Alternativas para el tratamiento de las fracturas complejas de pilón tibial <span class="so-article-trans-title" dir="auto"> Translated title: Alternatives for the treatment of complex tibial pilon fractures </span>

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Abstract

Las fracturas de pilón tibial representan una de las fracturas más graves, no sólo por la complejidad de su tratamiento, sino también por las importantes secuelas que pueden originar. Además de que un importante porcentaje de éstas son abiertas o con importante afectación de partes blandas, lo que dificulta aún más su tratamiento. Se revisaron 37 pacientes con fractura de pilón tibial tratados de forma quirúrgica, analizando los resultados con la escala de valoración funcional FREMAP y con los criterios radiográficos de Burwell-Charnley. Aunque no existe consenso en relación al tratamiento ideal, parece evidente que el tratamiento combinado con fijación externa e interna con placa ofrece los mejores resultados.

Translated abstract

Tibial pilon fractures are one of the most severe types of fractures, not only due to the complexity of their treatment, but also due to the important sequelae they may cause. Moreover, an important percentage of them are open fractures or importantly involve the soft tissues, thus making treatment even more difficult. Thirty-seven patients with tibial pilon fractures treated surgically were included in this study. The results of the FREMAP functional assessment scale were analyzed together with Burwell-Charnley's radiographic criteria. Although there is no consensus on which is the best treatment, it is evident that combined treatment including external and internal fixation with a plate provides the best results.

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Most cited references 26

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A staged protocol for soft tissue management in the treatment of complex pilon fractures.

Tessa Sanders, M Sirkin, D Herscovici … (1999)

To determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications. Retrospective. Level 1 trauma center. Between January 1991 and December 1996, 226 pilon fractures (AO types 43A-C) were treated, of which 108 were AO type 43C. Fifty-six fractures were included in a retrospective analysis of a treatment protocol. Injuries were divided into Group I, thirty-four closed fractures, and Group II, twenty-two open fractures (three Gustilo Type 1, six Type II, eight Type IIIA, and five Type IIIB). The protocol consisted of immediate (within twenty-four hours) open reduction and internal fixation of the fibula when fractured, using a one-third tubular or 3.5-millimeter dynamic compression plate and application of an external fixator spanning the ankle joint. Patients with isolated injuries were discharged after initial stabilization and readmitted for the definitive reconstruction. Polytrauma patients remained hospitalized and were observed. Formal open reconstruction of the articular surface by plating was performed when soft tissue swelling had subsided. Complications were defined as wound problems requiring hospitalization. All affected limbs were then evaluated via chart and radiograph review, patient interviews, and physical examination until surgical wound healing was complete, for a minimum of twelve months. Group 1 (closed pilon): Follow-up was possible in twenty-nine out of thirty fractures (97 percent). Average time from external fixation to open reduction was 12.7 days. All wounds healed. None exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively. Seventeen percent (five out of twenty-nine patients) had partial-thickness skin necrosis. All were treated with local wound care and oral antibiotics and healed uneventfully. There was one late complication (3.4 percent), a chronic draining sinus secondary to osteomyelitis, which resolved after fracture healing and metal removal. Group II (open pilon): Follow-up was possible in seventeen patients with nineteen fractures (86 percent). Average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days). By definition, all Gustilo Type IIIB fractures required flap coverage for the injury. Two patients experienced partial-thickness wound necrosis. These were treated with local wound care and antibiotics. All surgical wounds healed. There were two complications (10.5 percent), both deep infections. One Type I open fracture developed wound dehiscence and osteomyelitis requiring multiple debridements, intravenous antibiotics, subsequent removal of hardware, and re-application of an external fixator to cure the infection. One Type IIIA open fracture of the distal tibia and calcaneus developed osteomyelitis and required a below-knee amputation. Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.

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Two-staged delayed open reduction and internal fixation of severe pilon fractures.

J. E. Cole, J. Patterson (1999)

To evaluate the use of a two-staged technique for the treatment of C3 pilon fractures. Retrospective. Level I trauma center. Twenty-one consecutive patients with twenty-two C3 pilon fractures. Patients with C1 or C2 fractures and patients with open growth plates were excluded. All patients underwent immediate fibular fixation and placement of a medial spanning external fixator. After, on average, twenty-four days, patients underwent removal of the external fixator and formal open reduction and internal fixation of the pilon fractures. At average follow-up of twenty-two months, all patients were evaluated by using subjective, objective, and radiographic measurements as described by Burwell and Chamley (J Bone Joint Surg 1965;47B:634-659). Range of motion and postoperative complications were also recorded. Twenty-one of the twenty-two fractures healed within an average of 4.2 months. Average range of motion was 7 degrees of dorsiflexion, 33 degrees of plantar flexion, 17 degrees of eversion, and 11 degrees of inversion. Subjective and objective measurements showed 77 percent good results, 14 percent fair results, and 9 percent poor results. Radiographic reduction showed 73 percent anatomic and 27 percent fair reductions. There were no infections or soft tissue complications. The arthrodesis rate was 9 percent. A two-staged approach offers acceptable results for the treatment of severe pilon fractures. These results compare favorably with those of primary open reduction and of internal fixation and external fixation techniques. The major advantages include limited soft tissue complications and improved articular reconstruction.

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Fractures of the tibial plafond.

D Ovadia, R K Beals (1986)

The cases of one hundred and forty-two patients with 145 fractures of the ankle joint that involved the tibial plafond were reviewed. The fractures were classified into five types according to the severity of the injury. The methods of treatment were divided into two groups: open reduction and rigid internal fixation by the AO technique, and other methods. The most important variables that affected the final clinical result were the type of fracture, the method of treatment, and the quality of the reduction (p less than or equal to 0.05). The best results were obtained by rigid open reduction and internal fixation, with which 65 per cent of the more severe type-III, IV, and V fractures obtained a good or excellent result.

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Journal

Journal ID (publisher-id): aom

Title: Acta ortopédica mexicana

Abbreviated Title: Acta ortop. mex

Publisher: Colegio Mexicano de Ortopedia y Traumatología A.C. (Ciudad de México, Ciudad de México, Mexico )

ISSN (Print): 2306-4102

Publication date (Print and electronic): October 2014

Volume: 28

Issue: 5

Pages: 291-296

Affiliations

[02] orgnameHospital Clínico Universitario de Valencia orgdiv1Centro de Recuperación y Rehabilitación de Levante

[01] orgnameHospital Clínico Universitario de Valencia España

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Publisher ID: S2306-41022014000500005 Publisher ID: S2306-4102(14)02800500005

SO-VID: 2cffe482-9911-4062-bd7d-4076ca5d2fc4

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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Alternativas para el tratamiento de las fracturas complejas de pilón tibial Translated title: Alternatives for the treatment of complex tibial pilon fractures

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Most cited references 26

A staged protocol for soft tissue management in the treatment of complex pilon fractures.

Two-staged delayed open reduction and internal fixation of severe pilon fractures.

Fractures of the tibial plafond.

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