Patients
The data from 64 patients with type-C3 pilon fractures who met the exclusion criteria between June 2018 and June 2022 were retrospectively analyzed. The patients were divided into two groups according to whether a miniplate was used during the surgery. There were 31 patients in the miniplate group (miniplate, MP) and 33 patients in the traditional treatment group (traditional treatment, TT). Of these, there were nine cases of traffic accident injury, 19 cases of high-fall injury, and three cases of smashing injury in the MP group, and nine cases of traffic accident injury, 20 cases of high-fall injury, and four cases of smashing injury in the TT group. The average age of the patients in the MP group was 40.26 ±2.49 years and of those in the TT group was 39.58 ±2.60 years. All patients were of the type-C3 according to the AO/OTA classification. Other general data are presented in Table 1.
Table 1 Comparison of general characteristics between the two groups of patients
Patients
|
TT group (n=33)
|
MP group (n=31)
|
t/ꭓ2 value
|
P value
|
Age (years)
|
39.58±2.60
|
40.26±2.49
|
-1.073
|
0.288
|
Sex (n, F/M)
|
20/13
|
18/13
|
0.043
|
0.836
|
Side (n, L/R)
|
17/16
|
16/15
|
0.000
|
0.994
|
BMI (kg/m2)
|
24.58±2.53
|
24.81±2.75
|
-0.349
|
0.728
|
Smoking (n)
|
23/10
|
20/11
|
0.195
|
0.659
|
Open/Close (n)
|
8/25
|
6/25
|
0.223
|
0.636
|
Causes of injury (n)
Fall from height
Car accident
Hit by heavy object
|
20
9
4
|
19
9
3
|
0.106
|
0.948
|
BMI, body mass index; F, female; M, male; L, left; R, right; MP, miniplate; TT, traditional treatment
This study was approved by the hospital ethics committee, and all patients provided informed consent. The inclusion criteria were as follows: type-C3 pilon fracture based on AO/OTA classification; age >18 years and <60 years; follow-up duration >1 year and complete clinical data; and open reduction and internal fixation. The exclusion criteria were as follows: old fracture; open fracture; and malfunction of ankle joint before injury, such as traumatic arthritis, congenital ankle deformity, and Kaschin-Beck disease.
Surgical Procedure
Preoperative management
After admission, all patients underwent calcaneal tubercle traction, improved ankle joint position and lateral radiography, computed tomography (CT) in the coronal and sagittal planes, and articular surface reconstruction to determine the fracture of the affected limb (Fig 1). The affected limb was raised and local ice compression, mannitol, and other detumescence treatments were applied, following which the soft tissue swelling subsided, and skin wrinkles were observed after open reduction and internal fixation.
Surgical Technique
The limb was slightly internally rotated followed by a small medial incision, approximately 15-cm long, along the fibula crest. On slight medial deviation at the ankle level, the fractured end of the fibula was exposed, which was then cleaned, reduced under direct vision, affixed with a 3-tube steel plate, and the fibula fracture was fixed with screws. The extensor support band was opened and the muscles of the anterior group of the leg were pulled to the inside to expose the fractured end of the distal tibia and clean the blood clots. A small external rotation of the affected limb; posterior medial incision of the skin; incision of the skin, subcutaneous, and fascial periosteum; exposure of the medial and posterior ends of the tibia; cleaning of the incarcerated periosteum and tissue at the fracture end; traction reduction; and fixation of the posterior and medial fracture segment of the lower end of the tibia with two 1 × 3 titanium plates were used to maintain the position of the force line and ankle joint. After the medial and posterior malleoli were treated through the anterolateral incision, the fracture of the distal tibia was crushed. In the MP group, large bone fragments were fixed with a 2.7-mm miniplate. Finally, bone fragments of the distal tibial joint were prepared and reduced, and the fracture was temporarily fixed with a 1.2-mm Kirschner wire. After a good ankle reduction, L-type titanium plates were placed on the anterolateral side. In the TT group, the larger bone mass was temporarily fixed with a Kirschner wire or plate and the main plate was placed anterolaterally after good ankle joint reduction. After the surgery, the operative field was irrigated, the negative-pressure drainage device was retained, and the incision was sutured layerwise and bandaged with gauze and cotton pad. The postoperative data are shown in figures 2 and 3.
Postoperative Care and Rehabilitation
After the surgery, the gauze covered with an elastic bandage was slightly pressurized, the affected limb was adequately raised, and routine treatment was administered, such as detumescence, analgesia, anti-inflammatory agents, and prevention of blood thrombus. The wound dressing was changed 24 hours after the surgery, and the active flexion and extension of the toe and ankle joints began to be exercised 2 days after the surgery with a gradual increase in the exercise intensity. One month after the surgery, according to the results of the radiographic re-examination, the affected limbs were subjected to weight-bearing exercises until normal walking was achieved.
Observation Assessment
Perioperative data, including the duration of waiting before surgery, surgery, hospital stay, and weight-bearing, were recorded. Postoperative complications, such as incision infection, incision non-union, deep venous thrombosis, and fracture non-union, were closely observed. According to the Burwell–Charenley radioactive reduction standard, the reduction was divided into anatomical, fair, and poor reductions. Six months after the surgery, the fracture healing was evaluated using the modified Radiographic Union Scale for Tibial fractures (mRUST) (1= no callus, 2 = callus formation, 3 = bridging callus, and 4 = remodeling). The sum of callus formations in the four cortices was calculated. mRUST score with a cut-off value of ≥ 11 was considered as high callus and < 11 as low callus. During the follow-up period, the functional activity range of motion (ROM) of the affected limb was recorded, and the clinical effect was evaluated according to the visual analog scale (VAS) and American ankle-hindfoot score (American Orthopedic Foot and Ankle Society [AOFAS]).
Statistical analysis
Statistical analyses were performed using SPSS 26.0. The measurement data are expressed as x̅±s. When the data were normally distributed, the independent sample t-test was used for comparison between the two groups, and the rank-sum test was used when the data were not normally distributed. Counting data were analyzed by the ꭓ2 test or Fisher’s exact test. The difference was considered statistically significant if P < 0.05.