Treatment Algorithm for Pilon Fracture - Clinical and Radiological Results

PURPOSE OF THE STUDY The aim of the present study was to evaluate the postoperative outcome of patients with pilon tibial fractures with a minimum follow-up of 24 months, treated according to a staged treatment algorithm. MATERIAL AND METHODS In total, 27 patients (mean age 43.6 ± 13 years, range 18-69) with a pilon tibial fracture and a minimum follow-up of 24 months were included in the study. Medical recordings (discharge documents and surgical reports) and radiographic examinations were analyzed. All enrolled patients were invited for a clinical and radiological follow-up examination (ROM, AOFAS hindfoot score, Kellgren score). The mean follow-up time was 44.5 ± 16 months (range 24-82). RESULTS In 21 cases a two-stage operative strategy with initial closed reduction and external fixation was necessary prior to definitive osteosynthesis. Overall, the patients scored 82.1 ± 20 points (range 30-100) in AOFAS hindfoot score, which represents a good clinical outcome. Patients with B-type fractures scored significantly better than those with C-type fractures. Patients with closed pilon tibial fractures reached significantly higher values in the AOFAS hindfoot score than those with open ones. Age and gender did not affect the functional outcome. Total ankle range of motion was 41° ± 10° for B-type fractures (range 20°-55°) and 35° ± 17° (range 0°-60°) for C-type fractures respectively (p > 0.05). Only five patients reached higher scores (Grade III) in Kellgren classification system. DISCUSSION Within the last decades, the therapeutic algorithm of pilon fractures underwent a paradigm shift; a two-stage protocol has prevailed today. However, the initial severity of the fracture in terms of initial absorbed energy, bony comminution and softtissue trauma still affects the outcome. Moreover, the necessity for bone grafting, as an indirect measurement of bone comminution and bone defects, resulted in higher degrees of osteoarthritis in the final follow-up. Higher initial soft-tissue injury also had an impact on the functional outcome of the patients, as patients with closed fractures scored better in AOFAS at the final follow-up. In order to counteract these risk factors and to reduce complications that define the outcome of these severe injuries, clearly defined surgical principles and standardized treatment protocols are needed. CONCLUSIONS The present study confirms the fact that meticulous planning, respect of the soft-tissues and choice of the optimal timepoint for the definitive osteosynthesis and overall treatment according to standardized protocols can optimize the outcome of this severe injury. Key words:pilon, distal tibia fracture, outcome, algorithm.