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      A Case of Closed Pilon Fracture Resulting in Soft-Tissue Necrosis and Treated with Reverse Sural Artery Flap and Circular External Fixation

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          Abstract

          Tibial pilon fractures are difficult to treat due to articular comminution and soft-tissue injuries caused by high-energy trauma. Open reduction and internal fixation is a commonly used method of treatment. However, it has a high risk of infection and soft-tissue complications due to the extensive detachment of soft tissue. We report on a case with a tibial pilon fracture and soft-tissue necrosis that we treated using limited internal fixation combined with a circular external fixator (LIFCEF) and reverse sural artery flap (RSAF) as part of an orthoplastic approach within the orthopedic surgery department alone, which obtained good results. A 51-year-old man was injured in a motorcycle accident and transported to a nearby hospital. X-rays at the time of injury showed tibial pilon fractures (AO Foundation/Orthopedic Trauma Association 43c3.3, Ruedi–Allgower: Type III). Soft-tissue necrosis with blisters on the medial side of the lower leg (AO soft-tissue classification: IC3-MT1-NV1) was observed. In addition, the patient was referred to our hospital on day 10 of the injury. LIFCEF was chosen for treating the fracture because plate fixation was accompanied by the risk of plate exposure, soft-tissue complications, and an increased skin defect area, and RSAF was chosen to reconstruct the soft tissue defect. Four years after the surgery, the American Orthopedic Foot and Ankle Score was 92 points. X-ray alignment evaluation showed mLDTA 93° and aADTA 91°. Stage 2 arthrosis was present according to the Takakura ankle osteoarthritis classification, but the patient was able to walk without pain. Tibial pilon fractures are difficult to treat due to articular comminution and soft-tissue injuries caused by high-energy trauma. The timing and choice of treatment are crucial concerning the soft tissue.

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          Most cited references15

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          The mechanics of external fixation.

          External fixation has evolved from being used primarily as a last resort fixation method to becoming a main stream technique used to treat a myriad of bone and soft tissue pathologies. Techniques in limb reconstruction continue to advance largely as a result of the use of these external devices. A thorough understanding of the biomechanical principles of external fixation is useful for all orthopedic surgeons as most will have to occasionally mount a fixator throughout their career. In this review, various types of external fixators and their common clinical applications are described with a focus on unilateral and circular frames. The biomechanical principles that govern bony and fixator stability are reviewed as well as the recommended techniques for applying external fixators to maximize stability. Additionally, we have illustrated methods for managing patients while they are in the external frames to facilitate function and shorten treatment duration.
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            Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications.

            Distal tibial or pilon fractures are usually the result of combined compressive and shear forces, and may result in instability of the metaphysis, with or without articular depression, and injury to the soft tissue. The complexity of injury, lack of muscle cover and poor vascularity make these fractures difficult to treat. Surgical treatment of distal tibial fractures includes several options: external fixation, IM nailing, ORIF and minimally-invasive plate osteosynthesis (MIPO). Management of distal tibial fractures with MIPO enables preservation of soft tissue and remaining blood supply. This is a report of a series of prospectively studied closed distal tibial and pilon fractures treated with MIPO.
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              Delayed wound healing, infection, and nonunion following open reduction and internal fixation of tibial plafond fractures.

              The literature concerning tibial plafond fractures is briefly reviewed, and a series of 11 tibial plafond fractures of the compressive variety is presented. These fractures fall both prognostically and therapeutically into different categories based upon whether the primary mechanism of injury is rotational or compressive. The severity of the fracture, the degree of contamination, and the severity of concomitant soft-tissue injury in large part appear to determine the morbidity of surgical therapy in these patients. If rigid internal fixation can be performed in those patients with closed injuries that are primarily of the rotational type and performed with a minimum of soft-tissue trauma, this appears to be a reliable alternative in the hands of surgeons experienced with A-O technique and with this type of fracture specifically. In the presence of severe comminution and open wounds, however, the efficacy of rigid internal fixation performed by surgeons without great experience with these types of fracture is dubious.
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                Author and article information

                Contributors
                Journal
                Case Rep Orthop
                Case Rep Orthop
                CRIOR
                Case Reports in Orthopedics
                Hindawi
                2090-6749
                2090-6757
                2023
                9 August 2023
                : 2023
                : 9222479
                Affiliations
                1Department of Orthopaedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
                2Department of Orthopaedic Surgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
                3Department of Plastic and Reconstructive Surgery, Showa University School of Medicine, Tokyo, Japan
                4Department of Orthopaedic Surgery, Showa University Northern Yokohama Hospital, Yokohama, Japan
                Author notes

                Academic Editor: John Nyland

                Author information
                https://orcid.org/0009-0001-5794-6273
                https://orcid.org/0000-0002-3362-4958
                https://orcid.org/0000-0002-5929-6534
                https://orcid.org/0000-0001-6199-7949
                https://orcid.org/0000-0003-4027-798X
                https://orcid.org/0000-0002-4294-075X
                Article
                10.1155/2023/9222479
                10432129
                d210e80d-f326-47ca-a0ac-588001c7788f
                Copyright © 2023 Ryu Igaki et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 3 May 2023
                : 12 July 2023
                : 22 July 2023
                Categories
                Case Report

                Orthopedics
                Orthopedics

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