Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY 14642, USA.
J Orthop Trauma. 2012 Jun;26(6):341-7. doi: 10.1097/BOT.0b013e318225881a.
Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures.
Prospective clinical cohort.
A Level I trauma and tertiary referral center.
PATIENTS/PARTICIPANTS: From January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months).
All patients were treated with open reduction and internal fixation for their pilon fractures.
Quality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications.
There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group.
The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.
在高能 Pilon 骨折中，通过标准的前侧或内侧切口很难准确地复位后踝骨块，导致关节复位不理想。本研究的目的是报告我们使用直接入路结合分期前固定治疗高能 Pilon 骨折的结果。
前瞻性临床队列研究。
一级创伤和三级转诊中心。
患者/参与者：2005 年 1 月 1 日至 2008 年 12 月 31 日，19 例 Orthopaedic Trauma Association 43C Pilon 骨折（16 例 C3 和 3 例 C2），存在单独的、移位的后踝骨块，作者对这些患者进行了治疗。9 例患者通过后外侧入路行胫骨后外侧钢板（PL）固定，然后分期行直接前入路。10 例具有类似骨折模式的患者采用标准的前侧或前内侧入路（A）进行间接复位后踝骨块。所有 19 例患者平均随访 40 个月（范围，28-54 个月）。
所有患者均接受开放性复位和内固定治疗 Pilon 骨折。
术后平片和 CT 评估复位质量。术后定期拍摄 X 线片，评估愈合进展和关节关节炎的发生。临床随访包括体格检查和踝关节评估，使用美国矫形足踝协会踝关节和后足评分、马里兰足部评分，以及记录所有并发症。
两组在损伤模式或手术时间上无差异。在 A 组的 10 例患者中，4 例（40%）术后 CT 扫描显示后关节骨折边缘存在超过 2 mm 的关节不平整，而 PL 组无患者存在这种情况。在末次随访时，A 组 7 例（70%）患者出现关节间隙狭窄的放射学证据，而 PL 组 3 例（33%）患者出现这种情况。A 组的踝关节活动度为 35.8°，而 PL 组为 34.2°（无统计学差异）。A 组有 2 例伤口愈合延迟并发症，PL 组有 1 例深部感染。A 组有 2 例患者因创伤后关节炎行关节融合术，而 PL 组无患者行此手术。两组术后并发症无显著差异。PL 组的马里兰足部评分和美国矫形足踝协会/踝关节和后足评分平均为 86.4/85.2，而 A 组为 69.4/76.4。
附加后外侧入路可直接观察胫骨 Pilon 后远端骨块的复位。虽然无法直接观察关节表面，但这种复位可使前侧结构在以后的日期与稳定的后踝骨块固定。这种技术改善了我们根据 CT 扫描获得解剖关节复位的能力，并在至少 1 年的随访中保留了距下关节间隙。此外，与 A 组相比，它与临床结果的改善相关，马里兰足部评分和踝关节和后足评分增加。尽管有希望，但需要进一步的随访来确定使用这种技术治疗胫骨 Pilon 骨折的长期结果。
