Sinan Oguzkaya, Mehmet Halıcı, Halil Ibrahim Kafadar, Ibrahim Karaman Erciyes Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, Kayseri, Türkiye
with ligamentotaxis and manipulation olive wires inserted to fix articular fragments. Once reduction is confirmed with fluoroscopy, additional schanz screw inserted to distal ring and constriction completed(Tasarım Medikal/İstanbul).
Pin site care was made with antiseptic solution daily.
All patients received antibiotic and anti-thromboembolic prophylaxis. Partial weight bearing is allowed from first postoperative day. After 4th-week foot ring removed.
The system removed under sedation anaesthesia after clinical and radiological union obtained(Figure-1).
In the second group, MIPO performed with one stage or two-stage according to soft tissue conditions. Patients with Tcherne grade 2 and 3 soft tissue injury received two-stage treatment. If concomitant fibula fracture existed, fixation performed with distal anatomic or 1/3 tubular plate in the first stage and simple ankle spanning external fixator constricted with two schanz screws to proximal tibia respected to future planned incisions and one screw to calcaneus(Figure-2)(Tubular Circular Rod System- Tasarım Medikal/İstanbul). Anteromedial or medial approach used for this group. Articular reduction was obtained with traction and manipulation from anteromedial incision. Articular fragments fixed temporarily with Kirschner wires. Appropriate plate length determined according to fracture length and plate introduced percutaneously(Figure-3). Alignment of metaphysis corrected with closed manipulations and locking screws applied for both sides of fracture and
%40 of proximal holes filled. Reduction and fixation of anterolateral fragment is performed via limited approach with 3.5 or 4.5 mm cannulated screws when needed.
Posterior fragment fixed with closed or open reduction with cannulated screws. Ankle joint immobilized for two weeks and weight-bearing allowed after postoperative 6th week(Figure-4).
A monthly follow up protocol was performed for the first three months than patients were seen in an outpatient clinic with 3 months interval.
parameters, union time, early and late complications recorded. Postoperative 15th-month X-Ray images used in first group for standardization.
Shapiro- Wilk test is used for evaluation of distribution of variables. Ki square test is used for comparing categorical variables and Mann Whitney- U test is used for comparing data between two groups. Reduction quality of both groups compared with Kruskal Wallis test.
A P-value < 0.05 was considered statistically significant.
All statistical analysis was performed using IBM SPSS for Windows, version 22 (IBM corp., Armonk, NY).
3.Results
There was no significant difference according to demographic data between two groups(P>0.05). 36 patients had closed, 14 patients had open fracture. 4 patients had type 1, 7 patients had type 2 and 3 patients had type 3A open fracture. 37 patients (%74) suffered from high energy trauma (traffic accident, fall from high, industrial accidents) and 13 patients (%26) had low energy trauma.
Mean follow up time was 28.28 month(SD:13,7) in the first group and 15.88 month (SD:5.05) for the second group. In the first group, 23 patients had accompanying fibula fracture and 18 patients had fibula fracture in the second group. 12 patients had accompanying skeletal pathologies(Table-1).
There was no difference according to postoperative reduction quality between two groups(P>0.05).
Independent from the fixation method, postoperative reduction quality was significantly related (P=0,02) with ankle range of motion (Table-2). In the follow-up period, one patient from each group had nonunion. There was no difference for union time (mean 3,87 month and 3,75 month, P=0,7, SD:1.96 and 1.79 respectively).
Mean AOFAS score was 76 in group 1 and 78 in group
each group had grade 1 osteoarthritis. 5 patients from first group and 2 patients from second group had superficial wound complications. Surgical debridement performed for two patients from first group and full-thickness skin graft was performed for one. There was no difference for superficial wound complication rates between two groups(P=0.22). There were no deep infections in both groups.
In MIPO group 15 patients received single stage, 10 received two-stage treatment. There was no significant difference between that subgroups about functional scores and soft tissue complications.
4.Discussion
Pilon fractures are difficult to treat. Treatment options increased in last decades but prognosis remains poor.
Advances in automobile safety and basic life support decrease mortality after high-speed motor vehicle accidents[12]. Therefore Orthopedic surgeons deal with more complex and high energy fracture patterns.
For displaced intraarticular fractures, open reduction and rigid fixation is a well-accepted method but soft tissue problems after ORIF are common and it can lead to catastrophic complications such as septic nonunion, arthrodesis and even amputation. Therefore treatment strategies focused on to protect soft tissue envelope as much as possible.
In the literature, there is no golden standard treatment for displaced pilon fractures. Main options are ORIF, Minimally invasive plate osteosynthesis, definitive external fixation with or without limited open reduction and staged treatment.
The most important finding of present the study is Ilizarov external fixator technique has similar efficacy and safety with minimally invasive plate osteosynthesis.
Although both techniques have some advantages and disadvantages, these methods are widely accepted for the management of pilon fractures.
fracture fragments and all of them failed to fix medial fragment[14]. Anteromedial approach is reliable for reduction and fixation of the medial and anterior part of the joint but since soft tissue coverage is thin in medial side, soft tissue complications are big concern. In the present study we used anteromedial approach to perform MIPO and additional cannulated screws used via limited anterolateral approach used for fixation of anterolateral fragment as needed.
Literature favors two-stage treatment to perform ORIF[15-17]. Tang et al. compared results of early and late ORIF and they found no difference in functional, radiological outcomes and soft tissue complication rates[18]. Use of temporary external fixator is an accepted method for two-stage treatment but this method increases hospital stay and costs. Therefore we speculated that simple calcaneal traction can be useful and cost-effective alternative to temporary external fixator. 15 patients received single stage and 10 received two stage treatment in MIPO group according to soft tissue conditions. There was no difference regarding soft tissue complication rates and postoperative clinical scores.
Ring external fixators remain reliable method for management of pilon fractures[19 20]. Ilizarov external fixator system allows distraction and ligamentotaxis with minimal soft tissue damage. The most significant advantage of ring fixators is their ability to achieve stability with minimal soft-tissue dissection. Internal fixation can be challenging in osteoporotic patients. Iliopoulos et al. performed Ilizarov external fixator to elderly pilon fracture and they report reliable results with less severe complication rates[21]. Immediate weight-bearing is another important advantage of Ilizarov system. Early weight bearing protects bone from osteopenia and early mobilization reduces complication rates especially in high comorbidity population[22].
Treatment of co-existing fibula fractures when using
improvement of results[25]. Luo et al. reported %85 good or excellent results after arthroscopy assisted ExFix application for pilon fractures[26]. The role of ankle arthroscopy for pilon fractures is not clear yet.
This study has some limitations. First, this study has a retrospective design with short follow up period.
Osteoarthritis is time depended process and it is expected that rates of OA will increase over time. Second, medial plate performed all patients in MIPO group so differences between plate options not evaluated. Third, outcomes and treatment modalities in different fracture types not discussed because of the relatively small study population.
5.Conclusion
As a result, we concluded that both MIPO and Ilizarov techniques are effective and safe method for the management of pilon fractures. Surgeon’s experience and availability of implants also important factor to decide fixation method. Independent from fixation method postoperative reduction quality is predictive to determine prognosis and complications.
6.References
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Table 3-Correlation between Postoperative Reduction Quality and Osteoarthritis
Correlations Reduction quality Osteoarthritis
Reduction quality Pearson Correlation 1 -,353*
Sig. (2-tailed) ,012
N 50 50
Osteoarthritis Pearson Correlation -,353* 1
Sig. (2-tailed) ,012
N 50 50
*. Correlation is significant at the 0.05 level (2-tailed).
Table 4. Distirbution of postoperative reduction quality in groups
Groups Reduction Quality
P
Goodn(%) Fair
n(%) Poor
n(%) Total
n(%)
Group 1 15(%60) 8(%32) 2(%8) 25(%100) 0.25
Group 2 19(%76) 6(%24) 0(%0) 25(%100)
Table 5. Relation of postoperative reduction quality and range of motion
REDÜKSİYON KALİTESİ ANKLE ROM
Median(25.p-75.p) SUBTALAR ROM
Median(25.p-75.p)
GOOD 45(34-55) 20(12-24)
FAIR 20(16-40) 10(5.25-15)
POOR 40(25-45) 9(8.00-10.50)
Giriş
Tibia plato kırıkları tipik olarak genç hastalarda yüksek enerjiden kaynaklanan travmalarla, yaşlı erişkinlerde ise travma veya osteoporoz sonucu ortaya çıkmakta ve tüm kırıkların yaklaşık % 1’ini oluşturmaktadır (1).
Tibia plato kırıklarının tedavisinde ana amaç iyi redüksiyon sonunda ağrısız eklem hareket açıklığını kazanacak eklem uyumunu elde etmektir (2). Diz ekleminin kompleks yapısı ve birçok ligament tarafından çevrelenmesinden ötürü eklem restorasyonunun anatomik olması gereklidir.
Bu nedenle greftleme açık redüksiyon işlemi esnasında eklem rekonstrüksiyonun sağlanmasının ardından metafizyel boşluğu doldurmak için sıklıkla gerekmektedir (3,4).
Osteoindüktif büyüme faktörlerini sağlayan ve osteojenik hücreler için iskelet vazifesi gören otogreft greftleme işlemi için altın standarttır (5). Buna karşın hastaya yapılan ek morbidite donör bölge ağrısı, kan kaybı, enfeksiyon, yavaş bütünleşme ve ikincil kırıklar gibi zorluklardan dolayı insan kaynaklı ve sentetik allogreft seçenekleri kullanılabilmektedir (6). Bu nedenlerden dolayı, kalsiyum fosfatlar ve/veya apatit kalsiyum sülfatlara dayanan sentetik malzemelerin artan kullanımı mevcuttur.
Sentetik kemik greftleri, düzensiz kemik boşluklarının optimum şekilde dolmasına olanak sağlar.Tibia plato kırıklarında alınacak klinik sonuç direk olarak anatomik redüksiyonun derecesi ile ilişkilidir. Tibia plato kırıklarında kemik greft desteği kullanılmadığı taktirde yüksek oranda
Hastalar ve Yöntem
26 hasta 26 plato kırığı (6 kadın, 20 erkek; ortalama yaş: 47,15±13,96, dağılım 21-75 yaş) idi. 26 dizin 10’u sağ, 16’sı sol taraftı. Hastalarımızın 2’si diyabet, 17’si sigara içiydi. Kırık nedeni 13’ü düşme, 8’i trafik kazası, 3’ü yüksekten düşme, 2’si ağır cisim ile yaralanma idi. Sekiz hastamızda tibia plato kırığına eşlik eden ek ortopedik travma (5 femur kırığı olup, ikisi ipsilateral, 1 humerus kırığı, 1 radius distal kırığı ve 1 el parmak çıkığı) mevcuttu. Hastalarımızın dördünde ise çoklu alt ekstremite kırığı vardı. Schatzker Sınıflamasına göre 12’si Tip II, 4’ü Tip III, 1’i Tip IV, 1’i Tip V ve 8’i tip VI idi. 19 hastaya unilateral plak, 7’sine bilateral plak ve vidalarla açık redüksiyon ve internal fiksasyon yapıldı. Ameliyat sırasında saptanan metafizyel defektleri doldurmak için sentetik β-trikalsiyum fosfat grefti (Suprabone-TCP®;
BMT Calsis Sağlık Teknolojileri San. Tic. A.Ş., Ankara Türkiye) uygulandı. Hiçbir hastaya artroskopik cerrahi uygulanmadı. Son takipte; radyolojik değerlendirme Modifiye Rasmussen Kriterlerine (8) göre, kullanılan greftin kaynaması ise Van Hemert Skorlamasına (9) enfeksiyonun ilerlemesi sonucu artrodez ameliyatı