Patient characteristics
This study was performed under approval by the human ethics committee of the institution. Twenty-five patients were initially entered into this study, but only twenty were available for evaluation at the final follow-up. Characteristics of the twenty patients included in this study are presented in Table 1. Between March 2015 and September 2018, twenty patients (15 male and 5 female) with a mean age of 45.2 years (range: 19-68) underwent tibiotalar joint reconstruction using a large autologous ilium with periosteum harvested from the iliac crest (Figure 1). The inclusion criteria were: Rüedi-Allgöwer III pilon fractures, closing wound, Tscherne-Gotzen I-II soft tissue injury, no episodes of compartment syndrome, and no exudation or skin shrinkage. The exclusion criteria were: Rüedi-Allgöwer I or II pilon fractures, opening wound, Tscherne-Gotzen III soft tissue injury, and patients lost to follow-up.
Pre-operative radiographs and 3D reconstructed computed tomography (CT) images were obtained to assess the severity of joint comminution, impaction, and displacement of fracture fragments (Figure 2A). The visual analog scale (VAS) during daily activities and American Orthopaedic Foot & Ankle Society (AOFAS)[11] scores were recorded prior to surgery. These served as baseline data for comparison during follow-ups.
Surgical technique
Doppler ultrasonography was used to screen for deep vein thrombosis prior to commencing surgery. Surgery was performed under general anaesthesia or combined spinal-epidural anaesthesia in the float position under tourniquet control by a senior surgeon. The fractures were carefully protected and collected, and constructed stepwise according to procedures published by Rüedi and Allgöwer.[12] In 5 patients, ORIF was performed using an anteromedial combined with back-lateral surgical approach,[13] while in the other 15 patients an anterolateral combined with back-medial approach was used.[14] Alternative and supplemental approaches were used as required depending on the fracture pattern and soft tissue situation.
A large full-thickness autologous ilium (5 cm × 5 cm) was harvested from the patient’s iliac crest, consisting of cancellous bone with periosteal lamellae on each one side (Figure 1B). The distance between skin bridges was maintained at larger than 7 cm. A clear view of the entire plafond and talus was obtained after distraction of the ankle joint with the tensor and removing the fracture fragment (Figure 1C). The concave side of ilium with periosteum (about 1 cm thickness) was implanted directly into the residual subchondral bone using a k-wire, with the articular surface of the talus as template (Figure 2B). Cancellous bone from the graft was used to fill the bone defect following reduction of the articular segment (Figure 1D).
Fixation of the medial column was performed fundamentally with temporary k-wires, and small fragment screws were applied to give stability to the fracture site. The reconstructed tibiotalar joint and plafond were fixed by anatomically locked pates, which provided initial fixation and the ability to perform soft exercise (Figure 1E). Donati vertical mattress sutures were used to close the wound.[3] Post-operative radiographs were taken on the next day of surgery and at the latest follow-up (Figure 2C, D).
Post-operative management
All patients remained in splint or cast immobilisation until the wounds have healed and sutures could be removed. All patients commenced ankle motion exercises the day after operation or as soon as possible. Non-weight bearing movements were introduced thereafter, with progressively increasing amounts of weight bearing (10-15 kg) and range of motion. Patients resumed full weight bearing upon clinician recommendation based on fracture pattern and radiographic findings at follow-up. Prophylaxis for deep vein thrombosis was provided with the use of sequential compression garments and/or low molecular weight heparin throughout the time that the patient was hospitalised and during bed rest, until a maximum period of 14 days.
All patients were required to return for follow-up at 1, 3, 6 and 12 months after surgery, and each year thereafter. At follow-up, the progress of wound healing and any complications were recorded, and outcomes were evaluated using the VAS and AOFAS scores,[11] the range of motion of the ankle joint (Figure 2E), and radiographs which were used to assess the quality of fracture reduction, stability of fixation, and fracture alignment and union according to Burwell and Charnley criteria[15] (Figure 2C, D). Three patients were asked to undergo MRI examination to show the integrity of the distal tibia (Figure 2F). Implant removal was performed at 1-2 years post-operation, after the bone remodelling process was complete.