SLR - March 2022 - Samuel Y. Enyew
Reference: Zhao, Y., Wu, J., Wei, S., Xu, F., Kong, C., Zhi, X., Huang, M., & Cai, X. (2020). Surgical Approach Strategies for Open Reduction Internal Fixation of Closed Complex Tibial Pilon Fractures Based on Axial Ct Scans: A Retrospective Cohort Studies of 25 Patients. Journal of orthopaedic surgery and research, 15(1), 283. https://doi.org/10.1186/s13018-020-01770-yLevel of Evidence: IV
Scientific Literature Review
Reviewed By: Samuel Y. Enyew, DPM
Residency Program: New York Presbyterian, Queens – Flushing, NY
Podiatric Relevance: Pilon fracture is one of the most challenging and complex fractures addressed by Podiatric and orthopedic surgeons with fair-good results being the norm, and it’s difficult to predict the long-term outcomes. There are several surgical incision approaches for addressing complex pilon fractures proposed by the AO and American Academy of Orthopaedic Surgeons (AAOS) group, but this study describes two main approaches based on the axial CT scan findings. The goal of this study was to explore the application and clinical efficacy of surgical approach strategies in open reduction and internal fixation of closed complex tibial Pilon fractures based on axial CT scans.
Methods: In this retrospective cohort study, patients were recruited from the hospital documents, and a total of 25 patients (19 male and 6 Female ) with closed complex tibial Pilon fractures were treated during a three-year period in Wuhan General Hospital, China. According to the AO classifications, four cases were type 43C1, 10 were type 43C2, and 11 were type 43C3 based on the CT and 3D imaging findings. Postoperative patients were seen and evaluated in the clinic at 1, 3, 6, 12, 18, 24, 36, 48, 60 months after surgery and the quality of fracture reduction was determined using the Burwell-Charnley radiographic criteria. The post op radiographic evaluation showed that 19 cases had anatomical reduction, five had good reduction, and one had fair reduction, and that no internal fixator got into the joint. Patients’ postoperative function was evaluated using the AOFAS Ankle-Hindfoot Scale.
Results: The two main combined surgical approaches (Posteromedial with anterolateral or anterior and posterolateral with Anteromedial or anterior) proposed by this study using Axial CT imaging and understanding of the articular surface and level of comminuted provides excellent surgical planning with a good to excellent surgical and functional outcomes. Seven of the twenty-five patient’s fracture was addressed with posteromedial, and anterolateral approach and 18 of the 25 patients had a posterolateral and anteromedial approach. Patients’ postoperative function was evaluated using the AOFAS Ankle-Hindfoot Scale. The evaluation results showed that the 25 cases had an average score of 88.4 (range, 80–100), of whom 15 were excellent, 10 good, 0 fair, and 0 poor, with an excellent and good rate of 100 percent.
Conclusions: Surgical management of a Pilon fracture is challenging due to the articular surface comminution, significant bone and soft tissue loss, and a careful designed surgical approach avoids unnecessary further trauma to the soft tissues while protecting the angiosomes. The good and excellent surgical and functional outcomes claimed by this study is very unlikely secondary to the surgical approaches proposed by their study since all of the patients included in this study involves a closed pilon fracture, with no huge soft tissue defects and the post op reduction was evaluated by x ray which is unreliable in evaluating the articular surface involvement. In conclusion, the study provides compelling functional outcomes following a pilon fractures, but there are several limitations including the small sample size, short follow up, and its retrospective nature of the study.