SLR - September 2020 - Kalen Farr
Reference: Ren D, Wang T, Liu Y, Liu P, Wang P. Treatment of the Tibial Pilon Fractures Using the Antero-Medial Fibula Approach: Ten Case Series. Medicine (Baltimore). 2020;99(28):e20576. doi:10.1097/MD.0000000000020576Scientific Literature Review
Reviewed By: Kalen Farr, DPM
Residency Program: SSM Health DePaul Hospital – St. Louis, MO
Podiatric Relevance: In high impact fracture patterns, the soft tissue envelope is often in danger of dehiscence or necrosis, especially with the large amount of edema associated with pilon fractures. Innovative approaches are necessary to reduce these risks and complications of this surgery, as well as optimize visualization of the fracture fragments for appropriate reduction and fixation.
Methods: This was a case series of ten patients with closed pilon fractures including nine males and one female with a mean age of 36.3. Based on Ruedi-Allgower classification, there were three type I, three type II, and four type III fractures. Anteromedial fibular approach was utilized to reduce and fixate these fractures. Incision healing was evaluated at two weeks, one month, three months, six months, 12 months and 18 months after surgery. All patients were assessed with AOFAS score, ankle ROM, and clinical effects of the incision were analyzed.
Results: Post-operatively radiographs and CT scans were used to assess reduction via Burwell-Charnley system. It was determined that anatomical reduction was obtained in seven cases and satisfactory reduction was obtained in three cases. Two cases required percutaneous minimally invasive plate fixation of medial column fractures. No patients had long lasting neurovascular injury, and nine of the 10 incisions produced good healing, with one incision edge forming tension blisters that healed within two weeks and presented no skin necrosis. All fractures were healed at a mean of 13.7 weeks after surgery. The mean AOFAS score at the last follow-up was 85.6, with excellent results in seven cases and good results in three cases. Mean ankle dorsiflexion was 13.7 degrees and mean ankle plantarflexion was 27.4 degrees.
Conclusions: The authors of this article feel as though the anteromedial fibular approach can help protect soft tissue, reduce wound complications, and allow you to accurately visualize and fix distal tibiofibular fractures while maintaining functional activities of the ankle postoperatively. As a foot and ankle surgeon, soft tissue preservation is paramount due to the sensitive nature and limited real estate in the area. With the above approach, there is adequate space to appropriately reduce the fracture and fixate as necessary, with the added benefit of a safe and reproducible incision. This approach should certainly be discussed and considered in future pre-operative planning and decision making for similar fracture patterns.