Treatment Options
Conservative treatment of these fractures with traction, bracing, and immobilization in a cast rarely permits accurate reconstruction of fibular length and reduction of the articular surface of the tibial plafond. In type-C tibial plafond fractures, it is necessary to restore fibular length, anatomically reduce the articular part of the fracture to minimize the risk of secondary arthritis, and provide stable articular and metaphyseal fixation to promote fracture-healing 3,7 . These goals should be achieved with a technique that is as minimally invasive as possible. Open reduction and internal fixation with plates and screws, as introduced by Ruedi and Allgower 3 , and reported by several other authors to have provided good results 1,8,9 , permits accurate reduction of the articular surface but with a high rate of deep infection, wound dehiscence, and soft-tissue problems 10 . The use of closed reduction and percutaneous fixation techniques has reduced the incidence of wound complications 6,11 . This technique is usually sufficient to reduce and stabilize the articular fragments with use of fluoroscopic or arthroscopic guidance, but it is not adequate to control the metaphyseal fragments. For these reasons, some authors have recommended surgical techniques based on closed internal fixation of the articular fracture and circular external fixation of the metaphyseal fracture 5,12-16 .
Aim of the Study
The aim of this study was to review the results of fluoroscopically monitored closed reduction combined with percutaneous internal and hybrid external fixation of type-C tibial plafond fractures.
Twenty-two type-C tibial plafond fractures in twenty-one patients were reviewed. All of the fractures resulted from high-energy trauma. Sixteen fractures were closed, and six were open with two Gustilo grade-I, three Gustilo grade-II, and one Gustilo grade-III injury patterns 17 . The age of the patients ranged from twenty-four to seventy-two years. Eight sustained other fractures, and five had abdominal injuries or neurological involvement. All injuries were evaluated with standard two-projection radiographs of the entire leg, while the ankle was examined with two oblique projections as well. Five fractures were also studied with computed tomography scanning. The injured limbs were initially treated with transcalcaneal traction. Surgery was performed immediately after admission to the hospital in ten patients, and it was delayed eight to sixteen days after the injury in the other eleven, depending on the general condition of the patient.
Surgical Technique
Surgery is performed with the patient under general or spinal anesthesia. The patient is positioned on the operating table with the knee flexed to 30° and the limb held in transcalcaneal traction ( Fig. 1 ). A tourniquet is not an important advantage in closed reduction, but, if used, it should be deflated as soon as possible. The alignment of the fracture is checked with an image intensifier.
The fibular fracture is first treated by closed reduction obtained by traction and manipulation, and it is fixed with one or two Kirschner wires. Through a small skin incision over the anteromedial aspect of the tibial metaphysis, a small window is then drilled in the tibial cortex ( Figs. 2 and 3 ).
A blunt-tipped, curved 3-mm Kirschner wire is inserted through the hole and directed toward the articular fragments, which are then reduced under image intensifier control ( Fig. 4 ). In some cases, more than one Kirschner wire is required to reduce all of the articular fragments adequately.
Through small skin incisions, one or two Kirschner wires are inserted across the tibial plafond to stabilize the reduced fragments, and cannulated screws are introduced over the wires ( Figs. 5 and 6 ). One cannulated screw is usually inserted from the anteromedial surface, and another is inserted from the posterior surface; the position and number of the screws is determined by the fracture pattern ( Figs. 7- A and 7-B ).
After reduction of the articular surface, an Orthofix hybrid external fixator (Orthofix S.R.L.; Bussolengo, Verona, Italy) is applied ( Fig. 8 ). A ring of appropriate size is positioned just proximal to the ankle joint. All wires are applied in the transverse plane; two, from posterolateral to anteromedial; and the remaining two, from anterolateral to posteromedial. Each wire is tensioned to 1400 N and locked to the frame.
If comminution of the tibial plafond is severe, so that the ring will not guarantee adequate fracture fixation, a bridging external fixator is applied across the ankle joint, with one pin in the neck of the talus and another in the body of the calcaneus. The metaphyseal fracture is then reduced accurately, and the body of the external fixator is applied to the anteromedial aspect of the tibia. Two screw guides are inserted down to the bone through stab incisions. The screw-holes are predrilled with a 4.8-mm drill-bit, and two 5/6-mm tapered self-tapping hydroxyapatite-coated pins are inserted. The fixator is then locked to the screw shafts. The syndesmosis is checked with the image intensifier, and a screw is inserted through the fibula into the tibia to stabilize it, if required.
Our patients were discharged from the hospital between five and fifteen days after surgery, depending on their general condition. Postoperative care consists of early passive motion of the ankle joint after an average initial period of two weeks when the ankle clamp was locked. The patients with a Gustilo grade-II or III open fracture were checked weekly in the outpatient department. Other patients were seen monthly.
Patients with a bridging external fixator were usually readmitted to the hospital six weeks after surgery, and in a second operation the distal frame was substituted with a ring just above the ankle joint. In these patients, weight-bearing was allowed two to four weeks after the second operation.
Progressive weight-bearing was allowed between the eighth and twelfth week, depending on the radiographic appearance of the fracture. The external fixator was removed between fifteen and twenty-one weeks after surgery.