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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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          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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            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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              Open reduction with internal fixation versus limited internal fixation and external fixation for high grade pilon fractures (OTA type 43C).

              The optimal treatment for high energy pilon fractures is controversial. Good clinical and functional results have been reported with traditional open reduction techniques and minimally invasive techniques utilizing external fixation (EF). The purpose of this study was to critically evaluate clinical, radiographic and functional outcomes following high-energy fractures of the tibial plafond.

                Author and article information

                Case Rep Orthop
                Case Rep Orthop
                Case Reports in Orthopedics
                9 August 2023
                : 2023
                : 9222479
                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
                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.

                : 3 May 2023
                : 12 July 2023
                : 22 July 2023
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