[Long-term results in the surgical treatment of pilon tibial fractures. A retrospective study].

BACKGROUND: While Pilon fractures of the tibia have been treated for decades by primary open reduction and internal fixation by plate osteosynthesis, during the last 10 years differential treatment was developed: After primary open reduction nowadays patients are treated with (according to type of fracture and tissue damage). As well as primary open reduction and internal fixation a two-step treatment (primary external fixator and delayed ORIF) or consolidation by external fixator combined with minimal invasive osteosynthesis (cannulated screws and K-wires) has been implemented. Furthermore, the significance of primary bone grafting in comminuted fractures to prevent aseptic pseudarthrosis has been acknowledged.

METHODS: Of 151 patients with 160 pilon fractures treated from January 1979 to May 1995, 107 patients (113 fractures) were evaluated. Only the results of C2 and C3 fractures could be compared, as only in these groups were all three types of treatment used.

RESULTS: Over 75% of the treated fractures were closed fractures, most of them being fractures with a soft tissue damage grade 2 of the Oestern and Tscherne classification. In the open fractures we found mainly grade 3 fractures according to the Gustilo and Anderson classification. In 54.9% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications (25.7%) were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication. Highest infection rate (55.5%) was in the two-step treatment group (primary external fixator and delayed ORIF) and lowest in the primary internal stabilization group, although especially in the C2 and C3 fractures best clinical late results were obtained with the two-step procedure.

CONCLUSION: The complication rate in the treatment of pilon fractures depends mainly on the type of fracture, the soft tissue damage and the type of treatment. The results of primary ORIF varied. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the two-step treatment. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires. We consider ORIF of the fibula necessary as stabilization of the second column of the ankle joint.