Abstract
Clinical Problem
Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems.
We started to use the XS and XS nail as minimal invasive procedure for the management of these fractures in July 2000 first for the fibula and since for the fibula and pilon itself but extended metaphseal comminution are contraindication for the XS nail.
Because of soft tissue problems and higher loading capacity of intramedullary implants the XS Nail was also used for ankle fracture osteosynthesis but as in all articular fractures with open reduction,
Material and Methods
the XS nail is a 4.5mm or the XXS a 3.5mm straight nail witch is locked by threaded wires witch are placed with an aiming device and allows also dynamic fracture site compression with a set screw. The Fibula is fixed percutaneusly and after distal locking with traction of the aiming device also tibia length and axis can be restored and fixed with the proximal locking. From july 2000 to july2006 54 pilon fractures where treated. The mean age was 54 years (range 25–92). In all cases except one referred after 4 weeks the fibula and joint dislocations where stabilised primarily. The tibia XS nail osteosynthesis or limited invasive plate fixation was performed after 5–8 days except two fixed primarily. Up to now 43 patients could be re-examined more than 12 months after surgery. The results were classified according to the Ovadia Score.
In a second study: from 05/2000 to 03/2002 214 ankle fractures were stabilised with a XS or XXS nail. The mean age was 51 year, 59% were woman. 35% were Weber B and 25% type C fractures. The re-examination after 6 months could be performed in 91 Patients and was evaluated according to the Ovadia score (clinical and radiological).
Results
All articular pilon fractures and fibula fractures healed without problems but in 3 metaphyseal fractures delayed union required bone grafting. According to the Ovadia Score after one year the results were very good or good in the subjective criteria in 69% of the patients and 61% in the objective criteria.
In the ankle fractures study in 2 patients haematoma revisions and in 2 patients with the primary used oblique insertion of the nail a proximal fibula fracture occured. At re-examination 71% showed an excellent and 25% a good result.
Conclusion
the minimal invasive stabilisation of pilon fractures with the XS nail and the absence of plates on the bone surface reduces significantly the healin.
The Xs nail is also a new option for ankle stabilisation. It improves the stability and reduces the complication of ankle osteosynthesis due to the lack of implant under the skin on the bone surface and due to the higher biomechanical stability of intramedullary implants.
