• View in gallery

    A and B, Initial plain radiographs from an outside hospital taken after an accident (a fall from a 4-m height) show a distal intra-articular comminuted fracture of the tibia. C and D, Postoperative plain radiographs show open reduction and internal fixation with a narrow plate and complete reduction of small fragments with multiple miniplates.

  • View in gallery

    Preoperative single-photon emission computed tomography scans show osteonecrosis in the distal tibia (A) (arrow) and nonunion of the posterior and lateral cortices (arrow) (B).

  • View in gallery

    A, Intraoperative photograph during hardware removal. The previous medial wound had a puslike discharge, and there was nonunion with avascular necrosis of the fracture fragment. B, On biopsy of the fracture fragment, there was only dead bone without osteocyte nuclei.

  • View in gallery

    Plain radiographs show vancomycin bead insertion after hardware removal (A and B) and ankle fusion with cannulated screws using autogenous bone from the posterior superior iliac spine and fresh-frozen allogeneic bone (C and D). E and F, Postoperative 1-year plain radiographs show complete fusion.

  • View in gallery

    Continued.

  • 1

    Calori GM. Tagliabue L. Mazza E. et al: Tibial pilon fractures: which method of treatment? Injury 41: 1183, 2010.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 2

    Tarkin IS. Clare MP. Marcantonio A. An update on the management of high-energy pilon fractures. Injury 29: 142, 2008.

  • 3

    Lavini F. Dall'Oca C. Mezzari S. et al: Temporary bridging external fixation in distal tibia fracture. Injury 45(suppl 6): S58, 2014.

  • 4

    Kretteck C. Bachmnn S. Pilon fractures: part 1. Diagnostics, treatment strategies and approaches [in German]. Chirurg 86: 87, 2015.

  • 5

    Song Z. Xue HZ. Zhang K. Pathogenesis and treatment strategies for pilon fractures with ankle dislocation. J Foot Ankle Surg 54: 815, 2015.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 6

    Poyanli O. Esenkaya I. Ozkut AT. Minimally invasive reduction technique in split depression type tibial pilon fractures. J Foot Ankle Surg 51: 254, 2012.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 7

    Kretteck C. Bachmnn S. Pilon fractures: part 2. Repositioning and stabilization technique and complication management [in German]. Chirug 86: 187, 2015.

    • Search Google Scholar
    • Export Citation

Complete Reduction for Pilon Fracture Can Make Complete Failure

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  • 1 Department of Orthopedic Surgery, Chonbuk National University Medical School, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea.

The surgical management of distal intra-articular comminuted fracture of the tibia (pilon fracture) is difficult because complications frequently develop. The minimally invasive plate osteosynthesis technique is generally accepted for this type of fracture. In this study, complications developed after open reduction and internal fixation using multiple miniplates for accurate reduction of small fracture fragments. Therefore, when we use this technique, we need to pay attention to the development of complications such as nonunion, avascular necrosis, and osteomyelitis by the disruption of both endosteal blood supply by fracture and periosteal blood supply during approach or reduction.

The surgical management of distal intra-articular comminuted fracture of the tibia (pilon fracture) is difficult because complications frequently develop. The minimally invasive plate osteosynthesis technique is generally accepted for this type of fracture. In this study, complications developed after open reduction and internal fixation using multiple miniplates for accurate reduction of small fracture fragments. Therefore, when we use this technique, we need to pay attention to the development of complications such as nonunion, avascular necrosis, and osteomyelitis by the disruption of both endosteal blood supply by fracture and periosteal blood supply during approach or reduction.

The surgical management of distal intra-articular comminuted fracture of the tibia (pilon fracture) is difficult because complications such as nonunion, avascular necrosis, and osteomyelitis frequently develop.

The surgical treatment of a distal tibiofibular comminuted fracture is various according to the soft-tissue condition of the fracture site.1,2 When the soft-tissue condition is not good (contaminated abrasion or laceration, open wound, and severe swelling), temporary external fixation, and subsequent internal fixation are performed to prevent complications.3 However, internal fixation is performed initially when the soft-tissue condition is good (no contaminated abrasion or laceration, open wound, or severe swelling). There is still controversy about whether there is the need for a complete reduction of the comminuted fracture fragments. However, the surgical principles are generally accepted as follows. First, the fracture fragment connected with the cartilage is completely reduced. Second, the other fracture fragment is reduced considering the alignment of axes in the coronal, sagittal, and rotational planes by minimal incision.2 The complete reduction technique would show good results on postoperative radiography due to accurate reduction. However, the accurate reduction of small fragments can lead to complications such as avascular necrosis, nonunion, and infection due to the disruption of periosteal blood supply by additional incision. This study was performed to introduce a case with complete reduction causing the opposing result.

Case Report

A 55-year-old man visited the hospital for left ankle joint pain. He had a history of a left distal comminuted intra-articular tibiofibular fracture caused by a fall from a ladder. He underwent open reduction and internal fixation at another hospital. Various miniplates and screws were used to reduce the comminuted small fragment. Plain radiographs showed distal tibiofibular comminuted fracture, nonunion, and ankle joint space narrowing (Fig. 1).

Figure 1. A and B, Initial plain radiographs from an outside hospital taken after an accident (a fall from a 4-m height) show a distal intra-articular comminuted fracture of the tibia. C and D, Postoperative plain radiographs show open reduction and internal fixation with a narrow plate and complete reduction of small fragments with multiple miniplates.
Figure 1

A and B, Initial plain radiographs from an outside hospital taken after an accident (a fall from a 4-m height) show a distal intra-articular comminuted fracture of the tibia. C and D, Postoperative plain radiographs show open reduction and internal fixation with a narrow plate and complete reduction of small fragments with multiple miniplates.

Citation: Journal of the American Podiatric Medical Association 108, 3; 10.7547/17-001

Single-photon emission computed tomography showed avascular necrosis on the distal tibia metaphysis and nonunion of the posterior and lateral cortices (Fig. 2). We performed revisional surgery to achieve a functional, shoeable, ambulatory, and infection-free deformity/injury. During surgery, we found puslike discharge on fracture fragments, avascular necrosis, and osteomyelitis and performed a biopsy on this area. The biopsy sample of the fracture fragment had only dead bone without osteocyte nuclei (Fig. 3). After removing the previous plates and screws, antibiotic (vancomycin) beads were inserted. Intravenous antibiotic (vancomycin) was used for 6 weeks according to culture results (methicillin-resistant Staphylococcus aureus). Ankle arthrodesis was performed after removing the antibiotic beads at postoperative week 2. Arthrodesis was performed with 6.5-mm cannulated screws and autogenous bone graft in the posterior superior iliac spine and an allogeneic fresh-frozen femoral head graft (Fig. 4). After the surgery, a short-leg cast was applied for 3 months. The cast was taken off and full weightbearing ambulation was allowed after 3 months. The patient currently has no pain. Postoperative 1-year plain radiographs showed complete union.

Figure 2. Preoperative single-photon emission computed tomography scans show osteonecrosis in the distal tibia (A) (arrow) and nonunion of the posterior and lateral cortices (arrow) (B).
Figure 2

Preoperative single-photon emission computed tomography scans show osteonecrosis in the distal tibia (A) (arrow) and nonunion of the posterior and lateral cortices (arrow) (B).

Citation: Journal of the American Podiatric Medical Association 108, 3; 10.7547/17-001

Figure 3. A, Intraoperative photograph during hardware removal. The previous medial wound had a puslike discharge, and there was nonunion with avascular necrosis of the fracture fragment. B, On biopsy of the fracture fragment, there was only dead bone without osteocyte nuclei.
Figure 3

A, Intraoperative photograph during hardware removal. The previous medial wound had a puslike discharge, and there was nonunion with avascular necrosis of the fracture fragment. B, On biopsy of the fracture fragment, there was only dead bone without osteocyte nuclei.

Citation: Journal of the American Podiatric Medical Association 108, 3; 10.7547/17-001

Figure 4. Plain radiographs show vancomycin bead insertion after hardware removal (A and B) and ankle fusion with cannulated screws using autogenous bone from the posterior superior iliac spine and fresh-frozen allogeneic bone (C and D). E and F, Postoperative 1-year plain radiographs show complete fusion.
Figure 4

Plain radiographs show vancomycin bead insertion after hardware removal (A and B) and ankle fusion with cannulated screws using autogenous bone from the posterior superior iliac spine and fresh-frozen allogeneic bone (C and D). E and F, Postoperative 1-year plain radiographs show complete fusion.

Citation: Journal of the American Podiatric Medical Association 108, 3; 10.7547/17-001

Figure 4. Continued.
Figure 4

Continued.

Citation: Journal of the American Podiatric Medical Association 108, 3; 10.7547/17-001

Discussion

There are two types of fracture reduction and stability. Open reduction and absolute stability can be obtained through the lag screw, compression plating, and tension band wiring. On the other hand, mini-open or closed reduction and relative stability can be obtained through the callus formation with a locking plate, intramedullary nailing, or external fixation.4 Various factors, such as the age and general condition of the patient, location and extent of fractures, and soft-tissue condition, should be considered before making a decision.5

For patients with serious comminuted fracture of the distal tibia, such as the present patient, the accurate anatomical reduction can get good results. However, this treatment can cause serious complications, such as nonunion due to osteomyelitis or avascular osteonecrosis by the disruption of both endosteal blood supply by fracture and periosteal blood supply during approach or reduction. Recently, rather than accurate open reduction and internal fixation in comminuted fracture of the distal tibia, anatomical alignment correction using the minimally invasive plate osteosynthesis technique is preferred more often when considering the risk-benefit of patients.6,7 Thus, accurate reduction can cause complete failure in patients with comminuted fracture due to the disturbance of bone healing.

We think that the causes of the complications are as follows: the periosteum may be injured during the reduction of small bone fragments, the damaged periosteum could cause nonunion or osteonecrosis, and osteomyelitis may occur because of poor viability of bone fragments and vulnerability to bacterial infection.

Therefore, although the soft-tissue condition looks good (no contaminated abrasion or laceration, open wound, or severe swelling), in the case of comminuted fracture of the distal tibia, there is a high possibility that anatomically accurate reduction of small bone fragments by the open technique can cause complications by decreasing the viability of the bone fragment. Thus, functional reduction should be performed while maintaining the alignment and relative fixation through the minimally invasive technique.

Financial Disclosure: This study was supported by grant CNUH-BRI-2012-02-005 from the Biomedical Research Institute of Chonbuk National University Hospital.

Conflict of Interest: None reported.

References

  • 1

    Calori GM. Tagliabue L. Mazza E. et al: Tibial pilon fractures: which method of treatment? Injury 41: 1183, 2010.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 2

    Tarkin IS. Clare MP. Marcantonio A. An update on the management of high-energy pilon fractures. Injury 29: 142, 2008.

  • 3

    Lavini F. Dall'Oca C. Mezzari S. et al: Temporary bridging external fixation in distal tibia fracture. Injury 45(suppl 6): S58, 2014.

  • 4

    Kretteck C. Bachmnn S. Pilon fractures: part 1. Diagnostics, treatment strategies and approaches [in German]. Chirurg 86: 87, 2015.

  • 5

    Song Z. Xue HZ. Zhang K. Pathogenesis and treatment strategies for pilon fractures with ankle dislocation. J Foot Ankle Surg 54: 815, 2015.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 6

    Poyanli O. Esenkaya I. Ozkut AT. Minimally invasive reduction technique in split depression type tibial pilon fractures. J Foot Ankle Surg 51: 254, 2012.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 7

    Kretteck C. Bachmnn S. Pilon fractures: part 2. Repositioning and stabilization technique and complication management [in German]. Chirug 86: 187, 2015.

    • Search Google Scholar
    • Export Citation

Corresponding author: Kwang-Bok Lee, MD, Department of Orthopedic Surgery, Chonbuk National University Medical School, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, 20 Gunjiro, Deokjingu, Jeonju, 54978, Republic of Korea. (E-mail: osdr2815@naver.com)