Formosan Journal of Musculoskeletal Disorders

Type of article: Original Article

Staged Minimally Invasive Osteosynthesis with Non-anatomical T-shaped Locked

Plates for Intraarticular Tibial Plafond Fractures
--Manuscript Draft--

Manuscript Number:

Article Type: Original Article

Keywords: Intraarticular tibial plafond fracture; staged operation; minimally invasive

osteosynthesis; locked plate

Corresponding Author: Chin-Hsien Wu, M.D.

E-Da Hospital
Kaohsiung, Kaohsiung TAIWAN

First Author: Siang Hsu, M.D.

Order of Authors: Siang Hsu, M.D.

Ching-Hou Ma, M.D.

Yuan-Kun Tu, M.D.

I-Ming Jou, M.D.

Chin-Hsien Wu, M.D.

Manuscript Region of Origin: TAIWAN

Abstract: Background

There are many literatures that assessed the outcome of extraarticular tibial plafond
fractures following staged minimally invasive osteosynthesis with different locked plate.
This retrospective study was designed to assess the outcome of intraarticular tibial
plafond fractures following staged minimally invasive osteosynthesis with non-
anatomical T-shaped locked plates.

Objectives

Taiwan National Health Insurance is considering to enroll the non-anatomical LCPs

into a benefit package recently. For tibia plafond fracture patients, non-anatomical T-
shaped locked plates may be a good choice for patients who were not able to afford
the anatomical anterolateral locked plate.

Materials and methods

From April 2010 to October 2016, eighteen consecutive patients with intraarticular
fractures of tibial plafond were treated by staged minimally invasive non-anatomical T-
shaped locked plate osteosynthesis. The median patient age of the nine women and
nine men at the time of surgery was 49 (22 to 71). First stage treatment consisted of
radical debridement followed by external skeletal fixation; second stage treatment
consisted of minimally invasive osteosynthesis with non-anatomical T-shaped locked
plates. We also identified factors that were predictive of poor results or delayed
union/nonunion of the fractures. Factors such as age, gender, open fracture, fracture
severity, concomitant injuries, presence of comorbidities and presence of arthrosis
were analyzed.

Results

At 6 months of follow-up, three patients (17%) had delayed/nonunion, according to the

radiographic definition of nonunion. At the final follow-up 17 of 18 patients (94%)
achieved union, while 1 (6%) did not. Patients with open fractures and concomitant
injuries tended toward poor clinical and radiographic results.

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 Conclusion

We found a high rate of satisfaction and union and few complications with staged
minimally invasive osteosynthesis with locked plates for treatment of patients with
intraarticular tibial plafond fractures. We believe that this technique is an effective and
safe procedure for treatment of tibial plafond fractures.

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Title Page (Author Information, COI, ethical clearance,
acknowledgement)

Type of article: Original Article

Title of the article: Staged Minimally Invasive Osteosynthesis with Non-anatomical T-

shaped Locked Plates for Intraarticular Tibial Plafond Fractures

Running title: Using Non-anatomical Locked Plates for Intraarticular Tibial Plafond

Fractures

Siang Hsu, M.D.1, Ching-Hou Ma, M.D.1,2, Yuan-Kun Tu, Ph.D. 1,2,
I-Ming Jou, Ph.D. 1,2, Chin-Hsien Wu, M.D. 1,2

1. Department of Orthopedics, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan

2. School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan

Correspondence and reprint requests should be made to: Chin-Hsien Wu, MD

Department:
1. Department of Orthopedics, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan
2. School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan

No.1, E-Da Road, Yan-Chau District, 824, Kaohsiung City, Taiwan

Tel: 886-7-6150011 ext. 2972

Fax: 886-7-6150913

E-mail: wuch2727@gmail.com

Total number of pages: 22

Total number of photographs: 14
Word counts
for abstract: 291
for the text: 2678
Source(s) of support: 4

Declaration of Conflicting Interests: The authors did not have association or financial
1
involvement with any organization or commercial entity having a financial interest in or
financial conflict with the subject matter or research presented in the manuscript.

Funding: The authors did not receive outside funding or grants in support of their research for
or preparation of this work.

Ethical Approval: This retrospective study was approved by the institutional review board.
The protocol No. was EMRP-103-051.

2
transfer agreement
conflict of interest
Manuscript (All Manuscript Text Pages in MS Word format,
including References and Figure Legends)

Staged Minimally Invasive Osteosynthesis with Non-anatomical T-shaped Locked Plates

1
2 for Intraarticular Tibial Plafond Fractures
3
4
5 ABSTRACT
6 Background : There are many literatures that assessed the outcome of extraarticular tibial
7
8 plafond fractures following staged minimally invasive osteosynthesis with different locked
9
10
11 plate. This retrospective study was designed to assess the outcome of intraarticular tibial
12
13 plafond fractures following staged minimally invasive osteosynthesis with non-anatomical T-
14
15
16 shaped locked plates.
17
18 Objectives : Taiwan National Health Insurance is considering to enroll the non-anatomical
19
20
21 LCPs into a benefit package recently. For tibia plafond fracture patients, non-anatomical T-
22
23 shaped locked plates may be a good choice for patients who were not able to afford the
24
25
26
anatomical anterolateral locked plate.
27
28 Materials and methods: From April 2010 to October 2016, eighteen consecutive patients
29
30 with intraarticular fractures of tibial plafond were treated by staged minimally invasive non-
31
32
33 anatomical T-shaped locked plate osteosynthesis. The median patient age of the nine women
34
35 and nine men at the time of surgery was 49 (22 to 71). First stage treatment consisted of
36
37
38 radical debridement followed by external skeletal fixation; second stage treatment consisted
39
40 of minimally invasive osteosynthesis with non-anatomical T-shaped locked plates. We also
41
42
43
identified factors that were predictive of poor results or delayed union/nonunion of the
44
45 fractures. Factors such as age, gender, open fracture, fracture severity, concomitant injuries,
46
47 presence of comorbidities and presence of arthrosis were analyzed.
48
49
50 Results: At 6 months of follow-up, three patients (17%) had delayed/nonunion, according to
51
52
53 the radiographic definition of nonunion. At the final follow-up 17 of 18 patients (94%)
54
55 achieved union, while 1 (6%) did not. Patients with open fractures and concomitant injuries
56
57
58 tended toward poor clinical and radiographic results.
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61 1
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 Conclusion: We found a high rate of satisfaction and union and few complications with
1
2 staged minimally invasive osteosynthesis with locked plates for treatment of patients with
3
4
5 intraarticular tibial plafond fractures. We believe that this technique is an effective and safe
6
7 procedure for treatment of tibial plafond fractures.
8
9
10
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12 Key Words: Intraarticular tibial plafond fracture, staged operation, minimally invasive
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osteosynthesis, locked plate.
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 INTRODUCTION
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2 Tibial plafond fractures account for fewer than 10% of all tibial fractures and remain a
3
4
5 challenging problem for orthopedic surgeons.[1,2] Reudi and Allogrower (1969) reported
6
7 successful results with four principles of primary open reduction and internal fixation for
8
9
10 tibial plafond fractures in 1969.[3] Recently these fractures have become more frequent
11
12 because of the advent of air bags in motor vehicles to protect occupants from deadly chest and
13
14
15
abdominal trauma, which allows patients to survive accidents that produce high-energy lower
16
17 extremity trauma.[4] In the past few decades many reports showed serious wound
18
19 complications including wound breakdown and infection when applying the principles of
20
21
22 primary open reduction and internal fixation for treatment of complicated fractures.[5-7]
23
24 Thus, management strategies have changed to use of external fixation due to wound
25
26
27 complications with internal fixation.[8-10] However, the use of external fixation sometimes
28
29 results in nonunion and malunion of the bones.[11-13] The newly developed, so-called
30
31
32 minimally invasive osteosynthesis with anatomical locked plates is successful in
33
34 multifragmentary distal tibia fractures in both extraarticular fractures[14-16] and intraarticular
35
36
tibial plafond fractures.[17-19] Given that anatomical implants had been widely promoted and
37
38
39 used, non-anatomical pre-contoured locked plate seemed to fade out of the stage recently. In
40
41 2004, Redforn et al. reported minimally invasive osteosynthesis with non-anatomical pre-
42
43
44 contoured locked plate may be applied in extraarticular metaphyseal distal tibia fractures
45
46 successfully.[20] We designed this study to assess the outcomes of intraarticular tibial plafond
47
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49 fractures following staged minimally invasive osteosynthesis using non-anatomical T-shaped
50
51 locked plates.
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 PURPOSE
1
2 Taiwan National Health Insurance is considering to enroll the non-anatomical LCPs into a
3
4
5 benefit package recently. For tibia plafond fracture patients, non-anatomical T-shaped locked
6
7 plates may be a good choice for patients who were not able to afford the anatomical
8
9
10 anterolateral locked plate.
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12
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 METHODS
1
2 We treated 19 consecutive patients with intraarticular fractures of the tibial plafond using
3
4
5 staged minimally invasive locked plate osteosynthesis in our institute between April 2010 and
6
7 October 2016. Patients with infections or nonunion following surgery in other institutes and
8
9
10 fractures in skeletally immature patients were excluded. Of the 19 patients, 1 was lost to
11
12 follow-up. Thus, 18 patients were included in this study. The median patient age of the nine
13
14
15
women and 9 men at the time of surgery was 49 years (range, 22–71 years). Their fractures
16
17 were caused by simple falls (n = 1), falls from > 2 meters in height (n = 6), sports injury (n =
18
19 1), or traffic accidents (n = 10). The severity of each fracture was classified according to the
20
21
22 AO/OTA classification.[21] There were seven C1 fractures, nine C2 fractures, and two C3
23
24 fractures. All patients had concomitant fibular fractures. Soft tissue injury was categorized
25
26
27 according to the Tscherne system.[22] There were 13 patients with grade 3 soft tissue injuries,
28
29 while the remaining five patients had grade 2 injuries. According to the classification of
30
31
32 Gustilo et al(1984), there were two type I, two type II, three type III A, and two type IIIB
33
34 open fractures.[23]
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39 Surgical Techniques
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41 Two-stage treatment protocols were initially planned for these patients. Meticulous
42
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44 debridement was immediately performed for open fractures. Transarticular external skeletal
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46 fixation was applied for temporary closed reduction and stabilization of fracture sites within
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49 24 h (Figure 1A). The axial and rotational alignments were checked for adequacy using
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51 fluoroscopy. Concomitant fibular fixation was performed percutaneously with pins or 4.5-mm
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cannulated screws, facilitating the exact reduction of the tibia and providing additional
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56 stability before definitive surgical stabilization. After swollen skin became soft or flap
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58 reconstruction was done for open type IIIB fractures, minimally invasive osteosynthesis with
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 locked plates was done for definitive stabilization.
1
2 Two small incisions were made, and anterior-inferior incision was done first (Figure 1B,C),
3
4
5 followed by another lateral-superior incision. Anatomical restoration of the ankle joint was
6
7 done via arthrotomy and temporary fixation was performed using Kirschner wires. Then
8
9
10 3.5mm cancellous screws or 3.0 cannulated screws was applied for fixation of small
11
12 intraarticular fragments if needed. A locked T-plate (4.5mm, Synthes, Paoli, PA) was
13
14
15
precontoured to fit the anatomy of the distal tibia. The locked plate was inserted via anterior-
16
17 inferior incision after tunneling in a proximal direction along the periosteum by a periosteal
18
19 elevator. The Schanz screws of the external fixator were useful to control length and
20
21
22 alignment of tibia for achieving fine reduction. Another superior lateral incision was made
23
24 and then screws were applied and locked to the plate. Then, the external fixation was removed
25
26
27 and mobilization with toe-touch weight bearing began for eight to 12 weeks. Full weight
28
29 bearing was allowed after fracture union was verified radiographically.
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31
32 Follow-up examinations were performed at 3 months, 6 months, 1 year, and annually. All
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34 patients attended follow-up examinations for a minimum of 2 years. The median follow-up
35
36
period was 2 years (range, 2–3 years).
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39
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41 Clinical Assessment
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44 At each follow-up visit, the clinical results and complications were evaluated and a
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46 radiographic assessment was performed. The Iowa ankle questionnaire was applied at 1 year
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49 and final follow-up visit to gauge clinical outcomes.[24] Preoperative co-morbidities included
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51 4 patients with hypertension and 3 with diabetes mellitus. At final follow-up, patients were
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classified as “satisfied” or “dissatisfied” according to self-reported outcomes.
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56 Radiographic Assessment
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58 Radiographs were taken after the first stage operation, second stage operation, 3 months, 6
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61 6
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 months, and 1 year after the first stage operation, and annually thereafter (Figure 2). Quality
1
2 of ankle joint restoration, axis deviation (malunion), presence of delayed union, nonunion,
3
4
5 and arthrosis were measured on anteroposterior (AP) and lateral (LAT) radiographs.
6
7 Reductions of the articular surfaces were categorized on the basis of radiographs according to
8
9
10 the modified Burwell and Charnley system.[8] The AP and LAT radiographs, which were
11
12 done at the final follow-up, were assessed for axis deviations (malunion). The Johnson angle
13
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15
was measured in both planes.[25] The angle between the tibia axis and the joint line,
16
17 measured on the AP radiographs, should be between 88° and 90°. More than 10° varus or
18
19 valgus deviation was defined as malunion. The angle between the tibia axis and the joint line,
20
21
22 measured on the LAT radiographs, should be between 75° and 85°. More than 10° deviation
23
24 was defined as malunion. Generally speaking, the assessment of fracture healing relies on
25
26
27 serial radiographic examinations with clinical correlation.[26,27] However, radiographic
28
29 union is frequently used as a study end point and can be an invaluable index when the
30
31
32 findings of clinical examination are contradictory or unreliable. In this series, union was
33
34 defined as more than 50% visible bridging callus across the fracture on plain radiographs.[28]
35
36
At final follow-up, ankle arthrosis was graded on the basis of radiographic evidence; grade 0
37
38
39 was no degenerative change; grade 1 was defined as small spurs, cysts, or osteophytes without
40
41 narrowing of the joint space; grade 2 was as the same as grade 1, but with mild narrowing of
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44 the joint space; grade 3 was defined as severe narrowing of the joint space with subchondral
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46 collapse.[8] All measurements were carried out manually using a goniometer by a single
47
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49 person.
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51 Complications such wound breakdown, infection, ankle arthrosis, malunion, and nonunion
52
53
54
were recorded.
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57
58 Statistics
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 Data were analyzed using the SPSS statistical software package (SPSS Inc., Illinois, USA).
1
2 Iowa ankle scores were compared between the 1-year and the final follow-ups using Student’s
3
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5 paired t-tests. Tests were two-tailed, and p < 0.05 was considered statistically significant.
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 RESULTS AND DISCUSSION
1
2 RESULTS
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5 The median interval between the staged operations was 10 days (range, 6–58 days). Average
6
7 hospital stay was 14 days (range, 13–40 days).
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10
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12 Clinical outcomes
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15
The Iowa ankle questionnaires were administered at the 1-year follow-up and at the final
16
17 follow-up. At final follow-up, the average Iowa ankle score was significantly higher than that
18
19 at the 1-year follow-up (90.1 vs. 80.1; p < 0.001), an improvement in mean Iowa ankle score
20
21
22 of 16%.
23
24 At final follow-up, patients were asked to rate their degree of satisfaction with the outcome
25
26
27 and whether, if given the choice, they would undergo the same treatment again. Nine patients
28
29 (50%) had satisfactory results, seven (39%) reported that they were somewhat satisfied, and 2
30
31
32 (11%) were somewhat dissatisfied. All patients responded they would undergo the same
33
34 treatment. Sixteen (89%) patients were assigned to the satisfied group and 2 (11%) were
35
36
assigned to the dissatisfied group.
37
38
39
40
41 Radiographic outcomes
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43
44 Seventeen patients had good articular reduction according to modified Burwell and Charnley
45
46 classification.[8] Fair articular reduction was noted in one patient. At 6 months of follow-up,
47
48
49 three patients (17%) had delayed or nonunion according to the radiographic definition of
50
51 nonunion. At final follow-up 17 of 18 patients (94%) had definite union and 1 (6%) had
52
53
54
nonunion.
55
56 At final follow-up, one patient had 12° of deviation on the lateral view radiograph, according
57
58 to the definition of the Johnson angle. No other axis deviation was noted. At the final follow-
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61 9
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 up, radiography showed 11 grade 1 and 2 grade 2 ankle arthritic change.
1
2
3
4
5 Complications
6
7 No deaths occurred in this study. No major medical complications (acute myocardial
8
9
10 infarction, cerebrovascular accident, pneumonia, etc.) were noted perioperatively. There was
11
12 one patient with skin edge necrosis of the open fracture site. The wound healed without
13
14
15
surgical intervention. There were four pin tract infections and two superficial infections. All
16
17 pin tract infections were eradicated later, after removal of the external fixators. All superficial
18
19 infections were eradicated later without surgical intervention.
20
21
22 Only one patient had malunion. Two patients had delayed unions and one patient had
23
24 nonunion. All of their fractures were open fractures. The patient with nonunion presented to
25
26
27 our service with a type IIIA open fracture and a type C2 fracture initially. Furthermore, he was
28
29 a heavy smoker. Two patients had delayed union on 6-months radiography, without clinical
30
31
32 symptoms, and both of their tibial plafond fractures were united at the 1-year follow-up,
33
34 without further surgery.
35
36
We also identified the factors predictive of dissatisfied or nonunion results for intraarticular
37
38
39 tibial plafond fractures following staged minimally invasive osteosynthesis with locked
40
41 plates. Factors such as age, gender, open fracture, fracture severity, concomitant injuries,
42
43
44 presence of comorbidities, and the presence of arthrosis were analyzed. While factors were
45
46 compared between satisfied and dissatisfied patients (Table 1), both patients with dissatisfied
47
48
49 results were male and had open fractures and concomitant injuries. While factors were
50
51 compared between patients with union and those with delayed union or nonunion (Table 2),
52
53
54
patients with delayed union or nonunion all had open fractures and concomitant injuries.
55
56 Although the case numbers are limited, patients with open fractures and concomitant injuries
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58 tended to have poor clinical and radiographic results.
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61 10
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 DISCUSSION
1
2 Management strategies for tibial plafond fractures have changed because primary open
3
4
5 reduction and internal fixation is associated with high rates of early wound complications,
6
7 such as skin necrosis, infection, and amputation.[7] In an attempt to reduce the wound
8
9
10 complications of tibial plafond fractures following primary open reduction and internal
11
12 fixation, external fixation was proposed. Most orthopedic surgeons are convinced that the
13
14
15
outcome of tibial plafond fractures are improved by maintaining anatomical reduction,
16
17 especially anatomic restoration of the ankle joint. Furthermore, it is usually impossible to
18
19 reduce an ankle joint or metaphyseal translation anatomically using a percutaneous technique.
20
21
22 Higher rates of delayed union, nonunion, and malunion were noted following external fixation
23
24 for tibial plafond fractures.[11,12,29] If the fracture is largely extraarticular with no or
25
26
27 minimal intraarticular displacement, use of medially percutaneous technique is popular.[14-
28
29 16,20] According to many surgeons’ opinion 7-cm skin bridge must be present between
30
31
32 surgical incisions to minimize soft tissue complications.[30,31] However, it is impossible to
33
34 have a 7-cm skin bridge between anterior arthrotomy incision and medially percutaneous
35
36
plating incision. Ideally, surgical approaches for these complex tibial plafond fractures should
37
38
39 be instructed by the fracture pattern to achieve the articular reconstruction. While treating
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41 intraarticular tibial plafond fractures our protocol has less soft tissue complications and good
42
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44 reduction of ankle joint as mentioned below.
45
46 The literature contains many reports of wound complications after primary open reduction
47
48
49 and internal fixation of tibial plafond fractures.[5,6] We used external fixation to restore axial
50
51 and rotational alignment. Concomitant fibular fixation was performed with pins or 4.5-mm
52
53
54
cannulated screws percutaneously, it facilitated the exact reduction of the tibia, and provided
55
56 additional stability before definitive surgical stabilization. During the first stage operation, we
57
58 avoid periosteum stripping and keep the soft tissue envelope intact. In the second stage we use
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61 11
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 anterolateral incision to avoid skin bridge less than 7cm. Only one patient with a severe initial
1
2 crushing injury had skin necrosis. Six patients had pin tract and superficial infections that
3
4
5 were eradicated later. No wound dehiscence, osteomyelitis or amputation occurred.
6
7 External fixation resulted in lower wound complication rates than plating.[8,11] Nonetheless,
8
9
10 use of external fixators in the definitive treatment of tibial plafond fractures tended to result in
11
12 malunion, delayed union, and nonunion, necessitating the need for additional
13
14
15
operations.[12,29] We allowed the swollen skin to soften or performed flap reconstruction for
16
17 open type IIIB fractures before the second stage minimally invasive osteosynthesis with
18
19 locked plates was performed for definite stabilization via anterior arthrotomy incision. Only
20
21
22 one fracture was not achieved good intraarticular reduction. One malunion was noted. Two
23
24 patients had delayed unions and one had nonunion. All of their fractures were open fractures.
25
26
27 The patient with nonunion presented to our service with a type IIIA open fracture. The
28
29 patients with delayed union presented to our service initially with type II and IIIA open
30
31
32 fractures. Open fractures underwent initial soft tissue stripping, which could have destroyed
33
34 the vascularity of the periosteum, resulting in delayed union and nonunion, even though we
35
36
used a minimally invasive osteosynthesis technique.
37
38
39 There are several interesting findings. Traditionally union is considered delayed when healing
40
41 has not advanced at the average rate for the location and type of fracture (usually 3 to 6
42
43
44 months). Then conservative treatment can be continued for 4 to 12 additional weeks. If the
45
46 fracture is still not united, bone grafting is always needed.[32] Two of our patients had
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48
49 delayed union on radiography, without clinical symptoms at 6 months of follow-up and both
50
51 of their tibial plafond fractures eventually united at the 1-year follow-up with no further
52
53
54
surgery. While we treated patients using minimally invasive plating osteosynthesis, the
55
56 definition of delayed union and nonunion was not well documented. Further study is
57
58 warranted to document the timing of surgical intervention for patients with delayed union
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60
61 12
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 following minimally invasive osteosynthesis with locked plates.
1
2 The factors affecting ankle function following tibial plafond fractures remain unknown.[9,33]
3
4
5 We found that patients with open fractures and concomitant injuries tended toward poor
6
7 clinical and radiographic results. Intra-articular high energy fractures of the tibial plafond led
8
9
10 to ankle arthrosis despite accurate reduction. Thirteen patients had ankle arthrosis. However,
11
12 ankle arthrosis did not have any correlation with the ankle function. Although tibial plafond
13
14
15
fractures led to a short-term negative effect on ankle function, it tended to improve at the final
16
17 follow-up.
18
19 In Taiwan, conventional plates are covered by National Health Insurance (NHI), and all the
20
21
22 locking plates, which include both non-antomical T-shaped locking plate and anterolateral
23
24 anatomical locking plate, are at one’s expense. Therefore if the patient was affordable for
25
26
27 locking plates, anterolateral anatomical locking plate would be our first choice when we were
28
29 facing an intraarticular tibial plafond fracture. However, NHI was considering to enroll the
30
31
32 non-anatomical LCPs into a benefit package recently. This study provided little evidence that
33
34 non-anatomical precontoured T-shaped locking plate was associated with satisfactory results
35
36
and low rate of complications and less expensive than anatomical locking plates.
37
38
39 The final outcomes of tibial plafond fractures are undoubtedly multifactorial. Patient
40
41 satisfaction was related to avoiding early soft tissue complications and late malunion or
42
43
44 nonunion. In addition to the limitation related to the small patient number, no equivalent
45
46 group existed to which this series of patients can be compared. Nonetheless, we showed that a
47
48
49 high rate of satisfaction and union with a relatively low complication rate is achievable with
50
51 staged minimally invasive osteosynthesis with non-anatomical T-shaped locked plates. We
52
53
54
propose that staged minimally invasive osteosynthesis with non-anatomical T-shaped locked
55
56 plates for treatment of patients with intraarticular tibial plafond fractures is an effective and
57
58 safe procedure.
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61 13
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 REFERENCES
1
2 1. Bonar SK, Marsh JL. Tibial plafond fractures: changing principals of treatment. J Am
3
4
5 Acad Orthop Surg. 1994;2:297–305.
6
7 2. Bourne RB, Rorabeck CH, Macnab J. Intra-articular fractures of the distal tibia: the
8
9
10 pilon fracture. J Trauma. 1983;23:591–6.
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34 7. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures.
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39 8. Marsh JL, Bonar S, Nepola JV, et al. Use of an articulated external fixator for fractures
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44 9. Marsh JL, Weigel DP, Dirschl DR. Tibial plafond fractures. How do these ankles
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49 10. Wrysch B, McFerran MA, McAndrew M, et al. Operative treatment of fractures of the
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2 13. Ristiniemi J, Flinkkilä T, Hyvönen P, et al. Two-ring hybrid external fixation of distal
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22 invasive plate osteosynthesis in disphyseal and distal tibial fracture: a retrospective study of
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24 32 patients. Injury. 2007; 38:365-70. (low bend, diaphysis)
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 Table 1. Factors that may be predictive of a dissatisfied result
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2
3
Satisfied(n=16) Dissatisfied(N=2)
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5 Age (years) 50(22-71) 39.5(34-45)
6 Gender (female) 9 0
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8 Open fracture 7 2
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10 Fracture severity(type C3) 2 0
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12 Concomitant injuries 7 2
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14 Cormorbidity 8 2
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16
Ankle arthrosis 12 1
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22
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30
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32
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35
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61 17
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 Table 2. Factors that may be predictive of a “Delayed union/nonunion” result
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2 Union(N=15) Delayed union/
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4 nonunion(N=3)
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6 Age (years) 45(22-71) 53(34-55)
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8 Gender (female) 7 2
9 Open fracture 6 3
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11 Fracture severity(type C3) 2 0
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13 Concomitant injuries 6 3
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15 Cormorbidity 8 2
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20
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22
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61 18
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 LEGENDS
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5 Figure 1. (A) In the first stage, a transarticular external skeletal fixator was applied for closed
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7 reduction and stabilization of the fracture sites. (B) and (C) In the second stage, the
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10 precontoured plate was inserted after tunneling into the soft tissue.
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Figure 2. A 50-year-old a man had a left distal tibial plafond fracture after falling from a
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17 height greater than 3 M. (A) and (B) At presentation, the patient had a AO/OTA type C3 and
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19 open type I tibial plafond fracture. (C) and (D) After acceptable closed reduction percutaneous
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22 pinning and immobilization with external skeletal fixator were performed. (E) and (F) At the
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24 3-month follow-up, the fracture was united without malalignment.
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61 19
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