A review of the data presented in the "Supplementary Material"
for the article "Outcomes After Treatment of High-Energy Tibial Plafond
Fractures"
(2003;85:1893-900), by Pollak
et al., reveals several disturbing trends that were not reported in the
published article. No data were listed to define the severity of the open
injuries. Therefore, the ramifications of the severity of the soft-tissue
wounds and the method of treatment chosen cannot be determined. The authors
reported that eleven of the forty-two fractures managed with open reduction
and internal fixation and twenty of the thirty-eight fractures managed with
external fixation with or without limited internal fixation were open
injuries. With an appropriate sample size, it could be predicted that the
group that had external fixation with or without limited internal fixation
would have a higher severity of soft-tissue injury compared with the group
that had open reduction and internal fixation. Likewise, a comparison of the
Type-B and Type-C fracture groups would reveal a trend that, with larger
numbers, would indicate that the external fixation group had a substantial
level of structural damage compared with the open reduction and internal
fixation group.
Failure to define the fractures into the C1, C2, and C3 groups and further
metaphyseal and shaft extension designations prevents a careful analysis of
the data.
Can the authors reliably compare one treatment with the other? I think that
the article by Wyrsch et
al.1, which was
cited in the Discussion, points to the answer. When pilon fractures were
treated in a prospective series in which the C3, GIIIB injury (a high-energy
fracture with a severe open wound) could not be shifted to external fixation
with or without limited internal fixation, the open reduction and internal
fixation resulted in several failures.
A review of recent articles and poster presentations by Watson et
al.2,
Marsh3, and Harris
et al.4 suggests the
need for an eclectic approach to these complex injuries. Less severe injuries
are amenable to open reduction and internal fixation, and fractures with
severe comminution and soft-tissue wounds should be treated with external
fixation with or without limited internal fixation.
The authors should reconsider the statement in the Abstract, which read,
"Multivariate analyses revealed that... having been treated with
external fixation with or without limited internal fixation [was]
significantly related to poorer results." Their data do not support this
conclusion. I believe that a large randomized trial is needed to shed light on
this difficult fracture, with careful documentation of the severity of the
fracture and soft-tissue wounds.
Dr. Hutson correctly recognizes a trend toward greater injury severity in
the group of patients treated with external fixation. This increase in injury
severity is measurable only by the increase in the number of open injuries and
the increase in the number of Type-C injuries in the external fixation
group.
We did not attempt to further classify these injuries into the C1, C2, and
C3 groups because of a demonstrated lack of reliability of the AO/OTA
classification system at that level of
specificity5.
Nonetheless, we agree that an ability to categorize the severity of the injury
more specifically and reliably would be a useful and better way to compare
treatment groups in this situation. This was but one of many limitations of
our retrospective study methodology. The Discussion section of our manuscript
included an appropriate description of those limitations.
The regression modeling used was intended to correct specifically for
differences in treatment groups by correcting for multiple variables
simultaneously. Thus, to the degree that our data demonstrated that the
severity of injury in the external fixation group was greater than that in the
internal fixation group, the regression modeling considered the differences
and we believe that the conclusions remain valid.
A more specific classification of injury severity would necessarily have
increased our ability to control for that variable. Nonetheless, we believe
that, in the context of the clearly described limitations of the current
study, the statements linking the use of external fixation to poorer results
are supported and should remain in the paper.
While we agree with Dr. Hutson that the more specific data about injury
severity that could be obtained in a prospective study might allow us to
better assess more subtle differences between the treatment groups, the
overall poor results seen in both treatment groups within the current study
strongly suggest that obtaining good results following this type of injury
will require a different treatment approach than either of the two modalities
employed in the current population.
We further agree with other authors who have determined that an
"eclectic" approach to these injuries is of critical importance.
Understanding the "personality" of these fractures is, we believe,
important to developing a treatment approach that will minimize complications
and provide the best result possible in the context of the overall poor
prognosis for these injuries.
Wyrsch B, McFerran MA, McAndrew M,
Limbird TJ, Harper MC, Johnson KD, Schwartz HS. Operative treatment of
fractures of the tibial plafond. A randomized, prospective study. J
Bone Joint Surg Am.1996;78:
1646-57.781646
1996
Watson JT, Moed BR, Karges DE, Cramer
KE. Pilon fractures. Treatment protocol based on severity of soft tissue
injury. Clin Orthop.2000;375:
78-90.37578
2000
[PubMed][CrossRef]
Marsh JL. External fixation is
the treatment of choice for fractures of the tibial plafond. J
Orthop Trauma.1999;13:
583-5.13583
1999
[CrossRef]
Harris MA, Srivinas R, Patterson BM,
Sontich JK, Vallier HA.Results and outcomes after operative
management of tibial plafond fractures: comparison of internal versus external
fixation. Presented as a poster exhibit at the Annual Meeting of the
Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake City,
UT.
2003
Martin JS, Marsh JL, Bonar SK,
DeCoster TA, Found EM, Brandser EA. Assessment of the AO/ASIF fracture
classification for the distal tibia. J Orthop Trauma.1997;11:
477-83.11477
1997
[PubMed][CrossRef]