Treatment of distal tibial fractures with the Ilizarov external fixator - a prospective observational study in 39 consecutive patients

BMC Musculoskeletal Disorders

Lars Nistor¹  Bengt I Eriksson²  Jón Karlsson²  Telmo Ramos¹ 

[1] Department of Orthopaedics, Central Hospital (Kärnsjukhuset), Skövde, SE-541 85, Sweden;Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy at Gothenburg University, Mölndal, SE-431 80, Sweden

关键词: External fixation;    Ilizarov method;    Distal tibial fractures;   

Others  :  1134160
DOI  :  10.1186/1471-2474-14-30

 received in 2012-02-12, accepted in 2013-01-10,  发布年份 2013

【 摘 要 】

Background

The management of displaced distal tibial fractures is still controversial. The different internal fixation techniques are often burdened by relatively high complication rates. Minimally invasive techniques with ring fixators have been introduced as an alternative allowing immediate reduction and stabilization, avoiding a staged protocol. The aim of this prospective study was to analyze the clinical and radiographic outcome the Ilizarov technique in patients with distal metaphyseal tibial fractures, with or without intra-articular involvement.

Methods

Thirty-nine consecutive patients with isolated fractures treated with the Ilizarov technique were followed prospectively for one year. Depending on the type of fracture, 4 or 5 rings were used, in some cases with additional foot extension. Unrestricted weight-bearing was allowed in all cases. Pre- and post-operatively conventional radiographs, post-operative pain assessment and complications were evaluated. The function was evaluated clinically and with self-appraisal protocols: EQ-5D, NHP and FAOS.

Results

No patient developed compartment syndrome or deep venous thrombosis. Pin infections were frequent, but they were mostly superficial and were treated with antibiotics and/or the removal of isolated pins. Two patients required debridement. One of them had a deep infection and developed a residual deformity which was corrected and healed after re-operation. Another patient had a severe residual deformity. The fixator was removed after a median period of 16 weeks (range 11–30). The radiological results were poor in 5 patients but the overall self-appraisal showed satisfactory results in 36 patients.

Conclusions

The Ilizarov method allowed early definitive treatment with a low complication rate and a good clinical outcome.

【 授权许可】

   
2013 Ramos et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Rockwood and Green’s: Fractures in Adults. 6th edition. Philadelphia: Lippincott Williams & Wilkins; 2006.
• [2]Joveniaux P, Ohl X, Harisboure A, Berrichi A, Labatout L, Simon P, Mainard D, Vix N, Dechoux E: Distal tibia fractures: management and complications of 101 cases. Int Orthop 2010, 34–4:583-588.
• [3]Dillin L, Slabaugh P: Delayed wound healing, infection, and non-union following open reduction and internal fixation of tibial plafond fractures. J Trauma 1986, 26–12:1116-1119.
• [4]McFerran MA, Smith SW, Boulas HJ, Schwartz HS: Complications encountered in the treatment of pilon fractures. J Orthop Trauma 1992, 6–2:195-200.
• [5]Teeny SM, Wiss DA: Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res 1993, 292:108-117.
• [6]Tull F, Borrelli : Soft-tissue injury associated with closed fractures: evaluation and management. J Am Acad Orthop Surg 2003, 11:431-438.
• [7]Ruedi TP, Allgower M: The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res 1979, 138:105-110.
• [8]Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999, 13:78-84.
• [9]Patterson MJ, Cole JD: Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma 1999, 13:85-91.
• [10]Blauth M, Bastian L, Krettek C, Knop C, Evans S: Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma 2001, 15–3:153-160.
• [11]Ma CH, Yu SW, Tu YK, Yen CY, Yeh JJ, Wu CH: Staged external and internal locked plating for open distal tibial fractures. Acta Orthop 2010, 81–3:382-386.
• [12]Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 2004, 18(Suppl 8):S32-S38.
• [13]Dickson KF, Montgomery S, Field J: High energy plafond fractures treated by a spanning external fixator initially and followed by a second stage open reduction internal fixation of the articular surface-preliminary report. Injury 2001, 32(Suppl 4):92-98.
• [14]Gardner MJ, Mehta S, Barei DP, Nork SE: Treatment protocol for open AO/OTA type C3 pilon fractures with segmental bone loss. J Orthop Trauma 2008, 22–7:451-457.
• [15]Mauffrey C, Vasario G, Battiston B, Lewis C, Beazley J, Seligson D: Tibial pilon fractures: a review of incidence, diagnosis, treatment, and complications. Acta Orthop Belg 2011, 77:432-440.
• [16]Zelle B, Bhandari M, Espiritu M, Koval K, Zlowodzki M: Treatment of distal tibia fractures without articular involvement: a systematic review of 1125 fractures. J Orthop Trauma 2006, 20–1:76-79.
• [17]Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM: Distal metaphyseal fractures of the tibia with minimal involvement of the ankle: classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br 1995, 77-B:781-787.
• [18]Casstevens C, Le T, Archdeacon MT, Wyrick JD: Management of extra-articular fractures of the distal tibia: intramedullary Nailing versus Plate fixation. J Am Acad Orthop Surg 2012, 20–11:675-683.
• [19]Newman SD, Mauffrey CP, Krikler S: Distal metadiaphyseal tibial fractures. Injury 2011, 42–10:975-984.
• [20]Tornetta P III, Weiner L, Bergman M, Watnik N, Steuer J, Kelly M, Yang E: Pilon fractures: treatment with combined internal and external fixation. J Orthop Trauma 1993, 7–6:489-496.
• [21]Wrysch B, McFerran MA, McAndrew M, Limbird TJ, Harper MC, Johnson KD, Schwartz HS: Operative treatment of fractures of the tibial plafond. A randomized, prospective study. J Bone Joint Surg Am 1996, 78–11:1646-1657.
• [22]Ristiniemi J, Flinkkila T, Hyvonen P, Lakovaara M, Pakarinen H, Jalovvara P: RhBMP-7 accelerates the healing in distal tibial fractures treated by external fixation. J Bone Joint Surg Br 2007, 89–2:265-272.
• [23]Barbieri R, Schenk R, Koval K, Aurori K, Aurori B: Hybrid external fixation in the treatment of tibial plafond fractures. Clin Orthop Rel Res 1996, 332:16-22.
• [24]Mc Donald MG, Burgess RC, Bolano LE, Nicholls PJ: Ilizarov treatment of pilon fractures. Clin Orthop Rel Res 1996, 325:232-238.
• [25]Lovisetti G, Agus MA, Pace F, Capitani D, Sala F: Management of distal tibial intra-articular fractures with circular external fixation. Strategies Trauma Limb Reconstr 2009, 4–1:1-6.
• [26]Vasiliadis ES, Grivas TB, Psarakis SA, Evangelos P, Kaspiris A, Triantafyllopoulos G: Advantages of the Ilizarov external fixation in the management of intra-articular fractures of the distal tibia. J Orthop Surg Res 2009, 4:35. BioMed Central Full Text
• [27]Vidyadhara S, Rao SK: Ilizarov treatment of complex tibial pilon fractures. Int Orthop 2006, 30–2:113-117.
• [28]Demiralp B, Atesalp AS, Bozkurt M, Bek D, Tasatan E, Ozturk C, Basbozkurt M: Spiral and oblique fractures of distal one-third of tibia-fibula: treatment results with circular external fixator. Ann Acad Med Singapore 2007, 36–4:267-271.
• [29]Ilizarov GA: A new principle of osteosynthesis using crossing wires and rings. In Collected Scientific Works of the Kurgan Regional Scientific Medical Society. Edited by Ilizarov GA. Kurgan: Union of Soviet Socialists Republic; 1954:145-160.
• [30]Ilizarov GA: Transosseous osteosynthesis. 1st edition. Berlin Heidelberger New York: Springer Verlag; 1992.
• [31]Ylmaz E, Belhan O, Karakurt L, Arslan N, Serin E: Mechanical performance of hybrid Ilizarov external fixator in comparision with the Ilizarov circular external fixator. Clin Biomech 2003, 18–6:518-522.
• [32]Fleming B, Paley D, Kristiansen T, Pope M: A biomechanical analysis of the Ilizarov external fixator. Clin Orthop Relat Res 1989, 241:95-105.
• [33]Müller ME, Nazarian S, Koch P, Schatzker J: The comprehensive classification of fractures of long bones. New York: Springer; 1990.
• [34]Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976, 58–4:453-458.
• [35]Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984, 24:742-746.
• [36]Tscherne H, Oestern HJ: Pathophysiology and classification of soft tissue injuries associated with fractures. In Fractures with soft tissue injuries. Edited by Tscherne H, Gotzen L. Berlin: Springer Verlag; 1984:1-9.
• [37]Davies R, Holt N, Nayagam S: The care of pin sites with external fixation. J Bone Joint Surg Br 2005, 87–5:716-719.
• [38]Checketts RG, Otterburn M, Mac Eachern AG: Pin track infection; definition, incidence and prevention. Int J Orthop Trauma 1993, 3(Suppl 3):16-18.
• [39]Brooks R: EuroQol: the current state of play. Health Policy 1996, 37:53-72.
• [40]Hunt SM, McEwan T: The development of a subjective health indicator. Soc of Health and Illness 1980, 2:231-246.
• [41]Wiklund I, Romanus B, Hunt SM: Self-assessed disability in patients with arthrosis of the hip joint. Reliability of the Swedish version of the Nottingham Health Profile. Int Disabil Studies 1988, 10:159-163.
• [42]Roos EM, Brandsson S, Karlsson J: Validation of the foot and ankle outcome score for ankle ligament reconstruction. J Foot Ankle Int 2001, 22–10:788-794.
• [43]Marsh JL, Buckwalter J, Gelberman R, Dirschl D, Olson S, Brown T, Llinias A: Articular fractures: does an anatomical reduction really change the result? J Bone Joint Surg Am 2002, 84A–7:1259-1271.
• [44]Burwell HN, Charnley AD: The treatment of displaced fractures of the ankle by rigid internal fixation and early joint movement. J Bone Joint Surg 1965, 47:634-660.
• [45]Krenk D, Molinero K, Mascarenhas L, Muffley M, Altman G: Results of minimally invasive distal fibular plate osteosynthesis. J Trauma-Inj Inf & Critical Care 2009, 66–2:570-575.
• [46]Berkes MB, Little MTM, Lazaro LE, Sculco PK, Cymerman RM, Daigl M, Helfet DL, Lorich DG: Malleolar fractures and their ligamentous injury equivalents have similar outcomes in supination-external rotation type IV fractures of the ankle treated by anatomical internal fixation. J Bone Joint SurgBr 2012, 94–11:1567-1572.
• [47]Bedi A, Le TT, Karunakar MA: Surgical treatment of nonarticular distal tibia fractures. J Am Acad Orthop Surg 2006, 14–7:406-416.
• [48]Redfern DJ, Syed SU, Davies : Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury 2004, 35–6:615-620.
• [49]Bahari S, Lenehan B, Khan H, McElwain J: Minimally invasive percutaneous plate fixation of distal tibia fractures. Acta Orthop Belg 2007, 73:635-640.
• [50]Aksekili MA, Celik I, Arslan AK, Kalkan T, Ugurlu M: The results of minimally invasive percutaneous plate osteosynthesis (MIPPO) in distal and diaphyseal tibial fractures. Acta Orthop Traumatol Turc 2012, 46–3:161-167.
• [51]Schouten R, Vincent A: Percutaneous plating of distal tibia fractures. J Bone Joint Surg Br 2009, 93(Suppl 3):376.
• [52]Borg T, Larsson S, Lindsjö U: Percutaneous plating of distal tibial fractures. Preliminary results. Injury 2004, 35–6:608-614.
• [53]Ronga M, Longo UG, Maffulli N: Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Res 2010, 468–4:975-982.
• [54]Hazarika S, Schakravarthy J, Cooper J: Minimally invasive locking plate osteosynthesis for fractures of the distal tibia- results in 20 patients. Injury 2006, 37–9:877-887.
• [55]Lau TW, Leung F, Chan CF, Chow SP: Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop 2008, 32–5:697-703.
• [56]Collinge C, Protzman R: Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures. J Orthop Trauma 2010, 24–1:24-29.
• [57]Cavusoglu AT, Er MS, Inal S, Ozsoy MH, Dincel VE, Sakaogullari A: Pin site care during circular external fixation using two different protocols. J Orthop Trauma 2009, 23–10:724-730.
• [58]Mahan J, Seligson D, Henry SL, Hynes P, Dobbins J: Factors in pin tract infections. Orthopaedics 1991, 14:305-308.
• [59]Parameswaran AD, Roberts CS, Seligson D, Voor M: Pin tract infection with contemporary external fixation: How much of a problem? J Orthop Trauma 2003, 17–7:503-507.
• [60]Ristiniemi J: External fixation of tibial pilon fractures and fracture healing. Acta Orthop 2007, 78–326(Suppl 3):5-34.
• [61]Etter C, Ganz R: Long-term results of tibial plafond fractures treated with open reduction and internal fixation. Arch Orthop Trauma Surg 1991, 110–6:277-283.
• [62]DeCoster TA, Willis MC, Marsh JL, Williams TM, Nepola JV, Dirschl DR, Hurwitz SR: Rank order analysis of tibial plafond fractures: does injury nor reduction predict outcome? Foot Ankle Int 1999, 20–1:44-49.
• [63]Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures. How do these ankles function over time? J Bone Joint Surg Am 2003, 85A-2:287-295.
• [64]Williams TM, Nepola JV, DeCoster TA, Hurwitz SR, Dirschl DR, Marsh JL: Factors affecting outcome in tibial plafond fractures. Clin Orthop Relat Res 2004, 423:93-98.
• [65]Pollak AN, McCarthy ML, Bess RS, Agel J, Swiontkowski MF: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003, 85–10:1893-1900.