TWO-STEPS APPROACH FOR TIBIAL PILON FRACTURES TYPE AO/OTA 43C. DOES THE PRIMARY TREATMENT OF THE FIBULA AFFECT THE CLINICAL AND FUNCTIONAL RESULT? Antonio Dalmau, MD Rafael Hernández, MD David Codina, MD Ainhoa Arias, MD Hospital ASEPEYO Sant Cugat Barcelona - Spain
Disclosure TWO-STEPS APPROACH FOR TIBIAL PILON FRACTURES TYPE AO/OTA 43C. DOES THE PRIMARY TREATMENT OF THE FIBULA AFFECT THE CLINICAL AND FUNCTIONAL RESULT? Antonio Dalmau, MD Rafael Hernández, MD David Codina, MD Ainhoa Arias, MD My disclosure is in the Final AOFAS Mobile App. I have no potential conflicts with this presentation.
Introduction Two stages approach Indirect reduction and protection of soft tissues Visualization and manipulation of the fragments Controversy Treatment of the fibula (3,4) 3.Calori G. M. Y col. Tibial pilon fractures: which method of treatment? Injury. 2010 Nov;41(11):1183-90 4.Brett D. y col. Pilon fractures: advances in surgical management. J Am Acad Orthop Surg2011 Oct;19(10) 612-22
Objectives Main Determining whether the time of synthesis of the fibula influence clinical outcome and functional complications Secondary Relate the fracture patterns observed on CT with clinical outcome and complications
Materials and methods Nov 2005 - Sept 2011: 37 cases OTA type 43-C Mean follow up 4,7 years (r: 1,4-7,2) Review of the clinical records: Demographic data Medical history Diagnosis Injury mechanism Complications Complementary studies: Ankle X-rays: AP, Lateral CT: Fracture pattern Functional outcome Inclusion criteria: Fx OTA type 43-C Fibula fracture Exclusion criteria: Without staged treatment
Results Patient demographics Mechanism of injury
5. Rüedi TP, Buckley RE, Moran CG. AO principles of fracture management, 2nd expanded ed., AO; 2007. 6.Robert W. Bucholz,James D.Heckman.Rockwood and Green s Fractures in adults, 5th ed.tomo I. 207.1041-1078 Results OTA classification (5) OTA Group I (n 14) Group II (n 15) 43 C1 3 4 43 C2 4 4 43 C3 7 7 Danis-Weber classification (6) Danis- Weber Group I (n 14) Group II (n 15) A 3 C 14 12 Type A Type C
Results Functional outcome AOFAS (IC 95%) Group I Group II p 76 (62-90) 59 (48-69) 0,02 AOFAS Group I Group II Excelent 4 - Good 3 1 Fair 6 10 Poor 1 4 Mann-Whitney U test
Results Fracture patterns 7 Type I Type II Die punch Group I Group II Total AOFAS ( x ) Type I 4 7 11 58 p Type II 8 6 14 76 0,052 Die punch 6 8 14 69 0,923 7. Topliss CJ. Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg Br. 2005 May;87(5):692-7.
Complications Complication rate 65%: 19 cases There were no differences between groups Radiologic patterns I and II showed no difference The presence of Die punch was not significant in terms of the incidence of complications
Discussion Many surgeons perform fibular ORIF at the time of external fixation to gain length and align the tibia. However, lack of anatomic reduction of the fibula may impede anatomic reduction of the tibia (8). 22 fractures C3 Group I protocol Good-excellent in 77% (8) (39% open Fx) In our series, 50% goodexcellent results in group I compared with 6% in group II Fracture pattern is important in preoperative planning (4.7) TC added information in 82% of patients and changed the surgical plan in 64% (4) The pattern II (fragments AL, PL and M) had better functional outcome than the pattern I 8. Patterson MJ, Cole JD. Tibial pilon fractures : A review of incidence, diagnosis, treatment, and complications. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999 Feb;13(2):85-91. 9. Dalmau A, Roger L. Fracturas del pilón tibial.monografías AAOS-SECOT Pie y Tobillo, Ed. Panamericana Madrid, 2006, 2: 1-6 4. Brett D. y col. Pilon fractures: advances in surgical management. J Am Acad Orthop Surg2011 Oct;19(10) 612-22 7. Topliss CJ. Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg Br. 2005 May;87(5):692-7.
Conclusions The two-steps approach shows better results clinically and functionally when the fibula is treated on the first step Complications are not linked to time the synthesis of the fibula but the severity of the fracture and sever damage to soft tissue is performed