Tibial Plafond Fractures

J.L. Marsh, MDProfessor

Dept. of Orthopaedics

Topic Outline

Introduction Incidence Local anatomy and mechanismClassification History and complications Treatment concepts Results Problems for clinical research Future and Conclusions

Introduction

The Spectrum of Fracture

The Spectrum of Soft Tissue Injury

The Injury/Management of the Soft Tissue Envelope is

the Key

Relative Success

Dismal Failure

vs

The Soft Tissue Injury!!

Red Blisters

Clear Blisters

OpenFracture

Tibial Plafond Fractures - Results General Comments

Terrible Injuries

“Excellent Results” are rarely achieved

Fair-Good results are the norm

Outcomes are impossible to predict

Treatment complications must be avoided

Tibial Plafond Fractures - ResultsTerrible Injuries

Tibial Plafond FracturesExcellent results are only rarely achieved

2 yrs.

Unusually good!

Tibial Plafond FracturesFair to Good Results Are the Norm

1991 - anterior B-3 fracture

6 months 3 years

Fair to Good Results Are the Norm

8 years

Fair to Good Results Are the Norm

Ankle score - 80Works as a laborer

Tibial Plafond FracturesOutcomes are impossible to predict

5 years - no painankle score 95Case 1

Tibial Plafond FracturesOutcomes are impossible to predict

6.5 yrs - miserable -

ankle score 45Case 2

Case 1 Case 2

Incidence

Axial LoadingTibial Plafond Fracture

Avg. age 35-40

Rare in children and elderly patients

Males 3 x more common

Associated injuries 25-50%

Increased incidence – Air Bags!!!

Save lives yes, but devastate the foot and ankle

Burgess et al JT 1995Lower extremity injuries in drivers

of air-bag equipped automobiles

Foot injuries impact outcomeof multiply injured patients

Turchin et al JOT 1999Tran and Thordarson Foot and Ankle 2002

Multiply injured patients with and without foot injuries ( 24 and 12 month follow ups)

Dramatic differences in pain, function and health related quality of life

Local Anatomy and Mechanism

Ankle Soft Tissues

? Thin skin? Absent muscle

and adipose tissue? Lack of deep veins

Particularlyvulnerable!

The soft tissues over the anteromedial tibia are vulnerable

Dense trabecular structure of distal tibia

Fracture Mechanics

Bone is viscoelastic Axial load is rapid Shift in stress strain curve Tremendous energy release

Displacement

Load

Stress strain curves for rapid vs. slow rate of loading

Rapid axial load

Slow rotational load

Note the greater energy under

the curve!!

Rotational ankle fracturesare different - good prognosis and

few complicationswith standard techniques

Dense trabecular structure Thin soft tissues Axial Loading Typical fracture pattern Severe soft tissue injury

Classification

Fracture Classification

Our language ofinjury severity

Reudi and Allgower - 1969

Classifying Tibial Plafond Fractures

J Ortho Trauma, 1997

Three studies: Swiontkowski and Sands, et al. Dirschl and Adams Martin and Marsh, et al.

Poor observer agreement! - Kappa .4-.5

Not a usefulresearch tool

Is this a tibial plafond fracture? Does it belong in 43?

Plafond yes!!

C-2?

Or

C-3?

History and Complications

Four principles “stood the test of time”

Anatomical reduction Stable internal fixation

Atraumatic technique

Early pain-free mobilization

“Precise reconstruction of articular surfaces is the goal, and is always preferred to tolerable malalignment”.

These Principals Illustrated for Fractures of the Tibial Plafond

Unfortunately these techniques led to the Dark Ages of

Soft Tissue Management

Ill-Advised

• Extensive surgical approaches

• Fracture stripping

• Prolonged tourniquet times

• Bulky implants

Increased soft tissue injury

A recipe for disaster

}

Limb Threatening Complications

McFerran et al JOT 199221pts (40%) with major complications

require 77 additional operations Wyrsch et al JBJS 1996

3/18 amputations in closed fractures Teeney and Wiss CORR 1993

37% infection and 26% fusion in Type 3’s

Cases Treated1980’sEarly 1990’s

We have learned from our errors!Current techniques emphasize the

soft tissue injury

Delays until surgery

Spanning ex fix part of most protocols

Percutaneous and limited approaches

Complications current techniques

• Spanning ex fx– Marsh et al JBJS 1995 – 43 cases 0%– Wyrsch et al JBJS 1996 – 20 cases 5 %

• External fixation same side– Court Brown et al JOT 1999 – 24 cases 4%– Tornetta et al JOT 1993– 26 cases 7%

• Delayed plating– Patterson and Cole JOT 2001 – 22 cases 0%– Sands et al CORR 1998– 64 cases 6 %– Sanders et al OTA 2002 - 28 cases 14%

0-10%

Treatment Concepts

SpanningExternalFixation

InternalFixation with

Plates

Hybrid, Ilizarov,

Plates/fixator

Current Spectrum of Treatment Techniques

Visualization of the articular reduction Delay until definitive surgery Spanning fixation Fixing the fibula Ankle motion

Things to Think About

Visualization of the Articular Reduction

1. Percutaneous with fluoro 2. Limited3. Extensive

Reduction forceps based on anterolateral incision

1. Percutaneous with fluoro

1. Percutaneous with fluoro

Based on major anterior fracture line

Direct approaches - no stripping

2. Limited

3. Extensive approach Direct visualization of fragments

View articular reduction directly

Preoperative PlanningThe more limited your approaches the more

planning is critical.

Surgical Delay to Definitive Surgery

Has decreased the complication rate! Spanning external fixation maintains length

and mobilizes patient For plating delays average 10-28 days Is there an argument not to delay weeks prior to articular surgery? Are there cases that do not need spanning fixation?

Problem Fracture is short Talus is in

left field Soft tissues are a

disaster Skin further

compromised What do you do?

Spanning fixator!

Problems solved!

Surgical Delay and Spanning External Fixation

Maintains length and alignmentDoes not reduce articular surfaceBetter imaging studiesMobilizes patientPre operative planningOperate on elective listSoft tissue recovery!!!

CASE EXAMPLE

28 y.o. female fell 10 ft. Skin at risk, imaging study useless!

Pre op plan – screwplan noted by arrows

Fracture at lengthGood imaging studies

Percutaneous reduction screw fixation according to plan

15 months

5 yrs, no arthrosis and excellent ankle function

Please note – this excellent result is not the norm withany currently available technique!

For Plating Delays Average 10-28 Days

For percutaneous reductions and external fixation they are less – Why?

Reduce the posteromedial tibia percutaneously? How long can you wait??

Note the spanning fixator does not reduce it!

Typical appearances of limited approach reductionsat 2-10 days after injury

This is too early for extended approach ORIF

But do you need spanning ex fix every time? Not in my practice

Not necessary – cast or splintCalcaneal traction

Temporary Treatment Calcaneal Traction!

Useful when definitive Surgery planned within

A few days

Fixing the fibulaOriginal AO Principles -

Plafond Fractures• Fibular length - PLATE• Articular reconstruction• Cancellous autograft• Buttress plate• Early motion• Long-term non weight bearing

Fibular fixation first step

External Fixation of Tibial Plafond Fractures: Is Routine Plating of the

Fibula Necessary?

Williams T.M., Marsh J.L., Nepola J.V., DeCoster T.A., Hurwitz S. and Bonar S.

J Orthop Trauma 12:16-20, 1998

Reduction - no difference

Ex Fx/Healing time - no difference

Ankle score/Arthrosis - no difference

Complications total - no difference

Fibular plating: caused fibular complications but resulted in less angular malunion

Could fibular fixation have prevented this valgus?

Fibular plating comes with some risk

1) Apply fixator 2) Fix articular surface

Do I want tofix the fibula?

With this technique of spanning ext fixation I almost always say no!

You fixed it -How about ankle motion??

Fixator same side for ankle motion?

Typical Motion inSpanning Frame with hinge

Despite all these techniques to achieve motionno data that ankle motion makes a difference!!

Issues that Relate to Internal vs External Fixation

Visualization of the articular reductiono Extensiveo Limitedo Percutaneous with fluoro

Surgical delay – how long and how do you know?

Plating the fibula – initial, at all? Spanning fixation – always or sometimes Ankle motion

Results

Two Years after Injury

Most have some pain

Most return to work

Detectable arthrosis - 50%

Arthrodesis rare

2 Year Minimum Follow-Up(Range 24-42 mos)

31 patients

Pain Analysis 50% - no/minimal pain 35% - pain with weight bearing 15% - continuous

Marsh et al. JBJS 1995

Measurable Effect on Health and Quality of Life

• Sands et al CORR 1998 - 2-4 years after injury– Delayed plating

• Marsh et al JBJS Feb 2003 – 5-11 years after injury– Spanning external fixation

SF-36: Plafond vs Aged Matched Norms

5-11 years after injury (JBJS Feb 03)

Significantlydifferent

Ankle Osteoarthritis Scale: Plafond 5-11 Years after Injury

Radiographic OA35 Ankles - 5-11 Years after Injury

02468

101214161820

Grade 0 Grade 1 Grade 2 Grade 3

# of patients

Clinical ResultsNot so Bad!

25/33 rated their ankle good or excellent

Motion avg. 75% opposite

Only 2/37 late arthrodesis 5.4%

Plafond-Results

Sequential Ankle Score: 67 at 24 mo, 86 at 92 mo (p<.004)

Time to maximal healing: 2.4 yr (9 mo-5 yr)

Reasonable evidencethat patients improvefor a long time!

Do not be too quick to offerreconstruction!

1986 - 24 yo Male

1 year

7 years

14 years

Works light labor Prefers high top boots Occasional pain Ankle score 80

5 to 11 Years after Injury

Most have some ankle painCan not run or play sportsMeasurable effect on general

health status70% with moderate or severe

arthrosis

Excellent results are only rarely achieved

5 to 11 years after injury

Most rate their outcome as good or excellent

Arthrodesis rate only ~ 5% Most feel they improve for years

Fair to Good Results Are the Norm

Problems forClinical Research

Quality of Reduction Determines Outcome?

Patterson and Cole JOT 1999 - delayed plating

14% fair reductions

Marsh et al. JBJS 1995 - articulated ex fix

30% fair or poor reductions

Late Arthrodesis

Marsh et al. 1995follow-up 30 mos.articulated ex fix

9%

3%

Patterson and Cole 1999follow-up 22 mos.plating

But…how can we compare these studies??

We must have better clinical research than that? Do we?

No! We have big problems indetermining the effect of the

articular reduction!

Injury Severity

Quality of Reduction

For Clinical ResearchWe must Separate ?

Better Reduction Worse Reduction

Reduction QualityAnd

Injury Severity Are Linked!

The Reductions are Different!

But how do you measure that difference?

Better Outcome Worse Outcome

Injury Severity isLinked to outcome!

Quality of reduction

Injury Severity

Patientoutcome

How do you measure reduction?

How do you measure injury!

In Summary for Clinical Research

These problems do not have solutions They provide insight into the difficulties with this

research They hamper our ability to understand the effect

of what we do Many things we thought most important may be

less so as we learn more Articular fractures are a fantastic area for innovative new investigation!

Future and Conclusions

SpanningExternalFixation

InternalFixation with

Plates

Hybrid, Ilizarov,

Pin fixation

Does there have to be one right way?

SummaryHow ever you treat them….

Bad injuries with unpredictable outcomes

Complications – 10% or less Results

Generally not greatBut if you stay out of trouble not awful

Potential to Produce Severe Complications of Treatment

Whatever TechniqueTreatment complications

must be avoided!

• What is effective?

• What works every time?

• What is not worse than the original situation?

Techniques

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