Results and outcomes after operative treatment of high-energy tibial plafond fractures.

BACKGROUND: The purposes of this study were to evaluate the clinical and radiographic results and the functional outcomes after operative treatment of tibial plafond fractures treated with internal or external fixation.

METHODS: A retrospective review identified 76 patients with 79 fractures (OTA 43-B or 43-C) of the tibial plafond. Their average age was 45 years. Twenty-one fractures (27%) were open, and 43 (54%) were type 43-C3. Five were type 43-B1, four were 43-B2, two were 43-B3, 15 were 43-C1, and 10 were 43-C2. Patients were treated with open reduction and internal fixation (ORIF) (n = 63) or limited open articular reduction and wire ring external fixation (EF) (n = 16). Tibial fixation was performed at a mean of 7.6 days after injury, with staged reconstruction in 56 fractures (71%). Bone graft was used initially in 32 fractures (41%). Early and late complications, secondary procedures, and radiographic evidence of post-traumatic arthritis were evaluated. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered.

RESULTS: Seventy-nine fractures were followed clinically and radiographically for a mean of 26 (range 24 to 38) months, and 33 patients completed outcomes questionnaires at a mean of 98 months after surgery. Early complications included two superficial wound problems and three deep infections. Late complications included two nonunions and four malunions. Thirty-one fractures (39%) developed post-traumatic arthritis. Complications occurred after six of 21 open fractures and after 11 of 43 type C3 fractures (p = 0.007). Patients treated with EF more frequently had type C3 fractures (88% versus 46%, p = 0.004) compared with patients treated with ORIF. The EF patients developed more complications (six of 16, p = 0.007) and post-traumatic arthritis (11 of 16, p = 0.01) when compared with ORIF. Patients treated with EF (88% were type C3 fractures) had lower FFI and MFA scores. The greatest impairment in outcome was noted after type C3 fractures, regardless of the method of treatment.

CONCLUSIONS: Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.