Management and Evaluation of the Outcome in Treatment of Tibial Pilon Fractures

Introduction:  Tibial pilon fractures present a significant management challenge. Currently, the treatment of tibial pilon fractures secondary to high-energy trauma remains controversial. Our objective was to evaluate the effect of surgical treatment one-year post-surgery on the outcome of patients diagnosed with tibial pilon fractures. 

Methodological design: Prospective descriptive study carried out with a cohort of patients over 18 years of age, who were diagnosed with a displaced tibial pilon fracture and treated at the "Calixto García" Hospital by surgical treatment and evaluated one year later.

Results: The sample consisted of 47 patients, 33 men and 14 women with a mean age of 30,6 ± 2,1 years; 18 fractures were in the left side and 29 in the right; sixteen open wounds were identified according to the Gustilo-Anderson classification. In accordance with the AO/OTA classification, 19 were classified as type A, 16 as type B, and 12 as type C. Urgent treatment was applied in 27 cases: 19 with internal fixation, seven with external fixator alone, and 21 with external fixator combined with screws. Consolidation was achieved in 12.9 weeks. Early and late complications occurred, and the majority of outcomes were classified as good.

Conclusions: People with high activity levels (young men) are more prone to tibial pilon fractures, which are often accompanied by soft tissue injuries. These fractures are serious traumatic injuries that can be treated surgically using various methods, but their prognosis is generally guarded.

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French term "pilon" (i.e., pestle) to describe the mechanical function of the distal tibia in the ankle joint. This term has also been used to describe the mechanism involved in tibial pilon fractures, in which the distal tibia acts like a pestle, exerting strong axial forces on the talus, which essentially causes the tibia to fracture [1,2]. Tibial pilon fractures present a significant management challenge for most orthopedic surgeons due to their frequent association with bone comminution and soft tissue injury, which increases the risk of wound dehiscence, infection, and pseudoarthrosis. This is further compounded by the fact that the optimal therapeutic approach for these serious injuries remains unknown [3,4]. The treatment of distal intra-articular tibial fractures has evolved over the last century. Historically, due to the scarcity of available implants and the poor results obtained with surgical treatment, these fractures were considered inoperable, and conservative measures were advocated [5]. In an effort to improve patient outcomes by reducing immobilization time, Learch [6] favored open reduction and internal fixation of the fibula and non-surgical treatment of the tibia. Subsequently, Rouff and Zinder [7] advocated for internal fixation of the fibula and minimal internal fixation of the tibial fragments. Some authors, such as Witt,[8] Weber,[9] Cox and Laxon,[10] and Müller,[11] proposed performing a tibiotalar arthrodesis as a first step for comminuted fractures, given the poor functional results obtained. 

In patients recovering from pilon fractures, long-term ankle function impairment was observed, reaching approximately 75% of full functional capacity, with patients reporting walking difficulties up to three years post-surgery. This highlights the severe disability often associated with these injuries [12,13]. Currently, the treatment of tibial pilon fractures secondary to high-energy trauma remains controversial. Most authors agree that surgical treatment of these injuries should be tailored to the degree of soft tissue damage, the fracture pattern (fracture personality), and the surgeon's experience, although the condition of the surrounding soft tissues ultimately determines the therapeutic approach. Two studies have recently been published describing a two-phase surgical protocol that has improved outcomes for severe intra-articular fractures [14,15]. Our objective was to evaluate the effect of surgical treatment one year after its performance on the outcome of patients diagnosed with fractures of the tibial pilon.

Prospective descriptive study carried out with a cohort of patients over 18 years of age, who were diagnosed with a displaced tibial pilon fracture and treated at the "Calixto García" Hospital by surgical treatment and followed up for tibial pilon fracture; operated on between January 2018 and August 2024 and evaluated one year later. The sample consisted of 47 patients, 33 men and 14 women.

A total of 59 potentially eligible patient, the sample was limited to 47 patients after the application of inclusion and exclusion criteria. Of them, 14 were women (28,9%) and 33 men (70,1%) with a mean age of 30,6 ± 2,1 years. The médium was 29,3 years with a range between 20 to 54. There were 18 fractures in the left side and 29 in the right; Most fractures were closed in a total of 31 patients (66.0%), while of the open fractures, with 16, the soft tissue injuries were predominantly type 2 according to the Gustilo-Anderson classification in 11 cases (69.0%). We think that the type of fracture according to the AO/OTA classification can influence both the consolidation time and the possible complications that could arise. It should be noted that there was no predominance of any of the types of fractures studied. The fractures were classified, according to AO/OTA as: 19 type A (8A1, 6A2 and 5A3); 16 type B (6B1, 5B2 y 5B3) and 12 type C (4C1, 5C2 and 3C3). All of this is visible in table 1.

Table 1: Biomedical variables of the sample.

Source: Data collection form.

Of the total number of fractures treated, urgent surgical treatment was performed on 27 occasions; this group includes 16 open fractures and 11 others, where the decision was always made with the premise that the soft tissue injury allowed it. The anteromedial approach was the most frequently used in our series, with a rate of 48%.

The surgical management of the 47 cases was as follows:

Nineteen cases (40,4%) were treated by internal osteosynthesis alone including (the isolated screwed plate in seven cases, associated with screwing in nine cases, associated with pinning in one cases and simple screwing in two cases). In 2 cases (4%) were treated by external osteosynthesis alone. In 28 cases (59,6%) were treated with external fixation; seven alone and 21 with combined treatment. This is visible in table 2.

Table 2: Repartition of the patients according to the type of surgical treatments.

Source: Data collection form.

The average post-surgical hospital stay was 27 days, with a minimum duration of five and a maximum of 67 days in some cases of open fracture. The mean period until consolidation of 12,9 ± 1,5 weeks with the median in 10 (range 9-14 weeks). That is shown in table 3.

Table 3: Time to consolidation

Source: Data collection form.

In our study, we observed two categories of complications: those occurring close to the surgical procedure (skin necrosis in two cases, infection in six cases) and those occurring later (malunion in nine cases, trophic disorders in five, and osteoarthritis in four). After 24 months, our patients were evaluated, and we observed the best and good results in 33 cases, fair results in nine cases, and poor results in five cases, according to the Olerud and Molander score (OMAS) [37,38] Table 4.

Table 4: Repartition of the patients according to the Olerud and Molander score (OMAS).

Source: Data collection form.

Tibial pilon fractures are uncommon and usually occur after high-intensity trauma in young people. Most authors report a predominance of young males, as well as high-energy trauma, whether from traffic accidents or falls from a height, which is comparable to our study [4,5].

In our study, the mean age was 30.6 years, and the male-to-female ratio was 2.5. These results coincide with those published in the literature, which can be explained by the hyperactivity of young people in their socio-professional activities to satisfy their needs, which exposes them to work-related or traffic accidents [16,17].

Tibial pilon injuries are classified by numerous authors. According to De las Heras and Milenkovic, [18,19] type C tibial pilon fractures represent 45% of tibial pilon fractures; Imren20 in his series, reported that they represented 43% of all tibial pilon fractures in his sample. The fractures in our study, according to the AO/OTA classification, showed terminal figures among the three different groups of this classification, with 19 type A (40.4%), 16 type B (34.0%), and 12 type C (25.6%).

The surgical treatment employed in this study included various methods, from simple screw fixation of articular fragments combined with external fixation, to the placement of a single or multiple anatomical plate, or simple or combined external fixation, always aiming for the correct correction of the anatomy of the articular surface and the alignment of the axis of the affected lower tibial segment. 

Tibial pilon fractures have always presented a challenge for surgeons due to their association with soft tissue injuries and some degree of associated bone comminution, which worsen the prognosis. For these reasons, surgery should preferably be performed urgently. Otherwise, it should be considered a deferred emergency. [21,22] In our series, [27] times urgent surgical treatment was performed, with an average operative time of 4 days, with a great influence of open fractures (No=16, 34.0%) that were all treated urgently. Open surgical treatment was mainly used in cases of type C1/C2 fractures, in cases of moderate skin lesions and closed surgical treatment was mainly used in cases of type C3 fractures and in cases of severe skin lesions.

The anteromedial approach was the most frequently used in our series, with a rate of 48%, which is consistent with the findings of several authors: Heim,[23] Mandracchia,[24] Aerlettaz,[25] Helfet [26] and Sirkin,[27] followed by the anterolateral approach. Surgical treatment utilizes different means and methods. Our approach was comparable to that of Heim,[23] who subdivided the steps of internal osteosynthesis into 4 stages: 

1) Fibular osteosynthesis to restore leg length and facilitate reduction. 

2) Anatomical reduction of the tibial articular surface. 

3) Filling of the cancellous bone deficiency with an autologous graft. 

4) Internal support and epimetaphyseal union in the diaphysis. 

According to Bbis's series of 48 patients,28 external fixation represents a therapeutic option when there is a skin opening or a closed fracture with high-risk skin lesions or communication. Several other authors concur with this opinion [29-31]. 

In our series, patients who benefited from combined treatment (external fixator + minimal internal fixation) presented with complex fractures, C2 or C3 type, open fractures, or fractures with soft tissue injury. Internal fixation, on the other hand, was mostly performed in patients with C1 type fractures or those with moderate skin lesions.

Infection is one of the main postoperative complications. It can be serious, affecting both soft tissues and the sequelae. In our study, six cases of infection occurred, representing 12.8% of the total. According to Heim,[23] infection complicates closed fractures in 2.5% of cases. Sirkin,[32] in his series, obtained better results, with a 2% rate of superficial infections. On the other hand, regarding the rate of deep infections, our results are better than those of Silluzio,[33] with a rate of 28%, and those of Bacon,34 who reports a rate of 40% of deep infections in 42 C3 tibial pilon fractures. 

Skin necrosis is a frequent and serious complication, as it complicates a fracture located in a complex anatomical area and is difficult to correct due to the superficial location and poor vascularization of the region; its rate varies from 9% to 15%. [32,35] We had skin necrosis in two cases that required flap coverage. 

The rate of postoperative malunion varies between series, from 3% to 16%.32,36 In our series, it reached 19.1% with nine cases. Similarly, we found trophic disorders in five patients. 

Osteoarthritis is one of the most important and feared complications. Most studies mention it. [4,12,13] In fact, there is a correlation between fracture type, the incidence of osteoarthritis, and poor clinical outcomes. Most authors place its frequency between 20% and 50% of cases; [14,16,17] in our series, we found four cases at the one-year follow-up, for a frequency of 22%. 

Our therapeutic results were evaluated according to the Olerud and Molander score (OMAS) [37,38] with a good result in 33 cases, an average result in nine cases, and a poor result in five cases. The majority of good results were found in type C1 fractures, with a rate of 19 cases, while type C3 fractures had poor results in four cases. 

Young, active men are more prone to tibial pilon fractures, which are frequently accompanied by soft tissue injuries from the outset (open fractures) or as a consequence of characteristics specific to the distal leg region. Tibial pilon fractures are serious traumatic injuries, as they compromise long-term functional prognosis in young individuals. Although open internal fixation generally offers good functional results, and despite frequent complications (infections, skin necrosis, loss of alignment), closed treatment with an external fixator, with or without osteosynthesis, has shown, according to some authors, good functional and radiological results, especially in highly comminuted C3 fractures and severe skin injuries.