SLR - November 2020 - Timothy J. McCord
Large Autologous Ilium with Periosteum for Tibiotalar Joint Reconstruction in Rüedi-Allgöwer Iii or Ao/Ota Type C3 Pilon Fractures: A Pilot Study
Reference: Li, D., Li, J. J., Hou, F., Li, Y., Zhao, B., & Wang, B. (2020). Large Autologous Ilium with Periosteum for Tibiotalar Joint Reconstruction in Rüedi-Allgöwer Iii or Ao/Ota Type C3 Pilon Fractures: A Pilot Study. BMC Musculoskeletal Disorders, 21(632)
Level of Evidence: Level III, retrospective cohort study
Scientific Literature Review
Reviewed By: Timothy J. McCord, DPM
Residency Program: Southern Arizona VA Health Care System – Tucson, AZ
Podiatric Relevance: Pilon fractures are much more complex than common ankle fractures and account for about 5 to 7 percent of all tibial fractures. Pilon ankle fractures are typically due to high energy trauma and because of this, they are associated with a high risk of complications and there is a high incidence of developing posttraumatic arthritis of the ankle joint. Many patients that experience a pilon fracture have the quality of life reduced post operatively. This presents a challenge for the surgeon to reduce the fracture and reconstruct the ankle joint as close as anatomically possible to retain a better quality of life. There have been various methods reported in the literature, but all procedures present with their own complications. Although there have been articles that have indicated poor prognosis with the use of bone grafts, this article discusses a single stage reconstruction procedure utilizing a large autologous ilium bone graft for Ruedi-Allgower type III fractures. In performing this experimental procedure, a decrease in complications and possible delay of posttraumatic ankle osteoarthritis may be achieved.
Methods: A 20 patient sample size was used for this study which consisted of 15 male and five females. The mean age was 45.2 years old. All patients that were entered into the study underwent ankle joint reconstruction using a large autologous ileum with periosteum harvested from the iliac crest. The inclusion criteria were Ruedi-Allgower type III or AO type C3 pilon fractures that had no concomitant compartment syndrome or exudation of the skin. The visual analog scale (VAS) and American orthopedic foot and ankle society (AOFAS) scores were used and were documented during daily activities. In addition, the scores were recorded prior to surgery to serve as a baseline for comparison during follow-ups which was at three, six and 12 month intervals.
Results: The mean operating time was 120 minutes and the average incision recovery time was 16 days. No patients developed deep surgical site infection, donor site complications or nonunion. The mean follow-up duration was 18.3 months. At this time, it was noted that all patients achieved bony union. The mean VAS score decreased by 4.9 points wall that AOFAS score improved by 74 points. By the last follow-up, 15 patient’s had anatomic reduction, 4 had good reduction and one had poor reduction.
Conclusions: There is no consensus in the literature regarding the optimal fixation method of pilon fractures. The primary complication is uncertainty of anatomical reduction which leads to arthritis of the ankle joint. The authors indicate that there was success in the short term when using the concave aspect of the ilium graft to help preserve motion and prevent increased stress at the ankle joint. However, the short follow up, small sample size and lack of non-objective ankle measurements were limiting factors which did not allow for a definitive conclusion on reduction of long-term complications. Since this was a pilot study, these should be expanded on for not only long-term evaluation but for efficacy of the reconstructive technique.