Kilian O, Bündner M S, Horas U, Heiss C, Schnettler R
Klinik und Poliklinik für Unfallchirurgie, Justus-Liebig-Universität Giessen, Rudolf-Buchheim-Strasse 7, 35385 Giessen.
Chirurg. 2002 Jan;73(1):65-72. doi: 10.1007/s104-002-8031-1.
While Pilon fractures of the tibia have been treated for decades by primary open reduction and internal fixation by plate osteosynthesis, during the last 10 years differential treatment was developed: After primary open reduction nowadays patients are treated with (according to type of fracture and tissue damage). As well as primary open reduction and internal fixation a two-step treatment (primary external fixator and delayed ORIF) or consolidation by external fixator combined with minimal invasive osteosynthesis (cannulated screws and K-wires) has been implemented. Furthermore, the significance of primary bone grafting in comminuted fractures to prevent aseptic pseudarthrosis has been acknowledged.
Of 151 patients with 160 pilon fractures treated from January 1979 to May 1995, 107 patients (113 fractures) were evaluated. Only the results of C2 and C3 fractures could be compared, as only in these groups were all three types of treatment used.
Over 75% of the treated fractures were closed fractures, most of them being fractures with a soft tissue damage grade 2 of the Oestern and Tscherne classification. In the open fractures we found mainly grade 3 fractures according to the Gustilo and Anderson classification. In 54.9% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications (25.7%) were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication. Highest infection rate (55.5%) was in the two-step treatment group (primary external fixator and delayed ORIF) and lowest in the primary internal stabilization group, although especially in the C2 and C3 fractures best clinical late results were obtained with the two-step procedure.
The complication rate in the treatment of pilon fractures depends mainly on the type of fracture, the soft tissue damage and the type of treatment. The results of primary ORIF varied. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the two-step treatment. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires. We consider ORIF of the fibula necessary as stabilization of the second column of the ankle joint.
虽然胫骨Pilon骨折数十年来一直通过切开复位钢板内固定进行一期治疗，但在过去10年中发展出了差异化治疗：如今，一期切开复位后，患者根据骨折类型和组织损伤情况接受相应治疗。除了一期切开复位内固定，还实施了两步治疗法（一期外固定架固定和延期切开复位内固定），或者采用外固定架结合微创接骨术（空心螺钉和克氏针）进行巩固治疗。此外，一期植骨在粉碎性骨折中预防无菌性假关节形成的重要性也得到了认可。
在1979年1月至1995年5月间治疗的151例有160处Pilon骨折的患者中，对107例患者（113处骨折）进行了评估对比。由于只有C2和C3骨折组使用了所有三种治疗方法，因此仅比较这两组的结果。
超过75%的治疗骨折为闭合性骨折，其中大多数为Oestern和Tscherne分类中的2级软组织损伤骨折。在开放性骨折中，根据Gustilo和Anderson分类，主要为3级骨折。在所有胫骨Pilon骨折中，54.9%的骨折愈合过程顺利。早期并发症（25.7%）主要为软组织感染，而假关节是最常见的晚期并发症。两步治疗组（一期外固定架固定和延期切开复位内固定）的感染率最高（55.5%），一期内固定组最低，尽管特别是在C2和C3骨折中，两步治疗法取得了最佳的临床晚期效果。
Pilon骨折治疗中的并发症发生率主要取决于骨折类型、软组织损伤情况和治疗方式。一期切开复位内固定的结果各不相同。在软组织损伤程度较低的情况下，可取得良好至极佳的效果。在软组织损伤程度较高的情况下，两步治疗法能够很好地解决软组织覆盖和关节面重建问题，效果良好。在此，对移位骨折块进行有限切开复位并使用空心螺钉和克氏针固定非常重要。我们认为腓骨的切开复位内固定对于踝关节第二柱的稳定是必要的。
