Med. J. Cairo Univ., Vol. 77, No. 4, June: 101-108, 2009

www.medicaljournalofcairouniversity.com

Management of Comminuted Tibial Pilon Fractures by Ilizarov

External Fixation

AHMED KHOLEIF, M.D.

The Department of Orthopedics, Faculty of Medicine, Cairo University.

Abstract

Various types of external fixators have been used to treat

Ruedi and Allgöwer Type III pilon fractures, as serious complications can occur using conventional treatment princi-ples. However, insufficient reduction and loss of reduction are the two main disadvantages of external fixator treatments.

This is a case series involving 15 patients with comminuted

closed fractures of the distal tibia (Ruedi type III) treated

using cross ankle external fixators. Five patients underwent

closed reduction, while the others required open reduction

using minimal incision techniques. The reduction score, reduction loss, early and late complications, and ankle symp-toms and functions were evaluated.

The mean duration of external fixation was 15.9 ±3.7 weeks. The patients were followed for an average of 20.1 ±4.1 months (range: 12-26 months). We achieved excellent to good

articular reduction in 66.7% of the patients. Fracture union

was achieved in all patients with only one case of malunion at 16º of varus encountered. Superficial wound infection

developed in one case. Pin tract infection was the most commonly encountered complication (60%) but all cases

responded well to antibiotic therapy.

In conclusion, treatment of pilon fractures by external fixation, using Ilizarov fixators, is a reliable method for

stabilization and healing of high-energy distal tibial intra-articular fractures with acceptable frequency of soft tissue

complications.

Key Words: Ilizarov – External – Fixation – Pilon –

Fracture – Tibia.

Introduction

PILON fractures represent a challenging area of

fracture surgery. These fractures can result from

a high-energy axial compression mechanism caused

by falls or motor vehicle accidents or lower-energy torsional mechanisms [1-3] . The high-energy mech-anisms have proved to be more challenging, with worse outcomes. Several strategies were suggested

to avoid the risk of soft-tissue complications in these cases [4-6] . Soft tissue component is consid-ered the main limitation to treatment, and hence

may be the primary determinant of the outcome

especially in open fractures [7] .

Several methods have been proposed for the

treatment of pilon fractures of the tibia [8,9] . Open reduction and internal fixation was used initially

but it is now known that open reduction increases

the risk of complications after high-energy trauma [10,11] . To minimize the risk of postoperative com-plications, methods combining external fixation with minimally invasive fixation materials were developed. Today, various external fixation meth-ods such as circular, unilateral, and hybrid frames

exist [8,9,12,13] . External fixation aims to reduce

fractures by ligamentotaxis but it is difficult for

an external fixator to reduce the tibial articular

surface alone [12,13] .

The Ilizarov fixator does not violate the soft tissues, hence it can suite intra-articular commi-nuted fractures of the tibial pilon with questionable soft tissue integrity. It can also help achieve arthro-diastasis. This study presents a case series of Ilizarov treatment of complex tibial pilon fractures

to analyze its clinical and radiological outcome as

well as complications encountered.

Methods

This study involved 15 patients with complex tibial pilon fractures of type III according to the Ruedi and Allgöwer classification [10] . We treated them with percutaneous reduction and fixation with the Ilizarov fixator from July 2005 to Decem-ber 2007. All of the fractures were closed; open

injuries were not included. Nine injuries were the

results of traffic accidents, and the other six were

falls from heights. Four patients had additional injuries: two had vertebral fractures, one a femur

fracture, and one a contralateral tibial diaphysis

fracture.

101

102 Management of Comminuted Tibial Pilon Fractures

On the day of admission, all patients were put in below knee posterior slab with elevation of the

lower limb over a Bohler-Braun splint, and mea-sures were taken to avoid edema. Anteroposterior

and lateral radiographs were carefully analyzed. Operations were delayed for an average of 3-5

days to allow tissue swelling to subside.

Early complications, the reduction score of the articular surface, reduction loss, symptomatic and

functional evaluation of the ankle, and osteoarthro-sis findings were reported for the patients. The

quality of the operative reduction was based on the initial postoperative roentgenograms and the criteria proposed by Ovadia and Beals [14] and modified by Teeny and Wiss [15] . The quality of reduction, in a variety of aspects, was rated numer-ically: widening of the mortise, tilt or displacement of the talus, fibular shortening, and gaps in the articular surface (Table 1).

Table (1): Scoring criteria for quality of reduction according

to Teeny and Wiss [15] .

Anatomical site Quality of reduction

Score

1 2 3

Lateral malleolus displacement

0-1 mm 2-5 mm 5 mm

Medial malleolus displacement

0-1 mm 2-5 mm 5 mm

Posterior malleolus displacement

0-0.5 mm 0.5-2 mm 2 mm

Mortise widening 0-0.5 mm 0.5-2 mm 2 mm

Fibular widening 0-0.5 mm 0.5-2 mm 2 mm

Talar tilt 0-0.5 mm 0.5-2 mm 2 mm

Articular gap 0-2 mm 2-4 mm 4 mm

Surgical technique: The limb was positioned on the table, and closed

reduction of the fracture by traction and manipu-lation was attempted in all the patients. If the

fibular length could not be restored by traction, an open reduction and plate osteosynthesis of the

fibula was carried out. Fibular plating was required in 3 patients. The uppermost Ilizarov ring was placed at the level of the fibular head. Four rods

were then placed with an attached ring approxi-mately 2 cm proximal to the fracture. Four rods

were then attached to the third ring just proximal

to the ankle joint. No wires were placed in the second or third rings at this stage. A calcaneal wire was then placed and attached to the fourth most

distal ring. The construct consisted of 3 proximal full rings along the shaft of the tibia with the most

proximal ring tensioned with wires, connected to

the tensioned calcaneal half-ring. Traction was

applied manually to the calcaneal half-ring, and

the bolts were secured. Reduction of the large

metaphyseal unreduced fracture fragments was

attempted using the olive wires through two meta-physeal rings. This usually resulted in a well-aligned fracture pattern. The decision on whether to use limited internal reduction with fixation was

now determined based on the intraarticular fracture

pattern. Generally, less than 2 mm was considered acceptable. If limited internal reduction with fixa-tion was needed, the limb was elevated and the tourniquet inflated before a small incision necessary to elevate the depressed fragments was made. This was needed in nine patients were mini open fixa-tions were done mainly by using interfragmentary

screws. In three patients with large metaphyseal

bone defects and articular depression, elevation and ipsilateral autogenous iliac crest cancellous

bone grafting was performed through a medial metaphyseal cortical window. For definitive treat-ment, attention was directed to rings 2 and 3. Under

direct fluoroscopic guidance, with previously de-termined fracture pattern awareness, olive wires

were placed to reduce and "squeeze" the fracture

pattern in a very methodical way. Generally, two

wires were placed proximal to the fracture, with

three wires placed in the distal fracture just above and parallel to the ankle joint. Care was taken to

prevent tethering of muscles or tendons by exten-sion or flexion of the foot as indicated.

Postoperative management: Intravenous antibiotics (a third generation ceph-

alosporin) were given for 48 hours postoperatively.

Antibiotic prophylaxis was prolonged until wound

closure. Intramuscular NSAID injections (diclofen-ac 75 mg) were usually needed in the first few

days postoperatively. Intravenous anticoagulants

were ensued when associated injuries prevented

early ambulation.

All patients started gentle ROM exercises of the knee on the second to the fifth postoperative

day. With most frames, the patient can achieve 90 ° of flexion while the circular frame is in place.

The half-ring was removed at the first follow-up after 6 weeks on an outpatient basis. The calca-neal half-ring used for joint distraction helped to

prevent equinus contracture of the ankle.

Active and passive ankle mobilization was then started, and the non-weight-bearing crutch-walking

was continued for 3 months postoperatively. At

the end of 3 months, the patients were allowed to

Ahmed Kholeif 103

start gradually increasing weight-bearing using a

single crutch with the Ilizarov in position.

Follow-up radiographs were done at 1, 3, 6, 9, and 12 weeks postoperatively. Any displacement, angulation or malalignment discovered postopera-tively or during follow up visits was readily cor-rected by adding plates or hinges in the outpatient

setting. Fixators were removed after clinical and

radiographic evidence of fracture healing. Before

the fixator pins were taken out, loosening of the frame or removal of the connecting rods were done,

then fracture consolidation was tested manually

or the patient was asked to walk. Absence of spring-ing on manipulation or pain on walking indicates full clinical union.

Outcome measures: The primary outcome was measured using a

modification 16 of the system proposed by Mazur

[17] at the last follow-up. Clinical results were

graded as excellent, good, fair, or poor (Table 2).

Osteoarthrosis was graded according to the criteria

of Marsh et al. [18] : Grade 0 indicated no evidence of arthrosis; grade 1, small spurs but no joint space

narrowing; grade 2, osteophytes and some joint-space narrowing; and grade 3, complete loss of the

joint space. Ankle instability was diagnosed by

way of joint space opening on stress radiographs.

Ankle arthritis was diagnosed by painful restriction

of all movements with or without crepitus with radiological evidence of reduced joint space.

Table (2): Modified Mazur classification: Clinical rating.

Rating Results

Excellent (> 92 points)

No pain, normal gait, normal ROM, no swelling

Good (87-92 points) Minimal pain, 3/4 normal ROM, normal gait, trivial swelling

Fair (65-86 points) Aching with use, 1/2 normal motion, normal gait, NSAID mild swelling

Poor (< 65 points) Pain with walking, or rest, 1/2 normal motion, limp, swelling

ROM

: Range of motion. NSAID

: Nonsteroidal anti-inflammatory drugs

Results

Table (3) shows the detailed characteristics of the 15 patients involved in the study. The age of the studied group ranged between 19 and 56 years with a mean of 35.9 ± 11.6 years. Only 2 females (13.3%) were included.

Table (3): Details of the characteristics of the 15 studied cases.

Case Age Sex Injury

mechanism Reduction

type Reduction

score Duration

of fixation Follow-up

(month) Osteoarthrosis

grade Ankle score

1 34 M Fall Closed Good 14 24 1 Good 2 46 M MCA Mini-open Good 12 19 1 Poor 3 19 M Fall Closed Good 21 12 1 Good 4 22 M MCA Mini-open Anatomic 12 26 0 Excellent 5 50 M Fall Closed Fair 18 16 3 Fair 6 48 M MCA Mini-open Poor 15 22 3 Poor 7 30 F Fall Closed Fair 16 18 1 Good 8 27 M MCA Mini-open Good 14 20 2 Fair 9 56 M MCA Mini-open Good 24 14 1 Fair 10 39 M Fall Mini-open Fair 12 24 3 Good 11 32 M MCA Closed Good 14 20 1 Good 12 25 M MCA Mini-open Good 20 18 1 Excellent 13 23 F MCA Closed Fair 18 24 3 Good 14 46 M MCA Mini-open Good 16 25 3 Good 15 42 M Fall Mini-open Good 12 20 3 Good

MCA: Motor car accident.

The mean duration of external fixation was 15.9±3.7 weeks, and the mean follow-up time was

20.1 ±4.1 months (range: 12-26 months). Reduction

of the fracture was either mini-open (60%) or

closed (40%). The articular reduction was consid-ered excellent or good in 10 ankles (66.7%), fair

in 3 and poor in 2 (Fig. 1).

Fracture union was achieved in all patients;

secondary bone grafting was not needed. No neu-rovascular injuries occurred due to Ilizarov fixation.

The patients achieved full weight-bearing walk-ing without crutches within an average of 21 ±4.4 weeks (range 18-26 weeks). One of our patients

Good 53.3%

Poor 13.3% Excellent

13.3% Fair

20.0%

104 Management of Comminuted Tibial Pilon Fractures

had loss of fixation of the medial articular fragment,

leading to fracture malunion in 16 ° of varus. Al-though nine patients had 1-2 mm articular depres-sion, only four developed ankle arthritis.

The movements of the ankle ranged from 5 ° to 15° of dorsiflexion and from 5 ° to 35 ° of plantar flexion (Fig. 2 and Fig. 3). The range of motion is

shown in Table (4) recorded for all patients. Three patients had symptoms or signs of mediolateral

instability. Osteoarthrosis grade in the 15 patients is shown in Table (5). Using the modified Mazur classification, the procedure resulted in excellent

and good outcome in 10 cases representing 66.7%.

Ten patients (66.7%) faced minor complications;

9 (60%) had pin tract infection; that was treated

with oral antibiotics and dressings. One patients

developed wound infection; the infection was controlled with parenteral antibiotics. No cases of

serious infection were recorded.

Fig. (1): Grading of the reduction score of the 15 cases.

Fig. (2): A case of 30 years old female with highly comminuted pilon fracture after fall from 4 th floor.

Fig. (2-A): Preoperative AP & Lat x-rays. Fig. (2-B): Post operative x-rays.

Fig. (2-C): X-rays at final follow up.

Fig. (3-A): Preoperative AP & Lat x-rays. Fig. (3-D): Range of motion at follow-up.

Fig. (3-B): Post operative x-rays.

Fig. (2-D): Range of motion at follow-up.

Fig. (3): Showing comminuted Pilon fracture in a 46 years old male after MCA.

Fig. (3-C): X-rays at final follow-up.

Ahmed Kholeif 105

106 Management of Comminuted Tibial Pilon Fractures

Table (4): Mean values of Range of motion for all patients.

Treated side Contralateral side

Dorsiflexion 11.2° 24° Plantar flexion averaged 19.5° 36° Inversion 4.4° 10.5° Eversion 4.7° 13 °

Table (5): Outcome of the procedure in the 15 studied cases.

Number Percent

Osteoarthritis grade:

0 1 6.7 1 7 46.7 2 1 6.7 3 6 40.0

Ankle score: Excellent 2 13.3 Good 8 53.3 Fair 3 20.0 Poor 2 13.3

Complications 10 66.7

Discussion

The most important principle to be considered for the successful treatment of tibial plafond frac-tures is the anatomic reduction of the joint surface [15,19-23] . Three decades ago, Ruedi et al. [10] re-ported that the anatomic restoration of the joint

surface could only be achieved through open re-duction and internal fixation. However, this ap-proach can result in serious complications owing to the nature and complexity of this type of fracture.

Minimally invasive techniques for reduction

of the articular fragments combined with stable fixation through an external device have been employed in more recent years [12,13,19,24-26] .

In this study, we treated our patients with per-cutaneous reduction and external fixation with Ilizarov apparatus. Circular frames with tension wires, like Ilizarov fixator, provide better stabili-zation especially in comminuted lesions and control

the fracture in all three planes of the reduction [26- 31] . External fixation techniques preserve soft tis-sues and the periosteum and yet provide stable

reduction. Ilizarov fixators, being very economical,

are suitable for patients of the developing countries

as in Egyptian population.

In a prospective randomized trial of plating versus external fixation of tibial pilon fractures,

Wyrsch et al. [32] concluded that external fixation of these fractures is associated with clinical out-comes similar to those obtained with traditional

methods of open reduction and internal fixation

but with significantly fewer complications. Simi-larly, Watson et al. [33] showed that there is a significantly higher complication rate with the use

of open plating techniques in fractures of the distal

tibia, and this is probably related to the amount of

dissection and stripping of soft tissues needed to

achieve reduction and plate fixation. Conroy et al. [34] reported good functional outcome and reduced

rates of amputation and infection after early internal fixation and soft tissue cover with vascularized

muscle flap.

We achieved excellent or good articular reduc-tion in 66.7% of patients. Using external fixators,

previous studies reported variable degrees of suc-cess from 69% [35] and 71.4% [36] to 90% [19] and 95% [13] . Vidyadhara and Rao [37] reported excel-lent or good functional results in 76% of 21 patients

with complex tibial type B and C pilon fractures.

Bonar and Marsh [38] treated a group of 49 patients by with trans-articular external fixation

and used limited surgical exposures to accomplish a small degree of internal osteosynthesis. They described an anatomic reduction in none, a good

reduction in 69%, fair in 20% and poor in 11%.

Barbieri et al. [19] also treated 37 fractures in 36 patients with external fixation and minimal internal

osteosynthesis.

On the other hand, Teeny [15] reported anatomic reduction in only 30% type III fractures using open reduction and internal fixation, while success rates were 77% for Ovaida and Beals [14] and 50% for Etter and Ganz [21] .

Similar to our results, many authors have re-ported satisfactory results using the two-staged protocol and shown a decrease in soft-tissue com-plications [4,25] . Patterson and Cole6 retrospectively

reported the outcomes of 22 cases of type C3 pilon

fractures with 77% good results, 14% fair results,

and 9% poor results. They had no infections or

soft-tissue complications.

In this series, 66.7% of patients had pin tract, while only one case developed wound infection. All patients responded well to antibiotic therapy.

Soft tissue complications and deep infections are

not frequent when external fixation is combined

with minimally invasive surgery: Wyrsch [32] had infections in 5%, Tornetta [12] in 1 out of 17 cases, Barbieri [19] in 3 out of 37 cases.

Ahmed Kholeif 107

Sirkin et al. [39] reported partial skin necrosis

that healed with local wound care in 5 of 34 patients

(15%) with closed fractures, in addition to one patient who developed a chronic draining sinus

from osteomyelitis that resolved after fracture

healing. In a retrospective study [25] of 37 type II and III pilon fractures, infection occurred in only

8% of patients. They achieved good to excellent outcomes in 81% of patients.

Harris et al. [40] reported an overall complication rate of 14%, including 2.5% wound complication,

4% infection, 2.5% nonunion, 5.1% malunion, and 39% posttraumatic arthritis in 79 high-energy type

C3 fractures.

The risk of non union and malunion in presence

of instability is higher. In a report by Dillin and Slabaugh [11] , there was 55% infection and 36% wound dehiscence rate with unstable internal fix-ation.

In conclusion, treatment of pilon fractures by

external fixation, using Ilizarov fixators, is a reliable

method for stabilization and healing of high-energy

distal tibial intra-articular fractures with acceptable

frequency of soft tissue complications.

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