Purpose: Non-union and secondary reduction loss complicate open distal femur fractures with bone loss. We hypothesize that locking plates decrease subsequent bone grafting in these injuries, yet maintain alignment; immediate post-fixation radiographic features predict primary union.

Method: From 2001 to 2004 inclusive, 34 adults with 36 open AO/OTA C-type distal femur fractures were reviewed. All were treated with locking plates and 3-month minimum follow-up. Union required radiographic bridging callus on 2/4 cortices combined with lack of symptoms. Alignment was assessed on initial and united radiographs. Antibiotic beads within a metaphyseal defect defined clinically important bone loss.

Results: Eleven of 20 fractures with bone loss (55%) underwent staged bone grafting to achieve union, versus two of 16 fractures without bone loss (13%). The presence of antibiotic beads was significantly associated with staged bone grafting (p< 0.01). Of those with bone loss and staged grafting, three had posterior cortical bone loss, and only three had medial and posterior cortical bone loss, and five had segmental defects. Of nine fractures with bone loss not requiring grafting, all had radiographic posterior cortical contact; seven had radiographic medial cortical contact. Posterior (p< 0.001) and medial (p< 0.025) cortical continuity were associated with injuries not requiring bone graft. Thirty-four had accurate frontal plane reductions; thirty-five had accurate sagittal plane reductions. Complications included two non-unions, and one reduction loss.

Conclusion: Despite metaphyseal bone loss, locking plates obviate the need for routine bone grafting of some open distal femur fractures. Those with radiographic posterior cortical contact and/or medial cortical contact are strongly correlated with primary union.

Purpose: Pilon fractures demonstrate complex osseous and soft tissue injury. Protocols involving immediate tibial reduction and external fixation, with or without fibular fixation, then delayed definitive fixation result in decreased complications. Our purpose was to evaluate the treatment course of pilon fractures provisionally stabilised at outside institutions and subsequently transferred, focusing on the incidence and reasons for revision procedures, and subsequent complication rates.

Method: An institutional trauma database was retrospectively reviewed, demonstrating 668 pilon fractures treated at our institution between 2000–2007. Of these, 39 patients with 42 fractures had a temporising surgical procedure prior to referral. Demographics, injury characteristics, reason for revision, and subsequent complications were determined. Clinical follow-up averaged 60 weeks (range, 1 to 281).

Results: Mean age was 41 years (range, 18–78). Twenty-two fractures (52%) were open; 38 (90%) demonstrated a fractured fibula. Referral occurred an average of 5.8 days (range, 1–20) after initial stabilization. Pre-transfer fixation was revised in 40 fractures (95%). Reasons for revision included tibial malreduction (33 fractures, 83%), fibular malreduction (4 fractures, 10%), pins in the proposed incision (5 fractures, 13%), or loose pins (3 fractures, 8%). Of the 34 fractures with distal pins, 24 (71%) required revision for pin malposition, loosening, drainage, talar placement, or extraosseous placement. Late complications occurred in 14 fractures (33%), including deep infection in 10 (24%), and non-union in 3 (7%). Twenty-three patients (55%) required additional procedures following definitive fixation, including 9 soft tissue coverage procedures and 3 amputations.

Conclusion: The majority of patients with pilon fractures treated with provisional stabilisation followed by referral to our institution required revision prior to definitive fixation. This resulted in many avoidable additional procedures, and a higher complication rate than recent contemporary controls. The authors recommend that, when possible, the initial and definitive management of these injuries be performed at the accepting institution.

Pilon injuries without fibula fractures may be associated with increased tibial plafond fracture severity. To evaluate this, we used the rank order technique, with traumatologists blinded to the fibular injury, who ranked the radiographic severity of forty pilon injuries with and without fibula fractures.

Pilon injuries with fibular fractures were ranked as more severe than those without. C-type injuries were ranked as more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type. The presence of an intact fibula is not predictive of a more severe injury to the tibial pilon.

To determine if the absence of a fibular fracture is predictive of tibial pilon fracture severity.

Fibular status is not predictive of a more severe injury to the tibial pilon, and is more commonly associated with the less severe B-type injuries.

Absence of an ipsilateral fibular fracture in patients with tibial pilon injuries may predict a more severe tibial plafond injury pattern. Presumably, the energy is completely absorbed by the tibia resulting in more severe epimetaphyseal injury. The reverse relationship, however, was identified. This fact may aid in prognosis and treatment strategies.

Twenty consecutive pilon injuries without associated fibular fractures were matched 1:1 to an age/gender-matched cohort of pilon injuries with fibular fractures. Initial radiographs were digitized, the fibular image concealed, and then independently ranked (One, least severe; forty, most severe) by three orthopaedic traumatologists according to tibial plafond fracture severity. Injuries were classified using AO/OTA guidelines.

Inter-observer agreement was moderate (κ =0.6). Mean rank for pilon injuries with fibula fractures was 24.4 versus 16.7 for those without (t = 0.02). C-type injuries demonstrated a mean of 10.3 for those with fibular fractures versus 8.7 for those without (t = 0.5). Mean rank for B-type injuries was 11.1 versus 24.5 for C-type injuries (t = 0.001).

Overall, tibial pilon injuries with fibular fractures are more severe than those without. C-type injuries with or without fibular fractures are equally severe. C-type injuries were ranked significantly more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type.