The two-stage surgical treatment vs primary internal fixation of pilon fractures

Abstract

Introduction. Tibial pilon fractures are severe injuries to the distal articular surface of the tibia and, although described for more than a hundred years, remain to be a challenge for the orthopedic surgeon, since it involves obtaining an anatomical reduction of the articular surface and an adequate management of the soft tissues, the lesions of which the most often dictate treatment options. Various treatment methods are available, depending not only on the fracture type but mostly on the extent of the soft tissue injury. Most frequent procedure is a two-stage surgery: the initial closed reduction of the fracture via primary placement of an ankle jointspanning external fixator, if possible in conjunction with open reduction and internal fixation of the fractured fibula followed by a secondary procedure after soft tissue recovery by open reduction and internal fixation of the tibial pilon. The new types of low-profile and locking plates available for internal fixation can allow the anatomical reconstruction of the fractured articular surface in a single stage. Aim of the study. This study was performed to analyse the results of staged treatment protocol and the primary internal fixation for treating distal tibial fractures. Materials and methods. A literature search was performed using PubMed. The combination of words “tibial pilon fractures staged treatment AND primary fixation” has been used for searching. Results. 21 articles were obtained as a result of the search. Six articles were excluded due to content (articles about primary arthrodesis, lymphedema and external fixator). Of the 15 articles included in the study, in 7 articles were presented the results of surgical treatment of pilon fractures in two stages, in 4 articles the results of the primary fixation and in 4 articles the comparative results of these two methods. In the studies the rate of infection (superficial or deep infection, osteomyelitis), malunion, nonunion, duration of hospital stay, neurovascular injury, pain intensity and patients' satisfaction with AOFAS score were compared between the two groups. There was no significant difference between the groups in measured variables except hospital stay which was significantly longer for the two-stage group. O’White, Carter, Duckworth and the co-authors recommend to treat definitely a patient with pilon fractures type C and Tscherne 1, 2 in one stage ORIF during the first 24 hours after the injury. Conclusions. Recent studies demonstrate low complications with early definitive fixation of pilon fractures type C (AO/OTA). However, the overall prognosis for these injuries often remains poor.