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Evaluation of Outcomes and Complications of Tibial Pilon Fractures Treatment in Six-Month Follow-Up
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Kourosh Kharkan Ghamsari1    , Seyyed Ramin Etemadi2 , Saeed Kokly *3 |
1- Residency in Orthopedics, Department of Orthopedics, 5th Azar Medical Education Center, Golestan University of Medical Sciences, Gorgan, Iran.
2- Assistant Professor, Department of Orthopedics, 5th Azar Medical Education Center, Golestan University of Medical Sciences, Gorgan, Iran.
3- Assistant Professor, Joint, Bone, Connective Tissue Rheumatology Research Center (JBCRC), 5th Azar Hospital, Department of Orthopaedic, Golestan University of Medical Sciences, Gorgan, Iran. , skokly@gmail.com |
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Keywords: Orthopedics [MeSH], Tibial Fractures [MeSH], External Fixators [MeSH], Internal Fracture Fixation [MeSH]
Article ID: Vol27-14 |
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Type of Study: Original Articles |
Subject:
Orthopaedics
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Abstract: (110 Views) |
Extended Abstract
Introduction
Distal tibial horizontal plane fractures are high-energy ankle joint injuries, commonly referred to as pilon or tibial plafond fractures. These fractures involve the weight-bearing articular surface and the adjacent metaphysis. Tibial pilon fractures are uncommon orthopedic injuries, accounting for 1-10% of all lower extremity fractures. These fractures are frequently accompanied by a comminuted fracture pattern and severe soft tissue damage, with bone extrusion from the surrounding soft tissue and skin occurring in approximately 10-30% of cases. The traditional approach, initially described by Ruedi and Allgöwer, involves extensive soft tissue dissection to access the tibia. This method is associated with significant rates of infection and wound dehiscence. Several surgical techniques and staged protocols have thus been proposed for treatment, including Open Reduction and Internal Fixation (ORIF), Minimally Invasive Plate Osteosynthesis (MIPO), and External Fixation (EF). These are often performed alongside internal fixation procedures. There are limited data regarding the three aforementioned methods. MIPO is an alternative that facilitates indirect reduction and stable fixation with minimal soft tissue complications. However, EF appears to be primarily indicated for extra-articular fractures (43A) and a limited number of undisplaced articular fractures (43B1-C1) or cases with restricted soft tissue involvement. While EF can be highly beneficial as a temporary measure for soft tissue correction, its use as a definitive treatment may lead to complications, such as mal:union:, pin-track infection, and ankle stiffness. On the other hand, ORIF has been associated with wound problems, high infection rates, and osteomyelitis in various reports. While this method has shown favorable outcomes in less severe and low-stress fractures, its efficacy in damages stemming from high-stress injuries has not been well-reported. The most common surgical approaches for treating Type C fractures generally involve EF, often combined with Limited Internal Fixations (LIF) and ORIF. While EF combined with LIF (EFLIF) causes reduced blood loss and soft tissue preservation, it can lead to poor articular surface repair, a high incidence of post-traumatic arthritis, prolonged hospital stays, and an increased risk of infection. For these reasons, some surgeons prefer to perform primary ORIF, which is associated with good outcomes, particularly in mild fractures. However, when there is severe soft tissue damage, patients often require prolonged hospitalization due to delayed wound healing and the risk of superficial or deep infections. Despite advancements in surgical techniques, outcomes are not always optimal, and unfortunately, many patients experience complications. None of the current methods appear to offer a definitive advantage for managing soft tissue injuries and various fracture patterns. This is because pain, stiffness, and weakness often persist for extended periods, sometimes becoming permanent. Even after successful treatment of these injuries, postoperative complications, such as infection, wound dehiscance, non-:union:, mal:union:, and osteoarthritis, are difficult to manage without the correct technique. It is acknowledged that more information is needed regarding the management and outcomes of these complex injuries, making the selection of an appropriate treatment controversial. This study was therefore conducted to evaluate the outcomes and complications of the tibial pilon fractures treatment in a six-month follow-up period.
Methods
This descriptive analytical prospective cohort study was conducted on 22 patients (18 males and 4 females; mean age = 39.4 ± 10.8 years), all of whom presented with tibial pilon fractures at the Fifth Azar Educational-Therapeutic Center in Gorgan, Iran.
Following the completion of treatment according to the established protocol, patients were evaluated based on a demographic and clinical checklist and the American Orthopedic Foot and Ankle Society (AOFAS) ankle score questionnaire. The AOFAS questionnaire scores and subscales were categorized into four outcomes: Excellent (greater than 90), good (80-90), moderate (70-80), and poor (less than 70).
Patients were evaluated at a six-month follow-up visit post-surgery for further assessment and completed the AOFAS questionnaire. Test-retest reliability for the subjective subscales was measured using intraclass correlation coefficient (ICC), yielding a value of 0.853. The reliability of the target subscale test was assessed using Kappa statistics, which indicated acceptable values. Moreover, floor and ceiling effects were calculated at 1.9% and 7.5%, respectively. Data collection occurred at pre-defined time points following the visits and questionnaire completion. The diagnosis of osteoarthritis was based on the Kellgren and Lawrence (K&L) classification system.
Results
Fractures were of closed type in 12 patients (54.5%) and of open type in 10 patients (45.5%). The mean surgical time was determined to be 110.0 ± 28.0 minutes, and the mean length of hospital stay was 7.5 ± 3.3 days.
Two-stage EF was the most frequently performed procedure, accounting for 40.9% of cases. In the initial stage, an external fixator was applied for approximately two weeks to allow for partial healing. Subsequently, the fixator was removed and replaced with plate and screw fixation. The most common postoperative complications were osteoarthritis and wound dehiscence, each occurring in 18.2% of patients.
The AOFAS score was determined to be excellent in 4 patients (18.18%), good in 12 patients (54.55%), moderate in 4 patients (18.18%), and poor in 2 patients (9.09%).
There was a significant inverse correlation between the mean surgical time and the AOFAS score (r = −0.661, P = 0.001). Additionally, a significant direct correlation was found between the mean surgical time and the mean length of hospital stay (r = 0.571, P = 0.006).
A total of four surgical procedures were performed on the studied patients: ORIF, expert nailing, two-stage EF, and MIPO.
Surgical time differed significantly based on the type of surgical procedure (P = 0.015). Pairwise comparisons revealed that MIPO procedures had significantly shorter surgical times compared to all three other procedures, i.e., ORIF (P = 0.002, 95% CI: 24.9-91.2), expert nailing (P = 0.038, 95% CI: 2.5-80.8), and two-stage EF (P = 0.012, 95% CI: 10.8-74.7). Moreover, the type of surgical procedure varied depending on the fracture type so that the frequency of ORIF was significantly higher for open fractures compared to other procedures (P = 0.026). No statistically significant differences were observed among age, length of hospital stay, and the AOFAS score based on the type of surgery. Correlation analysis between variables, categorized by the type of surgical procedure, revealed a significant positive correlation between patient age and length of hospital stay in the ORIF surgical group (r = 0.899, P = 0.006). In the two-stage EF surgical procedure, a significant positive correlation was found between patient age and the AOFAS score (r = 0.878, P = 0.012). Furthermore, a significant inverse correlation was identified between patient age and surgical duration (r = −0.772, P = 0.014).
In our study, the highest AOFAS scores were observed for MIPO, ORIF, and two-stage EF procedures, respectively. Overall, 72.7% of patients in our study experienced complications.
Conclusion
The present study reveals that two-stage procedures, involving EF application followed by plate and screw fixation, were the most frequently performed interventions among patients. The most common postoperative complications observed were osteoarthritis and wound dehiscence. The MIPO technique exhibited the shortest surgical time. Regarding treatment complications based on the type of intervention, osteoarthritis was observed in both the expert nailing and two-stage EF interventions. In contrast, complications like non-:union: and wound dehiscence were exclusively noted in ORIF procedures. Superficial infections and mal:union:s were only observed in the two-stage EF procedure, while all cases of deep infection were observed in the MIPO technique.
Our study revealed a significant direct correlation between patient age and length of hospital stay in the ORIF surgery. Similarly, in two-stage EF surgery, there was a significant direct correlation between patient age and the AOFAS score, and a significant inverse correlation was observed between patient age and surgical duration.
The overall complications for ORIF and two-stage EF procedures were similar in this study. However, ORIF was associated with a higher risk of non-:union: and wound dehiscence. Conversely, major complications in the two-stage EF method primarily included superficial infection, osteoarthritis, and mal:union:.
Ethical Statement
This study received approval from the Research Ethics Committee at Golestan University of Medical Sciences (IR.GOUMS.REC.1400.378). Written informed consent was obtained from all patients prior to their participation in the study, and they subsequently underwent standard surgical treatment.
Funding
This article has been extracted from the doctoral dissertation of Dr. Kourosh Kharkan Ghamsari in Orthopedics. This study received no institutional funding.
Authors' Contributions
Kourosh Kharkan Ghamsari, Seyyed Ramin Etemadi, and Saeed Kokly: Project administration and design, project execution, data collection, data analysis, interpretation of the results, drafting of the initial manuscript, and approval of the final manuscript.
Conflicts of Interest
No conflicts of interest.
Acknowledgments
We would like to thank the patients who participated in this study.
Key Message: Two-stage External Fixation and Reduction and Internal Fixation surgeries were identified as the most prevalent surgical techniques for tibial pilon fractures. Worse surgical complications, including non-:union: and wound dehiscence, were frequently observed in ORIF procedures; superficial infections were the most common complication in two-stage EF; and osteoarthritis occurred with equal frequency in both expert nailing and two-stage EF.
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