[Fractures of the tibial pylon: treatment options and outcomes]

Fractures of a tibial pylon are serious problems in traumatology. The methods of their therapy have not been unified yet and treatment outcomes are not satisfactory. This is often due to extensive comminution of the distal tibia, bone defects or a thin coverage of soft tissue. The objective of this study is to compare the literature data and, on the basis of this and our own experience, to present guidelines for the treatment of fractures of tibial pylons.

In the period from 1998 to June 2002, 60 patients (average age, 42 years) underwent surgery for a fracture of the tibial pylon in the Department of Orthopedics, IPVZ, and in the hospital Na Bulovce, First Faculty of Medicine, Charles University in Prague. In most of the patients, the injury was caused by falling from a height. Thirteen patients failed to turn up for follow-up.

Plate osteosynthesis or MIO, usually combined with plaster cast, were used in 42 patients. External fixation, with individual screws or Kirschner's wires in some cases, was employed in 18 patients. External fixation was applied in open fractures and in serious comminutions of the distal tibia.

A total of 47 patients were followed up for a period of 6 months to 5 years. Infectious complications occurred in 12 patients (20%), of whom five had to undergo repeat surgery. Twenty-five patients (53%) reported good results of treatment, with no or only very minor restriction of motion in the ankle joint. In 13 patients, the outcome was satisfactory and nine patients were not satisfied because of serious restriction of motion or ankylosis of the ankle joint. Three patients underwent a delayed arthrodesis of the ankle joint. The fractures healed completely in all patients.

The results achieved in our patients were comparable with those described in the international literature. The very good and satisfactory outcomes in 53% and 28% of the patients, respectively, are in agreement with the studies reporting good rates of success. Also the number of infectious complications (20%; 8% serious) was in the range generally reported. The initial method of treating fractures of the tibial pylon by plate osteosynthesis has gradually been abandoned. The major prognostic factors for the outcome of treatment are the extent of injury to soft tissues and the kind of surgical procedure used. Therefore, it appears that external fixation, usually in combination with semi-closed reduction and fixation of fragments with screws and Ki-wires, has a better prognosis not only in open fractures but also in closed comminuted fractures with seriously injured soft tissues.

Fractures of the tibial pylon are serious injuries and their therapy requires good experience in the field and appropriate technical facilities. The method of treatment should be chosen according to not only fracture type but also soft tissue involvement and the patient's overall state.