in the treat ment of type C frac tures be cause ex ter -nal fix a tion was used in 50% of them.

OPEN FRAC TURES

There was sig nif i cant re la tion ship be tween the type offrac tures -91.7% of open frac tures were from traficc ac ci -dent — and the mech a nism of in jury (x2 = 17.816, P <0.001).

FRAC TURE UN ION

Frac ture un ion was achieved in 5.9 months (4.0–11.0),SD 1.7. Group A had un ion in 6.9 months (4.0–11.0) SD2.4 months, group B in 5.6 months (4.0–9.0) SD 1.1 andgroup C in 5.1 months (4.0–6.0) SD 0.5. In group A,there were four de layed un ions in 11 months. There wassigniW-cant re la tion ship be tween the type offxation—ex ter nal fxation 6.9 months—and the time ofun ion (P 0.009). Ac cord ing to the post-hoc com par i sons,Group A had lon ger time un til un ion as com pared to both Group B and C (P = 0.046 and P = 0.013, re spec tively),while there was no signifcant diference re gard ing time toun ion be tween Groups B and C (P = 0.688). In stratifedsta tis ti cal anal y sis by type of frac ture, the mean un ion

time in type B was as fol lows: Group A mean 6.7, SD1.7; Group B mean 6.0, SD 0.8; and Group C mean 5.2,SD 0.4; F = 3.065, P = 0.07. Sim i larly, within frac turetype C we had the fol low ing un ion time: Group A mean7.0, SD 2; Group B mean 5.5 ,SD 1.1; Group C mean5.0, SD 0.7; F = 2.905, P = 0.06, . There fore, the as so ci a -tions noted for both frac ture groups com bined were alsonoted sep a rately within each frac ture group.

Twelve frac tures in group A, nine teen in group B andten in group C were bone grafted (corticocancelous allo -grafts) at the time of the ini tial pro ce dure. There was asignifcant re la tion ship be tween the type of frac -ture—61.1% of type C—and the use of grafts (P 0.006).There was no sig nif i cant re la tion ship be tween the use ofgrafts and the type of fix a tion (P 0.14).

There were four pa tients in group A, two in group Bwith pin in fec tion that re solved with a change in pin care, a short course of oral an ti bi ot ics, or re moval of the pin(three pa tients). One pa tient from group C—with a typeC and type I frac ture—de vel oped in fec tion with staph y -lo coc cus aureus in 2 months past sur gery and the platewas re moved. A sec ond sta bi li za tion was per formed with a hy brid ring fixator 3 weeks later. The fi nal re sult wasfair. There was no sig nif i cant re la tion ship be tween thetype fix a tion and the in fec tion (P = 0.307). In strat i fiedby frac ture type sta tis ti cal anal y ses, re sults were sim i lar.How ever the in fec tion in Group C was dev as tat ing as the

60 I.M.Kostic et al. ACI Vol.LXII

TABLE 2

THE THREE SURGICAL METHODS AND THE TYPE OF OPEN FRACTURES -GUSTILO CLASSIFICATION

Method of fixation Type

TotalClosed I II IIIa

1 External 11 5 2 2 20

2 Internal 5 5 0 3 13

3 Hybrid 15 5 2 0 22

Total 31 15 4 5 55

TABLE 3

THE THREE SURGICAL METHODS AND THE TGRADE OF CLOSED SOFT TISSUE INJURY -TSCHERNECLASSIFICATION

Method of fixation Grade

Total0 1 2 3

1 External 3 0 6 2 11

2 Internal 0 0 3 2 5

3 Hybrid 0 2 5 8 15

Total 3 2 14 12 31

pa tient had two more sur ger ies. There was signifcant re -la tion ship be tween the type of frac ture, 19.4% of type Chad in fec tion, and the in fec tion (x2 = 4.233, p = 0.04).

Six pa tients (10.9%) have de vel oped arthrosis and arecan di dates for arthrodesis. Four pa tients from group A,one from group B and one from group C—the one withthe in fec tion—have de vel oped ar thri tis and loss of jointspace. These have pain dur ing walk ing. These pa tientsare smok ers and had type C in ju ries. There was no sig nif -i cant re la tion ship be tween the mech a nism of in jury andthe de vel op ment of ar thri tis (P 0.069). There was sig nif i -cant re la tion ship be tween the type of frac ture—all weretype C—and the de vel op ment of ar thri tis (P 0.017).There was no sig nif i cant re la tion ship be tween the typeof fix a tion and the de vel op ment of ar thri tis (P 0.25). Instrat i fied by frac ture type sta tis ti cal anal y ses re sults weresim i lar.

The range of an kle mo tion was mea sured in com par i -son with the contralateral side. Lim i ta tion was de fined asrange of an kle mo tion < 25%. Nine pa tients (16.3%) hadlim i ta tion of an kle mo tion. In group A, in 30% (n = 6)there was lim i ta tion more than 25%. In group B, 10% (n= 2) had lim i ta tions less than 25%. The pa tient with thein fec tion from group C has lim i ta tion more than 25%.

There was no sig nif i cant re la tion ship be tween the typeof fix a tion with the lim i ta tion of mo tion (P 0.47). Frac -ture type strat i fied sta tis ti cal anal y ses did not pro ducediferent re sults. There was no sig nif i cant re la tion ship be -tween the mech a nism of in jury and the lim i ta tion of mo -tion (P 0.069). There was a sig nif i cant re la tion ship be -tween the type of frac tures (77.7%) type C—and the lim -i ta tion of mo tion (P 0.017). There was sig nif i cant re la -tion ship be tween the type of frac tures (six open frac tures) and the lim i ta tion of mo tion (P 0.012).

Br. 1 Treat ment of high-en ergy pilon frac tures with ex ter nal fix a tion as a method of 61min i mal in va sive ap proach

FIG URE 4 TYPE C PILON FRAC TURE TREATED WITH EX TER NAL FIX A TION COM BINED WITH MINI ARTHROTOMY IN

69 YEARS OLD MALE PA TIENT; FI NAL RE SULT WITH FULL WEIGHT BEAR ING WITH OUT PAIN AND EX CEL LENT

RANGE OF MO TION OF AN KLE JOINT ONE YEAR POST OP ER A TIVELy.

Six pa tients from group A and one from group B had aheal ing of with 5–10 of malalignment. The pa tient withthe in fec tion from group C had ten of varusmalalignment. In groups A and B, there was ten dency tolose the re duc tion. These pa tients had to be fol lowed-upmore of ten.

DIS CUS SION

Pilon frac tures are the re sult of high-en ergy in ju riesthat cre ate a large amount of bony comminution. Thisfrac ture re mains an un solved prob lem with var i ous meth -ods and phi los o phies of treat ment. The best re sults havebeen achieved with re con struc tion of the ar tic u lar sur face of the tibia, sta ble fix a tion, and only a short pe riod ofjoint im mo bi li za tion 12,13. In 1959, Jergersen 14 stated thatopen re duc tion and sta bi li za tion of tib ial pilon frac tureswould be im pos si ble. In 1969, Ruedi and Allgöwer 15 pre -sented their good re sults us ing in ter nal fix a tion ineight-four frac tures. In 1988, Ayeni 16 con firmed the poor re sults of nonoperative treat ment of dis placed pilon frac -tures.

Nu mer ous sur geons have turned to ex ter nal fix a tionwith span ning an kle joint for sev eral years. Ex ter nalfxation with an kle span ning is ad van ta geous be cause ofease of the ap pli ca tion and the abil ity to dynamize thefixator to pro mote un ion17,18,19,20,21. Al ter na tively, manyother au thors have re ported the use of hy brid ring fixators for treat ing these in ju ries. These frames have smaller pins and do not cross the an kle joint and it is pos si ble to sta bi -lize the frac ture soon af ter in jury when soft tis sues swell -ing would oth er wise pre vent for mal ORIF. This methodis ben e fi cial in the treat ment of open frac tures whereplates would not have ad e quate soft tis sue cov er age andfor se verely comminuted frac tures 22,23,24,25,26,33.

There are few se ries that have di rectly com pared in ter -nal and ex ter nal fix a tion. Blauth et al. 27 as sessed the long term re sults of one the three meth ods of man age ment forse vere pilon frac tures. They re ported that the group withthe two staged pro to col—ex ter nal fix a tion and then plat -ing—had the low est rate of com pli ca tions. Wyrsch et al.28

pro spec tively ran dom ized thirty-nine pa tients with pilonfrac tures to in ter nal fix a tion or ex ter nal fix a tion. With amin i mum 2-year fol low-up, they found more com pli ca -tions in the in ter nal fix a tion group, with out sig nif i cantdiference be tween groups in clin i cal score. How ever, ingroup one, pa tients un der went in ter nal fix a tion of thetibia on an av er age of 5 days which could ac count for the high com pli ca tions in this group. Pugh et al.29 re ported no sig nif i cant diferences in com pli ca tions rates be tween pa -tients who were treated with the three diferent meth ods,an kle—span ning ex ter nal fixator, sin gle-ring hy brid ex -ter nal fixator and ORIF. How ever the group with in ter nal fix a tion had se vere com pli ca tions—two am pu ta -tions—and the group with the ex ter nal fixator had moremalunions.

Our pa tients were treated with three diferent tech -niques. The group with the hy brid fix a tion had the moretype C frac tures—eigh teen—than the oth ers groups.There were no malunions and nounions. There were six

(10.9%) pa tients who have de vel oped ar thri tis and arecan di dates for arthrodesis. All the pa tients had type Cfrac tures. There was no sig nif i cant re la tion ship with thetype of fix a tion and the de vel op ment of ar thri tis. Pre vi -ous au thors have re ported rates of arthrodesis from 5–30% 27,30. There were nine pa tients with lim i ta tions ofrange of mo tion of the an kle. Al though, there was no sig -nif i cant re la tion ship with the type of fix a tion, six pa tients were from group A, one from group B and one fromgroup C. There was sig nif i cant re la tion ship be tween thelim i ta tions of range of mo tion and the type of frac tures(six open and seven type C frac tures). There were fourand two pa tients with pin in fec tions from group A and B, re spec tively, and one deep in fec tion in group C whichwas re solved with re moval of the plate and sta bi li za tionwith ex ter nal fixator 3 weeks later. Other stud ies 31,32 us -ing the same method with the de layed in ter nal fix a tionhave re ported a rate of deep in fec tion of 0–6%. In threepa tients from group A, the pins had to be re moved. There sults of this study are com pa ra ble with the lit er a turethat type C frac tures have the worst prog no sis. How ever,there is no ev i dence in the lit er a ture to in di cate whichmethod of treat ment is better for type C frac tures. In con -trast to other stud ies, our find ings showed a better clin i -cal out come with uni lat eral ex ter nal or hy brid ring fix a -tion com bined with mini arthrotomy though in this group there were the more type C frac tures.

CON CLU SION

Our con clu sion is that type C pilon frac tures are veryde mand ing in ju ries and me tic u lous pre op er a tive plan ning is nec es sary. Pa tients with type C frac tures had higherrate with in fec tion (P < 0.001), higher rate of lim i ta tionof mo tion (P < 0.001) and higher rate of ac tiv i ties re duc -tion (P = 0.026). Pre op er a tively, CT scan ning and 3D re -con struc tion for these frac tures seems nec es sary. Twostaged plat ing is a method with good re sults re gard ingthe un ion and the range of mo tion. In ad di tion, for type C frac tures, the ex ter nal fixator with an kle spar ring us ing a mini arthrotomy to have di rect vi su al iza tion to the frag -ments would be a use ful method.

SUM MARY

Prelomi pilona, izazvani silom visokog stepenainteziteta, predstavljaju jedinstven izazov u leè~enju kakoza ortopedskog hirurga tako i za samog pacijenta.Oè~uvanje mekotkivnog omota~èa distalne tibijepredstavlja podjednako va`an cilj u le~èenju kao i što jesama rekonstrukcija ovih zglobnih preloma. Ovaj ~èlanakprikazuje dugoro~ène rezultate le~èenja ovih prelomametodom spoljne fiksacije sa minimalno invazivnimpristupom. U radu su pra}eni rezultati le~èenja ukupnopedeset i pet pacijenata sa prelomom pilona tibije,leè~enih u periodu od avgusta 2008 do januara 2015godine, na Klinici za ortopediju i traumatologiju,Kliniè~kog centra u Nišu. Prelomi su klasifikovani naosnovu AO-OTA klasifikacionig sistema, pri ~èemu su65% (n=36) bili prelomi pilona tipa C (14 tipa C1, 16

62 I.M.Kostic et al. ACI Vol. LXII

tipa C2, i 6 tipa C3), a 35% ( n=19) tipa B (15 tipa B2 i4 tipa B3). Koriš}ena su tri hirurška protokola u le~èenju - spoljna fiksacija sa premoš}avanjem skoè~nog zgloba iunutrašnja fiksacija fibule, zatim hibridna fiksacija ilispoljna fiksacija sa unutrašnjom fiksacijom fibule iminimalno invazivnom artrotomijom, a kao tre}a -dvoetapno hirurško zbrinjavanje u vidu imidijentnespoljne fiksacije sa premoš}avanjem skoè~nog zgloba anakon smirivanja otoka mekih tkiva otvorene repozicije iunutrašnja fiksacija preloma. Analizom dobijenih rezul-tata u našoj studiji, nakon dugoro~ènog pra}enja paci-jenata, zaklju~èujemo da se metodom spoljne fiksacijemo`e posti}i i oè~uvati osovina distalne tibije ligamento-taksom i zna~èajno smanjiti rizik od nastanka infekcijeusled pa`ljivijeg postupanja sa mekim tkivima, i uz ogra- ni~èenu minimalno invazivnu artrotomiju mo`e poslu`itikao metoda definitivnog izbora u le~èenju ovih teškihzglobnih preloma.

Kljuè~ne re~èi: pilon prelomi, prelomi izazvani silomvisokog stepena inteziteta, metodaspoljne fiksacije

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