OTA 1999 Posters

High-Energy Tibial Plafond Fractures: Where Does Ilizarov Technique Fit In?

Robert J. Feibel MD; Philip Fleuriau Chateau MD, University of Ottawa, Ottawa Hospital, General Campus, Ottawa, Ontario, CANADA

The Rüedi-Allgöwer (R-A) classification has been used to describe tibial plafond fractures: Type I and II, low-energy rotational injuries; Type III axial loading and crush injuries of the articular surface. The purpose of the study was to examine the results of Ilizarov treatment of Type III fractures using a prospective algorithm for: limited internal fixation-ring fixation; primary ankle arthrodesis (PAA); or bone transport with PAA. Type III fractures were sub-classified as:

Type III-A Acceptable for limited internal fixation, Ilizarov ring fixation; Type III-B Bone and cartilage loss, greater than one-third articular surface; Type III-C Corticotomy of proximal tibial metaphysis - Ilizarov bone transport and ankle fusion due to segmental loss of the distal tibia.

A chart review and clinical assessment were completed for all patients referred to the senior author between 1994 and 1998. The follow-up interval, time in fixator, period of cast immobilization, pin-site and general complications were recorded in a prospective manner and alterations of the mechanical axis, subsequent interventions and nonunion examined. Type III-A fractures were treated by delayed open reduction through an anteromedial incision, and Type III-B patients underwent PAA.

Sixteen patients were treated. The mean patient age for the entire group was 49.2 years (range 21-77 years). Type III-A, 11 patients; III-B, 2 patients; III-C, 3 patients. The mean follow-up interval was 21.6 months for the entire group and 30.4 months for patients sustaining Type B and C injuries. Mean time in frame: Type A, 100 days; B, 95 and 138 days; C, 11 months (range 9-12). The mean segmental defect was 6.8 cm. (range 4.5-8 cm.) Complications according to sub-group were: A, 1 nonunion, 1 osteomyelitis, 3 wound necroses not requiring surgery, 1 fusion for arthritis; B, no infection or malunion; C, 1 nonunion, 1 deep wound infection, 1 valgus procurvatum proximal tibial regenerate, 1 free flap with initial reconstruction.

Pin site complications may be avoided by utilizing low-profile plating delayed AO technique rather than a ring fixator. The relatively short period of Ilizarov frame immobilization for III-B PAA resulted in a more rapid recovery. Traditional methods of PAA for acute plafond fractures had been associated with higher rates of malunion, but this was not observed in this study. Gustilo observed that subtypes of Type 3 open tibial fractures differed in prognosis and later expanded this group to 3 sub-classes. A similar observation is noted for R-A Type III tibial plafond fractures and may be used as a guide to treatment. Type III-B and III-C patients require referral for subspecialty care.