The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators.
We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score.
Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12–26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18–24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients.
Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.
In this prospective study, 30 patients (28 men and 2 women) with open ankle fractures were treated with early debridement and immediate stable internal fixation after anatomical reduction to achieve better functional results after early mobilization. The procedure was performed an average of 8 hours (range, 6–15 hours) after injury. According to the classification system of Gustilo and Anderson, 11 fractures (37%) were grade I, 12 (40%) were grade II, 5 (17%) were grade IIIA, and 2 (7%) were grade IIIB. Six complications occurred: four patients had superficial skin necrosis and two had loss of reduction, resulting in residual ankle stiffness. Twenty patients had excellent results, eight had good results, and two had fair results according to the modified criteria of Ketenjian and Shelton. We found that immediate debridement, anatomical reduction, and internal fixation of open ankle fractures leads to better functional results, especially in grade I and grade II injuries. (J Am Podiatr Med Assoc 96(2): 120–124, 2006)
For minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques applied to fractures of the lateral malleolus, there is no external guide for inserting the plate, determining the incision, and inserting the screws as used for fractures in other regions. With MIPPO, fluoroscopy exposure is unavoidable. The MIPPO technique is advantageous for patients; however, the unavoidable problem with this method for the surgical team is repeated exposure to fluoroscopy. To expose the surgical team to least radiation, we used a novel technique with an equal-sized plate as an external guide. We present the results of patients treated with this technique.
Patients with isolated lateral malleolar fracture who underwent MIPPO using an equal-sized anatomical lateral malleolar plate as an external guide were retrospectively investigated. VAS scores on postoperative day 1 and AOFAS scores at final evaluation were noted.
Twenty-six patients were included in the study. Mean ± SD follow-up was 42.46 ± 14.11 months. Mean ± SD VAS score on postoperative day 1 was 3.76 ± 2.58. On final evaluation, prominent implant was identified in two patients, with mean ± SD AOFAS score of 98.00 ± 2.17. No other complications were observed.
Using an equal-sized plate as external guide may ensure less use of fluoroscopy while determining the incisions. Until an external guide is produced commercially for minimally invasive fixation of lateral malleolar fractures, this method ensures determination of incisions and insertion of screws without requiring the use of fluoroscopy and may be reliably used for minimally invasive surgery.
Distal tibiofibular syndesmosis contributes to dynamic stability of the ankle joint and thereby affects gait cycle. The purpose of this study was to evaluate the grade of syndesmosis injury on plantar pressure distribution and dynamic parameters of the foot.
Grade of syndesmosis injury was determined by preoperative plain radiographic evaluation, intraoperative hook test, or external rotation stress test under fluoroscopic examination, and two groups were created: group 1, patients with grade III syndesmosis injury (n = 17); and group 2, patients with grade II syndesmosis injury (n = 10). At the last visit, radiologic and clinical assessment using the Foot and Ankle Outcome Score was performed. Dynamic and stabilometric analysis was carried out at least 1 year after surgery.
The mean age of the patients was 48.9 years (range, 17–80 years), and the mean follow-up was 16 months (range, 12–24 months). No statistically significant difference was noted between two groups regarding Foot and Ankle Outcome Score. The comparison of stabilometric and dynamic analysis revealed no significant difference between grade II and grade III injuries (P > .05). However, comparison of the data of patients with grade III syndesmosis injury between injured and healthy feet showed a significant difference for dynamic maximum and mean pressures (P = .035 and P = .49, respectively).
Syndesmosis injury does not affect stance phase but affects the gait cycle by generating increased pressures on the uninjured foot and decreased pressures on the injured foot. With the help of pedobarography, processing suitable orthopedic insoles for the injured foot and interceptive measures for overloading of the normal foot may prevent later consequences of ankle trauma.
The relationship between hyperglycemia and adverse outcomes after surgery has been widely documented. Long-term glucose control has been recognized as a risk factor for postoperative complications. In the foot and ankle literature, long-term glycemic control as a potential perioperative risk factor is not well studied. Our goal was to investigate whether hemoglobin A1c (HbA1c) level was independently associated with postoperative complications in a retrospective cohort study.
Three hundred twenty-two patients with a diagnosis of diabetes mellitus were enrolled in the study to assess risk factors associated with postoperative foot and ankle surgery complications.
Bivariate analyses showed that HbA1c level and having at least one comorbidity were associated with postoperative infections. However, after adjusting for other covariates, the only significant factor was HbA1c level, with each increment of 1% increasing the odds of infection by a factor of 1.59 (95% confidence interval [CI], 1.28–1.99). For postoperative wound-healing complications, bivariate analyses showed that body mass index, having at least one comorbidity, and HbA1c level were significant factors. After adjusting for other covariates, the only significant factors for developing postoperative wound complications were having at least one comorbidity (odds ratio, 2.03; 95% CI, 1.22–3.37) and HbA1c level (each 1% increment) (odds ratio, 1.25; 95% CI, 1.02–1.53).
In this retrospective study, HbA1c level had the strongest association with postoperative foot and ankle surgery complications in patients with diabetes.