SLR - June 2020 - Nicole L. Zahn
Reference: Benjamin Lurie, BA, Noelle Van Rysselberghe, MD, Andrew T. Pennock, MD, and Vidyadhar V. Upasani, MD. Functional Outcomes of Tillaux and Triplane Fractures with 2 to 5 Millimeters of Intra-Articular Gap. J Bone Joint Surg Am. 2020;102:679-86Scientific Literature Review
Reviewed By: Nicole L. Zahn, DPM
Residency Program: Bethesda Hospital East/West – Boynton Beach, FL
Podiatric Relevance: This article addresses nonoperative vs operative treatment of transitional fractures with remaining 2-5 millimeter gapping after manual closed reduction. This continues to be a somewhat controversial topic with no real consensus as to if non-operative or operative treatment result in better functional outcomes.
Methods: Between 2009-2017 a retrospective review of patients ages 8 -18 treated for closed distal tibial fractures at a single level-I trauma center was conducted. CPT codes were utilized for the initial search and then CT images were reviewed. Tillaux and triplane fractures with 2 to 5 millimeters of displacement (either gap or step-off) at the articular surface of the tibial plafond were identified. Only patients with CT scans obtained after closed reduction were included. Additional inclusion criteria: all patients have immediate post-treatment and follow-up ankle radiographs available for review and patients answered the Foot and Ankle Ability Measure (FAAM) questionnaire over the telephone at a minimum of two years after treatment. Nine potential predictors: follow-up, maximum step-off, maximum gap, sex, treatment group, grade-III complication, fracture classification, presence of tibial comminution and concurrent fibular fracture, were initially included in the multivariable regression.
Results:
• 57 patients (34 with triplane fractures and 23 with Tillaux fractures) with a 2-5 millimeter intra-articular gap
• 32 male/25 female
• Mean follow-up 2.0 to 9.2 years
• 34 treated operatively (31 ORIF, three with closed reduction and percutaneous fixation), 23 were treated with closed reduction and cast application
• Tillaux and triplane fractures had similar mean patient age, follow-up, gap, and step-off and were treated operatively with similar frequency and had similar functional outcomes; the mean FAAM Sports score was 91.6 percent ± 16.2 percent for Tillaux fractures and 87.5 percent ± 21.3 percent for triplane fractures
Conclusions: It is commonly thought that transitional fractures with > 2 millimeters gapping or intra-articular displacement benefit most from surgical stabilization, however, current literature supporting this theory, specifically when evaluated on CT vs standard radiographs is scarce. This study found that intra-articular gap and nonoperative treatment were negative predictors of both functional outcome measures. Despite the operative group having more complications post-operatively, operative treatment was a positive predictor of functional outcome in the multivariable models. Categorically, there was no difference in the mean FAAM Sports or SANE Sports scores between the two treatment groups.
Once again it seems that nonoperative treatment remains standard of care for intra-articular transitional fractures with approximately 2 millimeters of gap. Patients who were treated nonoperatively and had >2.5 millimeters of gap had significantly worse results than those patients with < 2.5 millimeters of gap (75 percent compared with 90 percent). Therefore, I believe this study supports that operative treatment may have the greatest benefit of outcome when the intra-articular gap exceeds 2.5 millimeters.