MINIMALLY INVASIVE REDUCTION AND FIXATION OF INTRA-ARTICULAR DISTAL TIBIAL FRACTURES

Abstract

Introduction: The pilon fracture extending from the distal tibial metaphysis into the ankle joint represents one of the most challenging injuries faced by orthopaedic surgeons. Achieving the ideal of anatomic reduction and stable fixation is often impeded by the frequently severe soft tissue injuries associated with these fractures. In June 2004 we began treating intra-articular pilon fractures by minimally invasive techniques.

Methods: The minimally invasive technique used involves reduction of the fracture by ligamentotaxis with the use of the traction table and manipulation of the foot to correct rotation, varus/valgus, pro/recurvatum. Any further reduction where necessary was performed using an ankle arthroscope and a probe introduced through stab incisions anteriorly. Following reduction a distal tibial locking plate was applied percutaneously to the medial of the tibia. Locking screws were then inserted percutaneously. All significant anterior or posterior distal tibial fragment were fixed separately with an anterior percutaneously inserted interfragmentary compression screw.

We compared all cases of closed intra-articluar fractures (AO types C2 and C3) fixed by the method described above in a one year period (June 2004 – June 2005) – Group 1 (n = 26), with the immediate previous one year period (June 2003 – June 2004) of matched closed fracture pattern fixed by formal open reduction and internal fixation – Group 2 (n = 16).

Mean follow up was 26 months. All bony and soft tissue complications were recorded. A specific assessment of foot and ankle outcome was undertaken using the American Orthopaedic Foot and Ankle Score (AOFAS). Scoring was undertaken on two separate occasions at a mean of 9 and 24 months post operatively, by orthopaedic surgeons blinded to the treatment modality. The mean of the two scores was then recorded. It has been previously demonstrated that the functional outcome in pilon fractures improves for approximately 2 years after injury.

Results: We observed a much higher incidence of complications in the open reduction group when compared with the minimally invasive group. An excellent AOFAS result was obtained in 83% (20/24) of the patients in the minimally invasive group, the same result was achieved in only 12.5% of the formal open reduction and fixation group.

Conclusion – The use of the minimally invasive reduction method described here in combination with the insertion of percutaneous fixation, in the form a medial locking plate with or without additional percutaneously inserted antero-posterior screws represents a valuable method of treating the most complex of closed pilon fractures.