Neglected Tibial Pilon Fractures: Can Arthrodesis Be Avoided?

SLR - September 2018 - Adel Aitali

Residency Program: Cedars Sinai Medical Center, Beverly Hills, CA

Podiatric Relevance: Intra-articular distal tibial fracture can be a devastating injury. The mechanism of injury can lead to extensive soft-tissue injuries, displacement, articular comminution and overall poor outcomes. Management of these injuries falls into two general categories of reconstruction with ORIF or fusion if reconstruction is not possible. This article provides the podiatric surgeon with a possible alternative to arthrodesis of the ankle joint in neglected pilon fractures. The purpose of this study was to evaluate the radiographic, clinical and functional outcomes of the management of neglected pilon fractures by the Ilizarov external fixator and to evaluate whether this technique was successful in avoiding an ankle arthrodesis.

Methods: This was a retrospective study, which included 18 unilateral pilon fractures between January 2003 and March 2015, eight fractures were type 43-C2 and 10 fractures were type 43-C3. The mean age was 42.17 years (range: 33–55; SD 6.82). Six patients were women and 12 were men. All fractures had presented more than a month without definitive treatment. They were a result of traumatic motor vehicle accidents or fall from a height. They were managed with circular fixation, and had a minimum follow-up of at least a year and a half. Outcomes were based on tibial alignment measuring the lateral distal tibial angle, the anterior distal tibial angle. Quality of reduction, arthrosis assessment, range of motion and functional assessment were all determined.

Results: It was found that all fractures successfully healed. At the last follow-up, mean ankle dorsiflexion was 8.67 degrees. Mean plantarflexion was 25.67 degrees. Three ankles had complete elimination of range of motion, which was done in prelude to arthrodesis. ROM was excellent in seven cases, good in six cases and poor in five cases. The hindfoot motion was normal or mild restriction in seven cases, moderate restriction in eight cases and marked restriction in three cases. Mild occasional pain was reported by four patients. Five workers changed to light jobs, including the three who underwent arthrodesis. Fifteen patients were walking without ambulatory aids and had returned to activities of daily living. The mean AOFAS score was 82.67. There was a significant positive correlation between the AOFAS score and reduction quality, between AOFAS score and ROM grade and between follow-up and arthrosis. There was a significant negative correlation between the AOFAS score and age. There was no correlation between the ankle-spanning duration and ROM grade.

Conclusions: The authors demonstrated satisfactory management of neglected pilon fractures using the Ilizarov fixator with a relatively low complication rate and the avoidance of arthrodesis in 15 of 18 cases. Early surgical intervention is paramount in successful treatment of pilon fractures. Traditionally, these delayed fractures would almost certainly be treated with arthrodesis and sacrifice range of motion to offset a painful osteoarthritic joint. The approach these authors discuss demonstrated that even in delayed surgical cases, as late as 15 weeks' postinjury, reduction could still be achieved, allowing for preservation of range of motion, return to activities of daily living, return to work and overall patient satisfaction.