To The Editor:
I read with interest the article entitled "Combined Percutaneous
Internal and External Fixation of Type-C Tibial Plafond Fractures. A Review of
Twenty-two Cases" (2002;84[Suppl 2]:109-15), by Manca et al. The method
of reduction of small articular fragments with use of curved 3-mm Kirschner
wire inserted through a proximal hole and under image intensifier control was
innovative and commendable. I am interested to know whether the reduction of
the fracture could have been better maintained with multiplane Ilizarov
fixation instead of the monoplane Orthofix hybrid that was used. Perhaps this
would have prevented the kind of malunion shown in one of the illustrations
(Fig. 10-D). Also, was there any difference in the results of the cases in
which the operation was delayed between eight and sixteen days and those of
the cases in which the operation was performed immediately? Finally, implants
around the ankle joint usually are supposed to be removed as soon as their
purpose is over. I wonder why some of the implants were not removed even as
long as seven years after the operation (Fig. 9-C).
Because of the presence of small fragments, we believe that fixation of the
distal part of the fracture is best achieved with a circular frame with
tensioned wires. Fixation of the proximal part can be performed according to
the surgeon's preference. Fixation can be achieved with either a hybrid (a
combination of screws and wires) or a circular frame. We prefer hybrid
fixation because implantation is quicker even in an emergency situation, it is
easier to manage, and it is more comfortable and less cumbersome for the
patient. Regarding the case illustrated in Figure 10, this was a polytrauma
case treated in an emergency setting with a quick surgery consisting of closed
reduction of the fracture and bridging external fixation.
The monoaxial external fixator was changed into a hybrid configuration,
with a distal circular frame applied six weeks after the injury. Even if a
certain degree of recurvatum of the tibia was present, the patient had an
excellent clinical result. At seven years postoperatively, he still had an
adequate range of motion of the ankle joint without pain. In these cases, a
certain degree of recurvatum of the tibia is generally well tolerated as it
helps to recover the extension of the ankle joint.
We did not find any significant difference between the results of the
patients treated immediately after injury and those of the patients treated
after eight to sixteen days. When reduction was delayed, reduction of the
fracture was more complicated, surgical time was longer, and both the patient
and the surgeon were exposed to x-rays for a considerably longer period.
We generally remove implants around the ankle joint as soon as
consolidation is achieved. In the case illustrated in Figure 9, the patient
refused to undergo a second surgery to have the implants removed.