THE ADVANTAGE/BENEFIT OF THE MIPPO METHOD IN EMERGENCY TREATMENTSOF TYPE A TIBIAL PILON FRACTURES IN VASCULAR LIMB DISEASES: A CASE REPORT.

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1 Research article THE ADVANTAGE/BENEFIT OF THE MIPPO METHOD IN EMERGENCY TREATMENTSOF TYPE A TIBIAL PILON FRACTURES IN VASCULAR LIMB DISEASES: A CASE REPORT. Gabriele Falzarano (1),Antonio Medici (1), Francesco Nobile (2), Vincenzo Lucio Roberto(4),Stefano Viglione(5), Giacomo Errico(5), Raffaele Franzese(5), Arianna Falzarano (3), Mario Pavone (3), Luigi Meccariello (2). 1) U.O.C. Orthopedics and Traumatology, AO G.Rummo, Benevento, Italy. Head: Dott. Gabriele Falzarano. 2) Department of Medical and Surgical Sciences and Neuroscience, Section of Orthopedics and Traumatology, University of Siena, University Hospital "Santa Maria alle Scotte", Siena, Italy. Head: Prof. Paul Ferrata. 3) Faculty of Medicine, VasileGoldis Western University of Arad, Arad, Romania. 4) Raggruppamento Neuroriabilitazione -Ortopedia Lungodegenza Riabilitativa, Casa di Cura Privata Villa Margherita S.r.l.,Benevento,Italy. 5) Orthopedics and Traumatology Clinic IInd University of Study of Napoli, Napoli, Italy. Correspondent Authors: Luigi Meccariello, MD Department of Medical and Surgical Sciences, and Neuroscience, Section of Orthopedics and Traumatology, University of Siena, University Hospital "Santa Maria alle Scotte", Viale Bracci 1, Siena, Italy. drlordmec@gmail.com Cell: This work is licensed under a Creative Commons Attribution 4.0 International License. Copyright crpub.com, all rights reserved. 1

2 Abstract Tibial pilon fractures, considered among the most complex and difficult to treat, representabout 1% of all fractures of the lower extremities, and up to 10% of the tibialfractures. In the assessment of such fracturesit contributes the high energy axial load due primarily to road accidents or falls from height. The treatment of these fractures has sparked much debate among trauma surgeons because of conflicting results from different surgical methods. We report a clinical case of type A tibial pilon fracture, in a 63 year-old male patient, suffering from vascular diseases of the limbs, injured in a car crash. The goal of this work is to confirm the validity of the treatment in the emergency patient with a tibial pilon fracture, following fixation with sliding plate in the Minimal Invasive Percutaneous Plate Osteosynthesis (MIPPO) method, in order to reduce complications of the soft tissues. Key Words: Tibial Pilon Fractures, Plates, MIPPO, LCP Plate, Obesity, Vascular Pathology. Introduction Tibial pilon fractures are complex and difficult to treat. They represent about 1% of all fractures of the lower extremities, and up to 10% of the tibial fractures. [1,2]. In 1911 the French surgeon Destot [3] described the tibial pilon as an anatomical unit, defining the anatomical limit within 5 cm from the joint line and the mechanism determining the fracture. Pilon fractures are more common in men than in women [4] and their incidence is on the rise, probably as a result of the increase in the survival rate from road accidents [4,5]. The damage is caused by high-energy trauma mainly in axial load [6] as the usual consequence of road accidents or falls from a considerable height. The tibial pilon, taken as an anatomical unit,shows a thin skin, a precarious vascularization and no muscle insertions:these factors concur to make the healing phenomena of the soft tissue more complex, also favoring the exposure of fractures due to high-energy trauma on this segment; (20-25% of these fractures are exposed) [7]. According to the AO classification, in the treatment of type A tibial pilon fractures, various surgical methods may be used,such as external fixation, the intramedullary nail, the synthesis to a minimum and the plate [8]. Case Presentation A 63 year old worker, 38.4 BMI, smoker, suffering from III vascular compromise according to the Leriche-Fontaine classification, he was taken to the Emergency department of AORN G.Rummo of Benevento, following a car crash. The patient reported a medical history of a very low adherence to behavioral standards and to medical therapy. Physical examination showed grade II Tscherne cutaneous abrasions at the level of the traumatized leg (see Figure 1). Following RX in AP and LL it was diagnosed a type A right tibial pilon fracture, according to the AO classification, associated with the fracture of the medial malleolus and a depression of the lateral part of the tibia (see Figure 2).It was also decided to make a TC assessment, which excluded Tillaux fragments or involvement of the ankle joint articular surface.there were not evident neurogenic deficit in progress. The patient with an ASA III anesthetic risk underwent emergency surgery following spinal anesthesia. The left tibial pilon fracture was reduced with the help of the image intensifier and stabilized with a Peri-Loc (VLP) with 8 Synthes holes through anterior medial openings implanted with the MIPPO method (slipping) with a cannulated screw to synthesize the medial malleolus and two cannulated screws to reduce the lateral tibial depression. Finally, a foam rubber brace was applied to keep the foot in a neutral position during the hospital stay. After discharge, the patient wore a resin leg cast for 30 days. Preoperative antibiotic prophylaxis was conducted with 2 grams of intravenous Cefazolin and 1 g intravenously every 8 hours after the surgery for a total of 6 administrations. Thromboembolic prophylaxis was conducted with Enoxaparin Sodium 6000 IU by subcutaneous injections for 75 days. The hospital stay was 4 days, Copyright crpub.com, all rights reserved. 2

3 and the patient didn t present any vascular suffering at the ecodoppler performed postoperatively. From the first postoperative day, the patient started the rehabilitation program characterized by: gait training with crutches and partial load (20 kg), active and passive kinesis of the ankle and left leg, and lymphatic drainage. The progressive/total load was allowed at 65 days after surgery. The patient was monitored with clinical and radiographic follow-ups at 15 days, 1 month, 2 months, 3 months and 6 months post-intervention, baropodometric test at 6 months after the surgery. The Foot & Ankle Disability Index (FADI) was used for the outcome evaluation. Results The radiological control performed at a 2 month follow-up showed an advanced consolidation stage of the fracture allowing to put the total load on the operated leg; the soft tissues were not damaged (see Figure 3). The FADI score showed a remarkable progress during the various controls with a comparable recovery to pre-trauma conditions evident between the third and the sixth postoperative month: FADI at 15 days from the trauma 28.6 points; 42.2 points at 1 month from the trauma, 62.4 points at 2 months,84.8 points at 3 months, 88.6 points at 6 months from the trauma; FADI pre-trauma 92.4 points (see Figure 4). The baropodometric examination performed 6 months after surgery showed no load difference between the left foot and the contralateral one. Discussion Already in 1979, Ruedi et al. claimed that since tibial pilon fractures had a high rate of severe soft tissue damage, they had to be treated in emergency as if they were all exposed fractures [7-9]. In 1997, Martinez et al. [10] recognized an important role in the trans-calcaneal traction as the initial treatment of tibial pilon unstable fractures, to be reserved mainly to closed fractures with soft tissue damage of grade I and II Tscherne, stressing that the external bridge fixation represents the ideal approach able to respect the soft tissue, by offering greater stability to the fractures, and also reducing the patient's pain and simplifying nursing care [10]. In our case, the patient's medical history, obese, uncontrolled insulin-dependent diabetic, put him at high risk of complications such as soft tissue damage, wound dehiscence and infection. The treatment option with External Fixator was excluded in view of the type of the type A fracture (AO classification) and poor compliance of the patient to this means of synthesis. The use of the intramedullary nail was not possible because the dual tibial fracture pushed medially to 2.9 cm from the tibial tarsal joint or below the limit of 3 cm for the implant of the nail [11,12]. Therefore, the choice fell on the use of plate withangular stability [8] implanted according to the MIPPO method in order to permit a good healing of the fracture and a rapid functional recovery by reducing surgical insult of the soft tissues and avoiding major complications [16, 20]. Collinge and Protzman have demonstrated excellent results in treating with plaque with angular stability in MIPPO method in 38 cases of tibial pilon type A fractures [13,14]. The difficulty of a proper alignment was also reported with the less invasive (MIPPO) method [17,18]. A malalignment of more than 5% was reported in 20% - 35% of cases [17,18]. Faschingbauer et al [19], had two cases of infection on 25 patients treated: the first case after removal of the external fixator and subsequent treatment with MIPPO method; the second in a large obese smoker, which was resolved by removing the plaque and subsequent treatment with external fixation [19]. The MIPPO is a valid method if used correctly and performed by expert hands because of its long learning curve [20]. Of fundamental importance is the role of the baropodometric analysis performed at 6 months postoperatively that showed a pattern of foot support in the absence of lateralization of the mechanical axis placed on the contralateral limb. As described by Jansen et al [15] the baropodometric results are directly correlated to the clinical outcome and are influenced by the severity of the fracture and the surgical outcome of the treatment of the tibial pilon fractures [15]. Conclusions Fixation of tibial pilon fractures with angular stability plates,implantedwith MIPPO method, appears to be a valid surgical option to reduce the risk of soft-tissue damage and infection in predisposed obese and vasculopathic Copyright crpub.com, all rights reserved. 3

4 patients. The analysis of the patient's medical history, the type of fracture and the state of the soft tissuescan guide the surgeon to choose the proper surgical methodto ensure the best clinical and functional outcome. References 1. Kellam JF, Waddell JP. Fractures of the distal tibial metaphysic with intra-articular extension-the distal tibial explosion fracture. J Trauma 1979; 19: 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 Mar; 21(3): Destot E. Traumatismes du pied et rayons X malleoles, astragale, calcaneum avantpied. Paris7 Mason. 1911: Marsh JL, Saltzman CL. Ankle fractures.rockwood and Green's fractures in adults. In: Buholz RW., Heckman JD., editors. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2001.pp Burgess AR, Dischinger PC, O'Quinn TD, et al. Lower extremity injuries in drivers of airbag-equipped automobiles clinical and crash reconstruction correlations. J Trauma 1995;38: , 6. Kapukaya A, Subasi M, Arslan H. Management of comminuted closed tibial plafond fractures using circular external fixators. Acta Orthop Belg 2005 Oct; 71(5): Marx JA, Hockberger RS, Walls RM, et al. Ankle and foot Rosen's emergency medicine 5th ed St. Louis Mosby. 2002; Hoenig M, Gao F, Kinder J, et al. Extra-articular distal tibia fractures: a mechanical evaluation of 4 different treatment methods.j Orthop Trauma Jan; 24(1): Ruedi TP, Allgower M. The operative treatment of intraarticular fractures of the lower end of the tibia.clin Orthop Relat Res. 1979;138: Martinez Otero A., Mafara Flores G., Rodriguez Ramirez S., Martinez Flores L: Preoperative management with skeletal traction in distal tibial fractures. Acta Ortop Mex, 2007; (21): Kuhn S, Hansen M, Rommens PM. Extending the indications of intramedullary nailing with the Expert Tibial Nail. Acta Chir Orthop Traumatol Cech 2008 Apr; 75(2): Wähnert D, Stolarczyk Y, Hoffmeier KL, et al. Long-term stability of angle-stable versus conventional locked intramedullary nails in distal tibia fractures.bmc Musculoskelet Disord 2013 Feb; 20;14: Collinge C, Protzman R. Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures. J Orthop Trauma 2010 Jan; 24(1): Varsalona R, Liu GT. Distal tibial metaphyseal fractures: the role of fibular fixation. Strat Traum Limb Recon 2006; 1: Jansen H Fenwick A, Doht S. Clinical outcome and changes in gait pattern after pilon fractures. International Orthopaedics (SICOT) 2013; 37: Probe RA. Minimally invasive fixation of tibial pilon fractures. Operative Techniques in Orthopaedics 2001;11(3): Maffull N, Toms AD, McMurtie A, et al. Percutaneous plating of distal Tibial fractures. Int Orthop 2004;28: Krackhardt T, Dilger J, Flesch I, et al. Fractures of the distal tibia treated with closed reduction and Minimally Invasive plating. Arch Orthop Trauma Surg 2005;125: Faschingbauer M, Kienast B, Schulz PA, et al. Treatment of distal lower leg fractures: Results with fixedangle plate osteosynthesis. Eur J Trauma Emerg Surg Spagnolo R, Fioretta G. Treatment of distal tibia fractures with mippo technique. Considerations after 5 years of experience. G.I.O.T. 2010;36: Copyright crpub.com, all rights reserved. 4

5 Figure Fig.1: I Tscherne cutaneous abrasions at the level of the traumatized leg. Fig.2: Emergency s XR of tibial pilon fracture with medial malleolar fracture Fig.3: XR after 6 months from the surgery, we can see the correct bone healing; the rigth photos show the not skin and vascular problems of the left leg after 6 months from the surgery. Copyright crpub.com, all rights reserved. 5

6 Foot & Ankle Disability Index Foot & Ankle Disability Index Fig.4: The FADI s Trend in six months of follow up Copyright crpub.com, all rights reserved. 6