SLR - August 2021 - Caroline Ko

A Systematic Review of the Role of Surgical Approaches on the Outcomes of the Tibia Pilon Fracture

Reference: Liu J, Smith CD, White E, Ebraheim NA. A Systematic Review of the Role of Surgical Approaches on the Outcomes of the Tibia Pilon Fracture. Foot Ankle Spec. 2016 Apr;9(2):163-8. doi: 10.1177/1938640015620637. Epub 2015 Dec 7. PMID: 26644032.

Level of Evidence: IV 

Scientific Literature Review

Reviewed By: Caroline Ko, DPM 
Residency Program: Kaiser North Bay Consortium - Vallejo, CA 

Podiatric Relevance: Tibial plafond fractures are complex fractures that have high rate of complications. Preoperative surgical planning with attention to detail is essential to ensure good outcomes for those fractures. Knowing the differences in the complication rates with each surgical approach will help guide a podiatric surgeon when one decides between different incisional approaches. 

Methods: Posterolateral, posteromedial, medial, anterior, anteromedial, anterolateral and lateral approaches were compared with the data from 19 research articles. The patient outcome, fracture type, complication type and functional results were analyzed for each surgical approach. The study focused on the quality of the clinical outcomes and the type of fracture types used for each approach as the functional results were not always documented. 

Results:
- 733 patients were included. 21 percent of the patients had OTA Type B and 79 percent had type C fracture. 
- About 33 percent of the cases used anterolateral approach and 20 percent used medial approach. 
- 117 complications were reported, amounting to 16 percent complication rate. 
- The most common complications were wound dehiscence (21 percent), delayed union/malunion (19 percent), superficial infection (17 percent). 
- The complication rates for each approach were as follows in order of ascending complication rate: medial (11.7 percent), anterior (11.8 percent), anterolateral (14.52 percent), lateral (18.6 percent), anteromedial (22.8 percent), posteromedial (20 percent) and posterolateral (23 percent). 

Conclusions: The authors concluded that while the anterolateral approach was the most common incision, medial and anterior approach had the lowest complication rates. The authors discussed several limitations of the study. Most articles included in the systemic review were retrospective case reviews. Operative uses of antibiotic beads or “no touch” techniques could not be included in the comparisons of the incisions. Different fracture patterns or differences in fixations or surgical techniques also could not be incorporated in the comparisons. However, considering that most of the included articles did not focus on the surgical approaches, the systemic review analyzed and summarized the outcomes of different surgical approaches well. This allows a more thorough discussion regarding possible complications associated with different incisions to be discussed with patients pre-operatively.

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