Aims. The aim of this study was to report the outcome following primary fixation or a staged protocol for type C fractures of the tibial plafond. Patients and Methods. We studied all patients who sustained a complex intra-articular fracture (AO type C) of the distal tibia over an 11-year period. The primary short-term outcome was infection. The primary long-term outcome was the Foot and Ankle Outcome Score (FAOS). Results. There were 102 type C pilon fractures in 99 patients, whose mean age was 42 years (16 to 86) and 77 were male. Primary open reduction internal fixation (ORIF) was performed in 73 patients (71.6%), whilst 20 (19.6%) underwent primary external fixation with delayed ORIF. There were 18 wound infections (17.6%). A total of nine (8.8%) were deep and nine were superficial. Infection was associated with comorbidities (p = 0.008), open fractures (p = 0.008) and primary external fixation with delayed ORIF (p = 0.023). At a mean of six years (0.3 to 13; n = 53) after the injury, the mean FAOS was 76.2 (0 to 100) and 72% of patients were satisfied. Conclusion. This is currently the largest series reporting the outcome following fixation of complex AO type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated that a satisfactory outcome can be achieved in the appropriate patients using primary ORIF. Cite this article: Bone Joint J 2016;98-B:1106–11

In a series of 126 consecutive pilon fractures, we have described anatomically explicable fragments. Fracture lines describing these fragments have revealed ten types of pilon fracture which belong to two families, sagittal and coronal. The type of fracture is dictated by the energy of injury, the direction of the force of injury and the age of the patient

Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

Purpose. Pilon fracture is a severe injury which has a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had pilon fractures. Materials & Methods. We have evaluated the gait pattern of patients who were treated with circular Ilizarov frame following pilon fractures in our department. The gait was tested by using a force plate in a walking platform. Ground Reaction Forces (GRF) and timing of gait phases data were collected during level walking at self-selected speeds. The patients performed two walking tasks for each limb and the collected data were averaged for each limb. Demographic, clinical, radiological, trauma outcome (COST) and quality of life questionnaire (SF-12) data were also collected. Results. We have analysed the gait through the GRF of twelve patients (aged 44.9 ±12.4 years), who had undergone treatment with circular Ilizarov frame following pilon fractures (67% were male). The tests were performed at an average of 10.5 months after the initial treatment. SF-12 Mental scores have returned to normal (mean 56.4 ±11.6) but physical scores remained impaired (mean 41.8 ±8.4). COST questionnaire scores reached average levels (47.1 ±15) in all dimensions (Symptoms: 51.4 ±16, Function: 44 ±14 and Mental Status: 56.6 ±16). During the push-off phase all the plantar flexor muscles are activated and the ankle plantar flexes to achieve the push off. It seems that this motion, is not achieved adequately with the affected limb and the patients are using their normal limb earlier (pre-swing is the start of the double support of the gait) in order to progress in their gait circle. Conclusions. Ten months following treatment with circular ilizarov frame for pilon fracture the patients still have impaired gait pattern. The differences can be explained by the lack of plantar flexion of the ankle which results to poorer push-off of the affected limb

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

Background:. Pilon fractures are complex intra-articular fractures of the tibial plafond associated with significant short and long morbidity. Minimising surgical complications is essential. Methods:. Clinical and radiological outcomes in 49 patients with AO type 43B and 43C fractures were evaluated retrospectively. Definitive management depended on patient factors, soft tissue injury and fracture pattern. Results:. The majority of fractures (n=26, 53%) were C3 type. 9 fractures were open (18%), grade 3A or 3B. 34 patients (69%) were definitively managed with open reduction and internal fixation (ORIF) predominantly through an anterior approach. 15 (31%) had mini-open or percutaneous plafond reduction and external fixation. No medial plates were used. There were no deep infections. Complications occurred in 5 (10%) patients, all relating to metaphyseal delayed or non-union. At last review, 18 patients (36%) had radiographic evidence of post-traumatic arthritis. Discussion:. Surgeons treating pilon fractures should be familiar with external and internal fixation techniques in order to minimise surgical complications. An algorithm for treatment planning is suggested. Conclusion:. It is possible to achieve low surgical complication rates through careful management according to the nature of the fracture and patient characteristics. For plating, the antero-lateral distal tibial Peri-Loc plate is an effective and safe implant

The aim of this study was to document the outcome following either early or delayed fixation for complex (AO-OTA type 43.C) fractures of the tibial plafond. From our trauma database we identified all patients who sustained a complex intra-articular fracture of the distal tibia over an 11-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary outcome measure was the development of early complications following surgery. The secondary outcome measure was the long-term patient reported outcome. There were 102 type C pilon fractures in 99 patients with a mean age of 42yrs (16–86) and 75.5% (n=77) were male. 73 (71.6%) patients underwent primary open reduction internal fixation (ORIF), with 20 (19.6%) undergoing primary external fixation with delayed ORIF. 34 complications were recorded in 28 (27.5%) patients. There were 18 (17.6%) infections, with a deep wound infection in 9 (8.8%) patients and a superficial wound infection in 9 (8.8%). Risk factors for developing infection were multiple co-morbidities (p=0.008), an open fracture (p=0.008), and primary external fixation with delayed ORIF (p=0.023). At a mean of 6 years (0.3–13; n=53) post injury the mean FAOS score was 76.2 (0–100), the mean FADI score was 75.7 (0–100), and 72% (n=38) of patients were satisfied. This is the largest series in the literature documenting the outcome following fixation for type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated a satisfactory outcome using primary early fixation in the vast majority of cases

There is an ongoing revolution in the use of data within orthopaedics and medicine in general, with an imperative for surgeons to be involved from the bottom up and better define the data collection culture. The use of registries plays a major role in the development of “big data” in orthopaedics. There are multiple examples that are already set up and running, both those inspired and set up by clinicians or those where the main stakeholders may lay people, with some input from clinicians. The British Limb Reconstruction society is no exception, with registries for lengthening nails and pilon fractures due to roll out imminently. The BLRS has tasked this years BOA clinical leadership fellow to investigate the current state of registries among the specialist orthopaedic societies. In particular, comparison of the already well established registries and national audits with the development of registry projects in the smaller societies. The issues of funding, consent, infrastructure and governance each infer particular challenges when translating the methods of the larger registries to the needs and resources of a smaller group. We have aimed to consider these challenges in relation to the set-up of the BLRS registries in order to better understand the potential future pitfalls and opportunities

Care of complex and open fractures may provide better results if undertaken in larger units, typically Major Trauma Centres (MTCs) or Orthoplastic units. Some ‘complex injuries’ may still be admitted to units lacking specialist services potentially delaying definitive treatment. The aim of this study was to analyse the referral pattern for acute inpatient transfer in an adult limb reconstruction unit for one calendar year. Prospectively collected data from an electronic database for 2016 was reviewed. All records were evaluated for, diagnosis, time from injury to referral, nature of initial treatment, time to transfer, details of definitive surgery, and time to repatriation. There were 91 formal electronic referrals, 84 of which considered appropriate for inpatient transfer. 74 were for fresh complex fractures, including 22 pilon fractures and 23 bicondylar tibial fractures. Median delay to request transfers for acute trauma was 3 days (0d-19d), delay from referral to transfer was 8.5 days (1d-31d) and delay from date of injury to definitive surgery was 13 days (1d-52d). 9 patients with Grade 3 open fractures and had primary debridement at the referring institution with a median delay to definitive orthoplastic surgery of 9 days (5d-20d). Only 17 of 61 per-articular fractures had spanning external fixation at the referring institution. Delay to repatriation was 8 days (0d–72d). This study demonstrates organisational failures in acute orthopaedic care: open fractures not being primarily treated in orthoplastic centres or MTCs, delays in transfers due to bed-blocks, and significant delays in repatriation. It also demonstrates scope for improvement in clinical practice, and in particular, the need to reinforce the advantages of spanning external fixation of periarticular fractures. Our data serves to highlight continuing problems in delivery of acute fracture care, despite widely publicised recent national guidelines

Background:. The aim of this study was to review the surgical complications and clinical outcomes of patients with Pilon fractures treated with Ilizarov frames. Methods:. Data collected included surgical complications, grade of initial injury using the Ruedi-Allgower classification and quality of reduction according to the Teeny and Wiss criteria. Outcome scores were collected retrospectively using the Foot and Ankle Disability Index (FADI). Results:. A total of 97 consecutive patients were identified. All patients were treated with indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov external fixator. The mean time to union was 6 months. Data was available for 70 patients. 35 patients developed a pin site infection. There were no cases of osteomyelitis. 4 patients developed a DVT and 1 patient a PE, 4 patients required ankle fusions. Quality of reduction according to the criteria of Teeny and Wiss was anatomic in 40 patients, good in 23 patients, fair in 6 patients, poor in 3 patients. Conclusion:. This is one of the larger series of Pilon factures on literature review. Ilizarov frame fixation achieves stable reduction of the fractured fragments without additional trauma to soft tissues with minimal complications and good functional results

A series of 76 distal tibial pilon fractures treated with surgical fixation were retrospectively reviewed from case notes, plain radiographs and CT imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow up period of 8.6 months (range 2–30). Definitive fixation was most commonly performed through an open technique (71 cases) with plate fixation. CT imaging was used to plan the most direct approach to access the fracture fragments. Single or double incision techniques were used to access the tibia, with fixation of the fibular performed when necessary. Superficial infection occurred in 5 cases (6.9%) and deep infection in 2 (2.8%). Aseptic wound breakdown occurred in 5 cases (6.9%). The rate of wound breakdown after three-incision technique was 37.5%. There were 10 cases of non-union (13.9%) and 8 of mal-union (10.5%). Post-traumatic arthritis was present on the most recent x ray in 17 cases (23.4%). Further surgery was required in 20 cases (27.8%), most commonly for metalwork related problems and also for treatment of non-union, post-traumatic arthritis and infection. This review gives comprehensive injury specific and surgical outcome data from one of the largest reported series of these complex and problematic injuries

Aims

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

AIMS. Pure tibial plafond traumatic pathology (excluding trimalleolar fractures) is rare but troublesome, considering the surgical challenges and the long term disability perspective. Treatment involves a wide variety of implants and techniques, and the procedures choice and timing is highly dictated by the soft tissue damage. We designed this study to assess the status of our patients operated with internal, external or combined procedures. METHODS. In a retrospective study, between July 2008 and July 2010 we reviewed 24 patients with available follow-up data. We reviewed the pre- and post-operative imaging available and the immediate follow-up data. A form is currently mailed to the patients to self-evaluate the general physical, mental and employment status, and also the affected limb, using general approved questionnaires. Data from this form is still in process. RESULTS. In this clinic we recorded 24 patients with tibial plafond fractures (17 male, 7 female, 2.43 sex ratio), with ages between 18 and 82 years (average 46.5, median 39 years). According to AO/OTA classification, we noted 8 type A (2 A1, 3 A2, 3 A3) extra-articular tibial fractures, 9 type B (4 B1, 4 B2, 1 B3) intra-articular pilon fractures and 7 type C (3 C1, 1 C2, 3 C3) both epi- and metaphyseal tibial fractures, usually with peroneus fractures at various levels. 10 of these fractures were open, from them 3 type IIIA and 2 IIIB Gustilo-Anderson, and 3 of the patients were politrauma (1 L1 lumbar fracture and distal radius fracture, 1 cranio-cerebral trauma and type I open distal radius fracture and 1 cranio-cerebral trauma). We performed a large array of surgical procedures, usually in emergency, based mainly on the local soft tissue status and both the age and recovery needs of the patient. In old debilitated patients we preferred to use minimal internal osteosynthesis, usually applying a supplementary external fixator or cast. In young active patients we used MIPO techniques in tibial fractures, both with regular or locking-screw plates, repairing also the peroneus in order to preserve the limb length in diaphyseal fractures, and to reconstruct the ankle in lateral malleolus fractures. In cases with severe soft tissue impairment we delayed the definitive osteosynthesis using an external fixator. The short term outcome was good, noting only one septic nonunion, which healed with the appropriate treatment, one calcaneus pin track infection and one deterioration of the external fixator in an alcoholic patient. Data for the mid-term outcome is still under evaluation. CONCLUSIONS. Choosing the appropriate procedure is vital for the outcome. Timing is important, especially in high energy trauma, when the proper surgery performed in emergency allowed us to overcome most of the possible complications. Short term results are encouraging, and the mid-term results will let us know if our attitude was correct

Introduction. Distal tibial fractures are notoriously difficult to treat and a lack of consensus remains on the best approach. This study examined clinical and functional outcomes in such patients treated definitively by circular external fixation (Ilizarov). Patients and Methods: Between July 2011 and May 2016, patients with fractures extending to within 1 muller square of the ankle were identified from our prospective Ilizarov database. Existing data was supplemented by review of clinical records. Fractures were classified according to the AO/OTA classification. Functional outcome data, including general measures of health related quality of life (SF-12 and Euroqol) and limb specific scores (Olerud and Molander Score and Lysholm scores) had been routinely collected for part of the study period. Patients in whom this had not been collected were asked to complete these by post. Adverse events were documented according to Paley's classification of: problems, obstacles and complications. Results. 142 patients with 143 fractures were identified, 40 (28%) were open, 94 (66%) were intra-articular, 85 (59%) were tertiary referrals. 32% were type 1, 28%, type 2 and 40% type 3 AO/OTA severity. 139 (97%) of the fractures united (2 non-unions, 1 amputation and 2 delayed unions who remain in frames), at a median of 165 days (range 104 to 429, IQR 136 to 201). 62% united by 6 months, 87% by 9 months and 94% by 1 year. Both non-unions have united with further treatment. Closed fractures united more rapidly than open (median 157 vs 185 days; p=0.003) and true Pilon (43C3) fractures took longer to unite other fractures (median 156 vs 190 days; p<0.001). 34% of patients encountered a problem, 12% an obstacle and 10% a complication. Of the complications, 6 (4%) were minor, 5 (3.5%) major not interfering with the goals of treatment and 4 (3%) major interfering with treatment goals (including the 2 patients with non-union and 1 who underwent amputation as well as 1 significant mal-union). This will increase to 4% if the 2 delayed unions fail to unite. Overall 56% reported good or excellent ankle scores at last report, 28% fair and 16% poor. Closed, extra-articular and non-43C3 fractures had better functional outcome scores than open, intra-articular and 43C3 fractures respectively. Conclusions. This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries. *Judged best paper*

Aims

The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems.

The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. In the UK, open reduction and internal fixation with locking-plates and intramedullary nailing are the two most common forms of treatment. Both techniques provide reliable fixation but both are associated with specific complications. There is little information regarding the functional recovery following either procedure.

We performed a randomised pilot trial to determine the functional outcome of 24 adult patients treated with either a locking-plate (n = 12) or an intramedullary nailing (n = 12). At six months, there was an adjusted difference of 13 points in the Disability Rating Index in favour of the intramedullary nail. However, this was not statistically significant in this pilot trial (p = 0.498). A total of seven patients required further surgery in the locking-plate group and one in the intramedullary nail group.

This study suggests that there may be clinically relevant, functional differences in patients treated with nail versus locking-plate fixation for fractures of the distal tibia and differences in related complications. Further trials are required to confirm the findings of this pilot investigation.

Our aim was to assess the reproducibility and the reliability of the Weber classification system for fractures of the ankle based on anteroposterior and lateral radiographs. Five observers with varying clinical experience reviewed 50 sets of blinded radiographs. The same observers reviewed the same radiographs again after an interval of four weeks. Inter- and intra-observer agreement was assessed based on the proportion of agreement and the values of the kappa coefficient.

For inter-observer agreement, the mean kappa value was 0.61 (0.59 to 0.63) and the proportion of agreement was 78% (76% to 79%) and for intra-observer agreement the mean kappa value was 0.74 (0.39 to 0.86) with an 85% (60% to 93%) observed agreement. These results show that the Weber classification of fractures of the ankle based on two radiological views has substantial inter-observer reliability and intra-observer reproducibility.

The incidence of deep-vein thrombosis and the need for thromboprophylaxis following isolated trauma below the knee is uncertain. We have investigated this with a prospective randomised double-blind controlled trial using low molecular weight heparin with saline injection as placebo in patients aged between 18 and 75 years who had sustained an isolated fracture below the knee which required operative fixation. All patients had surgery within 48 hours of injury and were randomised to receive either the placebo or low molecular weight heparin for 14 days, after which they underwent bilateral lower limb venography, interpreted by three independent radiologists. Further follow-up was undertaken at two, six, eight and 12 weeks.

A total of 238 patients fulfilled all the inclusion criteria, with 127 in the low molecular weight heparin group and 111 in the placebo group, all of whom underwent bilateral venography. There was no statistically significant difference in the incidence of deep-vein thrombosis between those patients treated with low molecular weight heparin or the placebo (p = 0.22). The number of deep-vein thromboses in the two groups was 11 (8.7%) and 14 (12.6%), respectively. Age and the type of fracture were significantly associated with the rate of deep-vein thrombosis (p = 0.001 and p = 0.009, respectively) but gender, comorbidities and the body mass index were not.

The overall incidence of deep-vein thrombosis in this series was 11%. There was no clinical or statistical significant reduction in the incidence of deep-vein thrombosis with the use of thromboprophylaxis. However, we accept that owing to a cessation of funding, recruitment to this trial had to be ended prior to establishing the necessary sample size. Our results cannot, therefore, categorically exclude the possibility that low molecular weight heparin treatment could be beneficial. We recommend a further multicentre trial be undertaken to resolve this matter.

We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound.

Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures.