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Study of outcome of pilon fracture of tibia treated with open reduction and plating

Background and Aim: Pilon fracture of tibia are difficult to treat. Age, Skin condition, Mode of trauma, Open injury further increases obstacles in healing process. Various modalities of treatment are available but no ideal treatment has yet evolved. Casting often leads to malalignment, increased chances of non-union and also stiffness in the joints from prolonged immobilization. Hence the aim of the study was to see the effectiveness of open reduction and plating in pilon fracture of tibia in adults. Material and Method: A total of 20 patients were included in the study. All the included patients had fracture of distal tibia (pilon), aged >18 during the period of 2019-2020 in our hospital. Fracture is classified according to AO-OTA Classification. All are treated by open reduction and plating. Length and type of plate was selected as per fracture pattern. Post-Operatively above knee cast with leg elevation given to decrease pain and edema. The patients are followed up at regular interval of 4,8,12 and 16 weeks and results were evaluated using AOFAS for the results of treatment. Results: we had 60% excellent results, 20% good results, 10% had fair & 10% poor results Discussion and Conclusion: Open reduction and plating achieves strength of distal tibial (pilon) fracture shaft in all three planes of loading- bending, compression and torsion. The rate of union compared to other modalities of treatment is excellent. The


Introduction
Tibial pilon fracture was described by the Etienne Destot, a French radiologist in 1911 to describe fracture occurring in distal tibia within 5 cm from the ankle joint line [1,2] . Tibial pilon fractures account for 1% to 10% of all lower extremity injuries [6] . These are intraarticular fractures involving the ankle joint. These fractures may occur due to high or low energy injuries [3,4,5] . The precarious vasculature around the ankle and the subcutaneous location of tibia make these fracture one of the serious injuries challenging orthopaedic surgeons [6] . Fractures of the distal tibia can be quite challenging to manage. They are notoriously difficult to reduce, align and stabilize, and are prone to develop wound complications and infections. As these fractures involve a major weight bearing joint, they result in functional impairment [7] . To preserve normal ankle function, it is must to maintain joint congruity, preserve the normal mechanical axis, ensure joint stability and restore full range of motion especially in Indian culture where squatting and sitting cross legged is must as routine. This is a formidable task to accomplish, especially in the phase of compromised soft tissues especially in open fractures, variable bone quality and associated medical conditions of the patients Conservative treatment by cast application lead to prolonged immobilization lead to ankle and knee stiffness affecting to quality of life of patient Many treatment options emerged over time for treating these injuries. Early open reduction and internal fixation lost its popularity due to wound related complications and external fixation emerged as the definitive fixation which was replaced by hybrid fixators with the advantage of early mobilization of ankle and better stability [9] . Hourglass shape of medullary canal prevents the tight endosteal which compromises stability thus limiting the use of intramedullary nails [9] .
Several different surgical approaches have been described for DISTAL TIBIAL fractures (medial, lateral and combined) depending on the location of the fracture. Combined extensive approaches, in particular, are associated with high complication rates, possibly due to compromised soft tissue perfusion and/or extensive soft tissue stripping from bone fragments. A review of the recent literature demonstrates a trend toward increasingly limited open reduction and internal fixation, often in association with some form of external stabilization. Minimally invasive techniques have also been described for intra-articular fractures (metaphyseal and diaphyseal metaphyseal) of the distal tibia [10,11] . These techniques avoid the long incisions and extensive soft tissue stripping associated with conventional techniques and are best used with shorter, lower profile plates. AO medial plating although showed promising results has its own drawbacks like wound dehiscence and implant prominence over subcutaneous border of tibia. Also in medial approach difficulty is encountered in visualization of the Chaput fragment [10,11] . Plating on the lateral surface of tibial plafond is a new entity and the anterolateral approach is gaining popularity for the fixation of tibial pilon fractures with many studies showing better soft tissue coverage and less chance of wound dehiscence [10,11] . Management of pilon fractures had shifted from acute to delayed fixation following the understanding that soft tissue healing is of paramount importance in treating these in injuries [12,13] . In this study, we are evaluating the plating for distal tibia fractures.  Exclusion Criteria 1) Adults below the age of 18 years 2) Fresh fracture with neurovascular deficit 3) Patients who don't give consent for study

Treatment protocol
All the patients were treated according to protocol which consisted of:-1) Standard A.P. & lateral plain X-ray.
2) Open wound were taken to operation theatre for wound debridement on emergency basis as early as possible. 3) Poly trauma patients were fixed as soon as their general condition allowed for surgery. 4) Ankle range of movement exercises started according implant used and stability of fixation of fracture, post operatively. 5) Patients discharged with BK slab or Ankle brace depending on stability of fixation. 6) Weight lifting and routine work, is allowed according to union status radiologically and clinically. 7) Patients follow up depended on the clinical examination as well as the x-ray findings.

Position
Patient was taken to the plain radiolucent table in supine position. The affected limb was scrubbed and prepared with savlon. Painting and draping was done under aseptic and antiseptic conditions. Draping was done in such a manner that the area from middle of the thigh to whole foot was exposed for proper recognition of anatomical landmarks. The foot was covered with either sterile pad or hand gloves. Inject able antibiotic administered prior to incision.

Selection of implant
In tibial fractures distal tibial metaphyseal plate was considered according to the fracture geometry on anteroposterior and lateral view of the affected limb.

Pre-operative measurement of implant size
Pre operatively on the x-ray antero-posterior view and lateral view the size of the implant was measured considering the magnification of the roentgenogram.

Surgical technique
Plate selection  The plates are available in various lengths and configurations, type of plate is decide according to type of fracture

Incision and dissection
Incision is taken as per previously mentioned surgical approaches and extended distally as per site of fracture. Dissection of subcutaneous tissue is done and make bone exposed, Identify fracture site and margins of fracture is cleared

Reduction of articular surface and provisional fixation
The fracture fragments were reduced and reduction confirmed using image intensification. Reduction was stabilized using one of the following methods: The locking screw didn't provide interfragmentary compression; therefore, any desired compression was achieved with standard lag screws. The articular fractures was reduced and compressed prior to fixation of the 3.5 mm LCP Medial distal tibial plate with locking screws. If a combination of cortex and locking screws had been used, the cortex screw had been first inserted to pull the plate to the bone.

Closure
 The stab wounds were closed with suture. Sterile dressing with spirit applied.  Below knee slab applied and patient was shifted to ward with vital signs monitoring.

Post Operative Management
 Postoperative patients were immobilized with BK slab from next postoperative day morning.  Postoperative analgesic is given according to patients complain.  Intravenous antibiotics given for 1 st 5 days then shifted to oral antibiotics.  1 st dressing done on 5th post-operative day and wound condition noted.  2 nd post-operative dressing done on 9th day.  After that patients was discharged with oral antibiotics and analgesics and with Bk slab and called on 12 to 14 th post-operative day for suture removal.  After suture removal we have given BK to patients whose fracture fixed with LCP and other patients given BK Slab till 3 weeks followed by Ankle mobilization and was advised to come at 1 month.

Results
This study includes 20 patients of tibial pilon fractures treated with Distal Tibia Plate. These included closed as well as open injuries and polytrauma patients. This chapter takes into account observations of the study and effect of various factors on the results. The study includes patients operated at department of orthopaedics, medical college and SSG hospital, Vadodara.   Patients in which inter fragment screw is inserted 10 patients out of 12 gets excellent results and 1 patient have good and 1 have poor result Two fair and one poor result is seen in the patients where inter fragment screw is not used This shows inter fragment screw is used as and when needed

Conclusion
Pilon fracture of tibia with or without intra articular extension is one of the difficult fractures to manage. None of the treatment options available perfectly fulfil requirements of fracture characteristics of distal tibia. The goals of treatment of a distal tibia fracture are anatomical articular reduction, restoration of axial alignment, maintenance of joint stability, achievement of fracture union, pain free weight baring and motion, without any wound complications. The treatment plan in distal tibia fracture depends on fracture pattern, soft tissue injury, patient co-morbidity, fixation resources. Fracture pattern, concomitant articular extension, condition of soft tissue are important factors to be considered before selection of fixation method. The present case series shows that plating is an effective treatment method in terms of preserves the biological environment by preserving soft tissue with better outcome interim of union time and complications rate which is comparable to other studies.