5. Article 690 - jbjdonline.comjbjdonline.com/wp-content/uploads/2018/12/5.-Article-690.pdfNath R et al Materials and Methods is was a prospective study, which was done in the department

Abstract

Original Article Journal of Bone and Joint Diseases| May-Aug 2018 | 33(2):16-19

© 2018 by Journal of Bone and Joint Diseases | Available on www.jbjdonline.com | �is is an Open Access article distributed under the terms of the Creative Commons A�ribution Non-Commercial License (h�p://c reativecommons.org/licenses/by-nc/3.0) which

permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

IntroductionFirst described by the French radiologist Destot in 1911, ankle fracture that involve the weight bearing distal tibial articular surface are known as “Pilon fracture.” Bonin also refer to a pilon fracture as “plafond fracture”[1,2]. �e pilon or plafond fracture is a descriptive term suggesting that the talus acts as a hammer, or pestle, that impacts and injures the tibial plafond. Distal tibial metaphysis is de�ned as by constructing a square, with side of length measured by widest portion of tibial plafond[3]. �e incidence of distal tibial fracture is 0.6% and it constitutes about 10%-13% of all tibial fractures[4]. �is injury is usually caused by a high-energy axial force which also results in severe so�-tissue injuries. Ruedi described that the type of fracture depends on application of injurious force and position of foot at the time of loading, so impact with foot in neutral position results in central comminution, while a vertical impact on a dorsi�exed foot result in cephalad and anterior force, with comminution of the anterior plafond. Similarly, the posterior plafond comminution suggests plantar �exion of foot at time of injury. �e AO/OTA classi�cation system provides a comprehensive description of distal tibial fractures. �ey are subdivided into:- 43 A fracture- extra-articular fractures, 43B fracture- partial articular fracture, and 43C fracture- complete articular fractures. In 1959, Jergesen stated that open reduction and stabilization of

severe tibial pilon fracture is impossible. In the early 1960s, the AO/OTA develop general guidelines for the treatment of intra-articular distal tibial fractures, which led to open reduction and anatomic and rigid internal �xation[5]. Because of the severity of so� tissue injury and the disastrous results of deep wound complication felt to be a�ributed to extensive surgical exposure and bulky internal �xation devices, external �xation emerged as successful technique for decreasing septic complication. But lack of consistent results with use of external �xation technique and an improved understanding of associated so� tissue injury gave way to the reconsideration of open treatment with internal �xation but only a�er a period of so� tissue recovery[6,7]. Although a variety of options are available to treat these fractures, timing of de�nitive surgery is crucial with respect to the condition of the so� tissues. Surgical stabilization of fractures and early mobilization of the patient provides best clinical outcome. Despite the advances that have been made in managing these fractures, new developments in the �eld continue to lead to be�er outcomes[8,9].

Aims and Objective:-�e purpose of this prospective study was to evaluate clinic-radiological outcome of plate osteosynthesis for distal tibial fracture by AOFAS score and serial radiographs, and to

document & record the injury-surgery interval, operative time, and preoperative, intraoperative & postoperative complications encountered in plate osteosynthesis.

¹Department of Orthopaedics, GSVM Medical College, Kanpur

Address of Correspondence:Dr. Ajay Raj Pal, Room No-18, NRH, L.L.R. Hospital, GSVM Medical College. Kanpur 208002. Email: [email protected] Dr. Rohit Nath Dr. Chetan Singh

Journal of Bone and Joint Diseases Volume 33 Issue 2 May-Aug 2018 Page 16-1916| | | | |

�e purpose of this study was to evaluate the management of distal tibial fractures treated by plate osteosynthesis and assess their functional outcomes and complications. MATERIAL AND METHOD: We included 25 patients (16 having AO43A type, 7 having AO43B type and 2 having AO43C type fracture) and all were treated with plating. Patients were regularly followed up at six weeks interval till union a�er that 3 monthly for period of 1 year and evaluated clinically and radiologically with respect to partial and full weight bearing time, union time and functional outcome on the basis of AOFAS Score. RESULT: Mean age of patients was 42.24 years. Mean operative time was 77.80 and average time for union was 21.56+2.58 weeks whereas functional outcome was 95.76+2.90. Lesser complications in terms of implant irritation, ankle stiffness, and infection were seen with MIPPO.Keywords: Distal Tibia fracture, Locking plating, MIPPO, AOFAS Score.

Rohit Nath¹, Chetan Singh¹, Ajay Raj Pal¹

A Prospective Study of Analysis of Functional Outcome of Distal Tibial Fracture Treated by Minimally Invasive Percutaneous Plate

Dr. Ajay Raj Pal

Nath R et al www.jbjdonline.com

Materials and Methods �is was a prospective study, which was done in the department of orthopaedics, L.L.R.Hospital Kanpur from Nov 2015 to Oct 2017. All 25 patients of distal tibial fractures were surgically treated a�er conforming to the inclusion and exclusion criteria and signing an informed consent. Inclusion criteria were skeletally mature (>18Years) patient with fracture distal end tibia (AO/OTA 43A/B/C Type). Patient having pathological fracture, bimalleolar / trimalleolar / ankle dislocations, fracture more than 3 weeks old at the time of surgery, grade IIIc compound fracture, previously operated ankle joint, segmental tibial fractures and patients who were medically un�t and not willing for surgery were not included in study.

Surgical TechniquePatient was laid on a radiolucent operating table on supine position and tourniquet was applied, pressure was set at twice the systolic pressure. Leg was prepped and draped upto mid-thigh. A posterolateral incision was given which was centered at �bular fracture. So� tissue was retracted, �bular end was cure�ed and reduced and �xed by 1/3rd tubular plate. Wound was closed in layers. �e length of the plate was estimated by placing it on skin while checking the position with �uoroscopy. �e plate was contoured by bending and twisting the plate using plate benders to �t on the anteromedial aspect of distal tibia. A 3-4 cm long anteromedial incision was given at distal end and one at the proximal end of anticipated plate position. If there was signi�cant metaphyseal comminution, the medial so� tissue was potentially more injured and medial plating may

cause wound breakdown. An anterolateral plate may be less risky and require anterolateral approach. Tunnel was made with blunt instrument connecting these two incisions in extraperiosteal fashion. Plate was placed through this tunnel and temporarily �xed by k wire. A non-locking lag screw through the mid portion of plate was placed for good bone-plate contact. Plate was �xed with 3.5 mm locking screws. A�er that wound was closed in layers and dressing was done.

Results In our study there were 25 patients, 16 patients having AO 43A type, 7 patients having AO 43B type and 2 patients having AO43C type fracture treated by plate osteosynthesis and 3 patients having AO 43A managed conservatively because they did not meet the inclusion criteria so not included in study. �e average age of patients in our study was 42.24 years. �e majority of the patients were in the age group of 30-55 years which re�ects a more active lifestyle in this age group. �e majority of the patients were males 16 (64%) out of 25 patients. In our study right side fracture (68%) was more common than le� side. In our study, 22/25 (88%) patients had closed fracture and 3/25 (12%) patients had open fracture. 6 patients of closed fracture had skin blisters. Blister was punctured and paraffin gauze dressing and limb elevation was done and when wrinkling sign appeared, only then de�nitive ORIF was done. In this study, 21/25 (84%) patients had ipsilateral �bular fracture and all were �xed. In this study, 13(52%) patients were treated within 1 week of injury, 6(24%) within 2 week and 6(24%) within 3 weeks. Mean duration of surgery was 77.80±17.02 min. 17 patients were


Figure 1: Intra-operative clinical pictures of MIPPO Figure 2: Complications encountered in our study

Figure 3: 35 yr female with AO/OTA 43A type fracture Figure 4: 37 yr male with AO/OTA 43A type fracture


mobilized with partial weight bearing with short leg walking cast and 8 patients were mobilized with partial weight bearing without cast. Average time for partial weight bearing (PWB) was 7.92±1.44 weeks. In our study, we allowed PWB only a�er sign of union in form of bridging

callus on at least three cortices out of four on radiograph and clinically as the absence of tenderness and movements at fracture site. �e average time for full weight bearing (FWB) was 13.96±1.59 weeks. �e mean union time in our study was 21.56±2.58 weeks. Functional outcome according to AOFAS score was measured at last follow up in those patient who completed at least six month follow up. �ere were no signi�cant difference between AOFAS score

at six month and one year. AOFAS score is based on pain, function and alignment. In current study the average AOFAS score at last follow up was 95.76±2.90. In our study, 6 (24%) patients had surgical site infection and delayed wound healing; 3 (12%) patients had ankle pain; and 1 (4%) patient had exposed implant. Delayed wound healing occurred in those patients who had closed fracture and fracture blister. 2 (8%) patients of MIPPO had varus deformity. �e complications in studies by Kumar et al[10], Ram et al[8], Vallier et al[11], Bahari et al[12], Pawar et

Figure 5: 40 yr male with AO/OTA 43A type fracture

Figure 6: 30 yr male with AO/OTA 43C type fracture

S.No Study YearMean Age

Of Pa�ent

Opera�ng

�mePWB FWB Union Time AOFASS

Pla�ng (mins) Pla�ng (weeks)Pla�ng

(weeks)Pla�ng (weeks) Pla�ng

1 Guo JJ et al 2014 44.3 0 97.9 _ _ 17.6 83.9

2 Pawar ED et al 2014 41.66 70.36 7.07 13.09 21.4 _

3 Paluvadi SV et al 2014 36 86.23 _ _ 21.4 95.06

4 Ravindra & Paramesh K 2016 40.5 -- -- -- 14-16 -

5 Daolagupu AK et al 2017 37.14 66.67 + 5.55 6.09 +1.33 13.38 +1.24 21.70 + 2.67 96.67

6 Our Study 2017 42.24 77.80 +17.02 7.92+1.44 13.96 +1.59 21.56 +2.58 95.76 +2.90

Table 1: Comparison chart of our study with other studies

S.No BHT No Age/Sex MOI AO TypeFibular

fractureSide

Open(G)/

Closed(T)OT ISI (Days) PWB FWB UT AOFASS LFU Result Complica�ons

1 32723 51Y/M RTA 43B YES R T1 75 1 6 12 20 97 EXCELLENT NONE

2 973 40Y/M RTA 43A NO R T2 55 8 6 12 22 98 EXCELLENT NONE

3 1016 28Y/F SOG 43B YES R T2 90 7 8 12 18 97 EXCELLENT NONE

4 5128 45Y/M RTA 43A YES R G2 80 2 7 12 18 98 EXCELLENT NONE


6 10036 55Y/F HBC 43A NO L T1 45 4 6 12 20 98 EXCELLENT ANKLE PAIN

7 10443 48Y/M RTA 43A YES R T1 60 1 8 14 22 98 EXCELLENT NONE


9 14448 26Y/F RTA 43B YES R T2 45 4 7 15 24 95 EXCELLENT DWH

10 17087 45Y/F FHO 43A YES L T2 45 17 7 12 20 95 EXCELLENT PAIN


12 20390 65Y/M FFH 43B YES L T2 75 6 9 16 22 98 EXCELLENT PAIN&DWH

13 23540 35Y/M FFH 43C YES R G2 75 16 7 15 24 95 EXCELLENT INFECTION

14 32617 39Y/M RTA 43A NO L T2 70 5 8 16 25 97 EXCELLENT NONE

15 37115 35Y/F RTA 43A YES R G1 80 5 7 13 23 97 EXCELLENT NONE

16 39119 85Y/F RTA 43A YES L T1 100 4 10 15 24 87 GOOD NONE

17 5644 42Y/M FFH 43B YES R T2 90 18 8 14 28 95 EXCELLENT NONE

18 9454 42Y/F APA 43A YES L T1 90 6 9 15 23 98 EXCELLENT DWH

19 15177 55Y/F FFH 43A YES L T1 90 14 9 14 24 97 EXCELLENT NONE


21 15544 19Y/F FFH 43A YES R T1 80 15 10 16 20 94 EXCELLENT SSI(DWH)

22 19409 28Y/M RTA 43A YES R T1 90 11 7 13 18 95 EXCELLENT SSI(DWH)&EI

23 24859 38Y/M RTA 43A YES R T2 80 14 9 14 19 96 EXCELLENT SSI(DWH)

24 26960 30Y/M FFH 43C NO R T2 110 19 12 18 24 87 GOOD ANKLE PAIN

25 29137 50Y/M RTA 43A YES L T2 90 10 8 13 18 96 EXCELLENT NONE

Table 2: Details of Cases included in our Study

Abbrev- SOG-Slip on ground, HBC- Hit by cow, FHO- Fall of heavy object , FFH- Fall from height, APA- Alleged physical assault, DWH-Delayed wound healing, SSI-Surgical site infec�on,

EI-Exposed implant, OT-Opera�ve �me, UT- Union Time, AOFASS- American Orthopaedic Foot Ankle Society score



1. Michelson J, Moskovitz P, LabropoulosP.The nomenclature for intra-articular vertical impact fractures of the tibial plafond: pilon versus pylon.Foot Ankle Int. 2004 Mar. 25(3):149-50.[Medline]

2. Bonin JG.Injuries to the ankle.London: William Heinemann; 1950.

3. Daolagupu AK, Mudgal A, Agarwala V, Dutta KK. A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra articular distal tibial fractures. Indian J Orthop 2017;51:292-8.

4. Bucholz R, Court-Brown C, Rockwood C. Rockwood and Green’s Fracture in Adult. New York: Lippincott; 2015. p. 98.

5. Brumback RJ, McGarvey WC. Fractures of the tibialplafond.Evolving treatment concepts for the pilonfracture.OrthopClin North AM. 1995 Apr.26(2):273-85.[Medline]

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7. Habernek H, Kwasny O, Schmid L, Ortner F, Complication of

interlocking nailing for lower leg fractures: A 3 year follow up of 102 cases. J Trauma 1992;33:863-9.

8. Ram GG, Kumar D, Phagal VV. Surgical dilemma’s in treating distal third leg fractures. IntSurg J 2014;1:13-6.

9. Collinge C, Kuper M, Larson K, Protzman R. Minimally invasive plating of high energy metaphyseal distal tibia fractures. J Orthop Trauma 2007;21:355-61.

10. Kumar D, Ram GG, VijayaraghavanPV.Minimally invasive plate versus intramedullary interlocking nailing in distal third tibia fractures.IOSR J Dent Med Sci 2014;13:15-7.

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References

Con�ict of Interest: Nil. Source of Support: None

How to Cite this ArticleNath R, Singh C, Pal A R. A Prospective Study of Analysis of Functional Outcome of Distal Tibial Fracture Treated by Minimally Invasive Percutaneous Plate. Journal of Bone and Joint Diseases May-Aug 2018;33(2):16-19.

al[28] and Nork et al[13] were comparable to our study.

ConclusionDistal tibial fractures remain a therapeutic challenge for orthopaedic surgeons. �ey are generally associated with so� tissue injuries, so de�nitive �xation is permissible only when so� tissue allows (wrinkle sign present). Most of these fractures are treated by intramedullary nail, open reduction & internal �xation by plate, closed reduction and percutaneous plate �xation or external �xators. Intramedullary nailing has complications like non-union or malunion whereas ORIF by plate has high chances of

wound infection but MIPPO had fewer complications. We didn’t encounter complications like non union and saphenous nerve injury in our study. Incidence of sagi�al plane deformities (recurvatum) is high in plate osteosynthesis hence during traction for reduction, posterior surface of the fracture should be supported, leaving the calcaneus free[10]. Further prospective randomized trials are required to determine the optimal treatment strategy for these injuries.


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5. Article 690 - jbjdonline.comjbjdonline.com/wp-content/uploads/2018/12/5.-Article-690.pdfNath R et al Materials and Methods is was a prospective study, which was done in the department