Double plate osteosynthesis in a C1-C2 tibial pilon fracture: two case reports| Lo Scalpello - Journal

Abstract

Tibial pilon fractures, despite their infrequency, while accounting for 4-10% of all tibial fractures and less than 1% of all fractures of the lower extremity, still represent a challenge for orthopedic surgeons due to their poor prognosis. We present two case reports of C1-C2 tibial pilon fractures, through which we try to demonstrate that double plate fixation offers a superior stability to the osteosynthesis both in case of articular rim multi-fragmentarity, wherein primary key-fragments can be fixed by anatomically shaped plates, to better restore the articular surface and joint stability, and in the scenario of long spiroid or extended oblique fractures, whereby a buttressing and a supporting plate best domain the vertically directed shear forces that tend to diastase the three pilon columns.

Introduction

Tibial pilon fractures, despite their infrequency, while accounting for 4-10% of all tibial fractures and less than 1% of all fractures of the lower extremity, still represent a challenge for orthopedic surgeons due to their poor prognosis ^1-3. These fractures are often associated with soft tissue involvement as well as by fibula fracture in about 75-90% of cases ⁴.

Differently from common ankle fractures, the mechanism of injury of a tibial pilon fracture depends on the association of heavy axial compression with variable angulation deformity, which in turn is influenced by the vectorial direction of the forces and the position of the foot with respect to the ground during the trauma ⁵. Therefore, when the foot is in neutral position at the time of the impact, the talus acts as a “pestle” resulting in the destruction of the entire articular surface. The explanation of how the epiphysis “bursts” when a diaphyseal “wedge” penetrates it, upon impact of the talus on the pilon, can be found in the distal tibial bone architecture, which is characterized by a particularly dense metaphysis and a fragile epiphysis with thin cortices ^6,7.

Topliss et al. cleared up a biomechanical distinction between high-energy fractures, mostly seen in younger patients, which develop along a sagittal plane and derive from placing the foot with a varus angulation at the time of the impact, and low-energy fractures, mostly seen in older patients, which manifest their own along a coronal plane by positioning the foot with a valgus angulation ⁸. Because of that, pilon fractures are physiopathologically classified into three groups: A) high-energy trauma (motor vehicle injuries), characterized by severe articular involvement and soft tissue lesions; B) rotation trauma (skiing accidents), with limited articular and soft tissue damage; and C) low-energy trauma, typically in elderly people ⁶. The classification system of distal tibial fractures, updated over the years, associate the mechanism of injury with the specific pattern of fracture by analyzing different factors like the extent of the comminution and the displacement of the articular surface.

The latest classifications are based on CT and represent a powerful tool to guide the physician toward the choice of the most appropriate surgical approach and the fixation device that best fits the pattern of fracture. Among these, the four-columns classification, proposed by Tand et al., three-dimensionally splits the ankle into a medial column, consisting of the medial one-third of the distal tibia, and a lateral column, i.e. the distal fibula, rather than dividing the tibial plafond itself into an anterior and a posterior column through an intermalleolar line that connects the lateral and medial malleolus ⁹.

Recently, Leonetti and Tigiani have proposed a new CT-based classification based on “architectural” factors like the level of displacement, number of articular fragments, plane of the main fracture line, and degree of comminution ¹⁰.

Therefore, a pre-operative CT scan is useful both to understand the fracture lines, tibio-fibular lesions, comminution and depression areas, and in planning the rightest surgical approach, i.e. to determine the likelihood that an anterolateral fixation plate will provide sufficient stability to the medial segment of the distal tibial epiphysis or it would be better to consider an additional medial support, in order to prevent any varus deformity ^2,11. Actually, it is strongly advisable to perform CT after the fracture has been aligned and stabilized in the emergency setting, i.e. after the “damage control” procedures have been accomplished.

The management protocol of a tibial plafond fracture was clearly outlined in 1979 by Ruedi and Allgower, who proposed a four-step procedure, structured in: 1) restoration of fibular length; 2) anatomic reduction of the articular surface; 3) filling the residual bone defect with cortico-cancellous autograft; and 4) stabilization of the medial column. The physiopathology behind this surgical sequence reflects the guiding principles of “how to approach a diaphysis-epiphyseal fracture”, consisting of pulling out the cortical wedge while restoring its length, reducing the epiphyseal fragments with restoration of the joint surface and rebuilding the diaphysis-epiphyseal continuity ⁶. The stabilization achieved must be strong, capable of both resisting varus stress and restoring the antero-posterior and lateral axes of the tibial distal extremity as well as the foot’s external rotation. Any filling of bone substance requires autografting or bone substitutes ¹².

The stability of the fixation, according to the extent of the fracture, along with the congruence of the articular surface and the axial alignment of the tibio-talar joint, seems to be an important predictor of functional outcomes ^1,2,13-16. Therefore, a valid osteosynthesis system has to domain the tibial fracture along all its development planes, and sometimes it cannot be achieved with a single fixation device.

Supplementary fixation with additional plates may be necessary, particularly along the medial column, in case of a shear-type pattern of fracture. Low profile plates are generally preferred, since they are associated with fewer wound complications and intolerance to fixation support ¹⁷.

This is especially true for A.O./O.T.A. C1-C2 fractures, since a single plate cannot adequately stabilize the three primary fracture fragments that are typically seen in these injuries. Anterolateral plates are superior in addressing, along the coronal plane, the fracture across the apex of the plafond, while medial plates can support and resist compound forces by buttressing the zone of comminution ¹⁸.

Summing up, a double plate osteosynthesis should be chosen in two different scenarios: a) articular rim multi-fragmentarity, in which small-fragment plates can better restore the articular surface and joint stability through the fixation of primary key-fragments (i.e. Chaput tubercle) ^19,20; b) long spiroid or oblique fractures, derived from vertically directed shear forces, which tend to diastase the three pilon columns ⁹.

In the first scenario, small-fragment low-profile plates can enhance the stability of the primary synthesis achieved with an anatomical locking compression plate (LCP), placed antero-medially or antero-laterally to restore diaphysis-epiphyseal continuity, by reducing the traction forces applied onto tibial capsulo-ligament attachments. This is particularly true for the stability of the Chaput tubercle fracture, upon which leading traction is given by the antero-inferior tibio-fibular ligament ^21,22.

In the second plot, a vertically long diaphysis-epiphyseal fracture, sometimes twisting along its own axis, tends to separate the tibial blocks along multiple spatial planes, as in the case of an extended spiral fracture which first divides the anterior and posterior columns and ends upon the articular surface by splitting it into divergent fragments. The best osteosynthesis solution in this pattern of fracture would be an association of a buttress plate along the mainly displaced side and a support plate on the opposite one.

Furthermore, along the medial and lateral tibial plates, distal coplanar screws form a crossing system over the articular dome, which is a stronger fixation construct that allows early ankle mobilization and partial weight-bearing, which can be associated with better functional outcomes ²³.

It is important to keep in mind that if a double surgical approach is chosen for a double plate tibial fixation, according to anatomical studies on distal lower limb angiosomes (typically 3 – anterior tibial, posterior tibial and peroneal angiosomes), a ~ 7 cm skin bridge is deemed to be a safe distance between the two surgical incisions. However, recent studies have shown that lower distances of ~ 5 cm also seem to be safe, especially when a minimally invasive technique is adopted ^24-28.

We present two case reports of C1-C2 tibial pilon fractures, surgically approached with double plate fixation, at the Department of Orthopedics and Traumatology of C.T.O. Hospital in Naples.

Case 1

A 42-tear-old man, during a car accident, suffered a 43-C2 distal tibial fracture, engaging both the anterior and the medial column and consequently displacing the ankle into a valgus position. A CT scan showed an important comminution of the anterior wall, a discontinuity of the posterior distal diaphysis and a free antero-lateral fragment still attached to the fibula through the antero-inferior tibio-fibular ligament (Fig. 1).

A double antero-lateral and medial approach was chosen to expose the entire anterior articular rim and the Chaput tubercle, in order to clearly see and manage the anterior and medial columns. The articular surface was carefully reduced under direct vision and temporarily fixed with k-wires. Next, one lag screw was implanted along an anterior-to-posterior and lateral-to-medial fashion, above the joint plane, to stabilize the Chaput fragment. Subsequently, the medial column fragment was reduced first and fixed by a medial anatomic LCP, placing the distal screws as shaping a shelf along the articular dome, then managing the anterior column with an antero-lateral anatomic LCP, through which the posterior cortex was caught and reduced. Intraoperative fluoroscopy showed a well-reduced fracture with a flat joint surface. (Fig. 2)

In this scenario, the main indication for a double plate osteosynthesis is to improve the stability of the diaphysis-epiphyseal block by scaffolding it along both sides and to counteract the displacing forces applied upon the Chaput tubercle fragment, led by the antero-inferior tibio-fibular ligament.

A rehabilitation protocol was started early, with foot massages and drainage to reduce edema, as well as restoration of ankle mobility, on the second day after surgery. The patient was kept out of load until radiographically confirmed bone union, at 60 days post-operative.

Case 2

A 31-year-old man, after a fall from a height, suffered a severe 43-C1 distal diaphysis-epiphysial tibial fracture. A CT scan showed an obliquely longitudinal displacement of the pilon with a 2 cm ascent of the large medial fragment along with the talus (Fig. 3).

A medial approach was chosen to domain the “ad longitudinem” displacement of the medial block and, through a minimal antero-lateral window, the distal tibia was reduced under direct vision, while the articular surface was dealt under fluoroscopic control and temporarily fixed. The final synthesis was obtained with a long medial anatomic LCP along the “stressed” side and supporting the contralateral one with a pre-bent straight plate, slid though the antero-lateral window, according to a minimally invasive approach (Fig. 4).

In this scenario, the primary goal of a double plate osteosynthesis is to enhance the stability of an extended spiral fracture, through which the articular surface is split into two fragments diverging along multiple planes, by an association of a buttress plate along the primarily displaced side and a support plate on the opposite one.

Despite the fact that, according to literature, after a surgical procedure in a complex tibial pilon fracture, the patient should generally be kept out of load for approximately 3 months, the stable fixation reached in this case with a double opposed plates allowed the patient to start a cautious partial weight bearing just a few days post-operative ²³.

Discussion

There is general agreement that the goal of all surgically-treated tibial pilon fractures should be an anatomical reconstruction of the tibial joint surface and that excessive soft-tissue dissection should be avoided ²⁹. However, there is no single ideal method of fixation for all pilon fractures that is suitable for all patients. Successful management requires knowledge of the mechanism of injury, the pattern of fracture and the state of the soft tissue, otherwise a wrong choice of fixation can lead to an increase of the risk of complications ³⁰. Among these, it is possible to consider acute soft-tissue complications, like cutaneous necrosis and surgical wound infection, along with subacute-chronic skeletal deformities, like secondary displacement, metaphyseal malunion or nonunion and tibiotalar arthritis ^6,31. Actually, the incidence of sagittal plane deformities, which remain the most common complications in a tibial pilon fracture, strictly depends on the quality of surgical reduction and stability of the fixation ³². Indeed, the main biomechanical problem in tibial pilon osteosynthesis is the secondary loss of reduction, which is due to an insufficient hold of screws in the area of a comminuted fracture of a mainly cancellous bone, leading to a loss of reduction in up to 11% and tibiotalar arthritis rates of 9-11% ^29,33.

In other words, the problems the orthopedic surgeons have to face are: 1) to choose a device that potentially has a brilliant grip strength on cancellous bone in order to accomplish an osteosynthesis construct with a high biomechanical validity; and 2) to exploit these tools to domain the fracture along all the displacement plans.

About the first point, the scenario of distal tibial fracture management has radically changed since locking plates have been introduced according to the MIPO technique, since it provides higher stability and minimizes loss-of-reduction ^29,34. Furthermore, subcutaneously applied plates have little or no effect on soft tissue and periosteal bloody supply, which leads to fewer soft tissue and healing complications ³⁵.

Several studies conducted on Rüedi type II and III pilon fractures, treated with minimally-invasive low-profile LCP, concluded that MIPO technique was an effective treatment choice with less invasiveness, faster bone union and quicker recovery in ankle function ^17,36-38.

In reference to the planning of an approach to a three-dimensionally displaced fracture, without prejudice to the choice of fixation device, it should be mandatory to domain the fracture along all the planes into which the displacement occurs. This sometimes means the necessity of adopting a multi-device strategy of osteosynthesis. The multi-device approach mainly studied in the literature is hybrid fixation, obtained by combining an ExFix with LCP MIPO, which is associated with higher healing rates and better functional outcomes compared to a mono-LCP ORIF approach alone in case of Rüedi type II and III pilon fractures ^30,39,40.

No study has been published on the biomechanical and functional implications of using a “double plate” fixation approach in case of multi-planar displacement of the distal tibia.

Therefore, the purpose of these case reports was to promote idea that double plate fixation offers superior stability in C1-C2 tibial pilon fractures, and the multi-device ORIF approach should be adopted in two circumstances: 1) in case of articular rim multi-fragmentarity, wherein primary key-fragments can be fixed by anatomically shaped plates to better restore articular surface and joint stability; and 2) in the scenario of long spiroid or extended oblique fractures, whereby a buttressing plate and a supporting one best domain the vertically directed shear forces that tend to diastase the three pilon columns.

In summary, we believe that AO C1-C2 tibial pilon fractures allow the application of a double plate ORIF approach, aiming for anatomic reduction, powerful stability and early function of the ankle joint.

Obviously, a case-control study should be conducted in order to demonstrate the superiority of a “double plate” approach over a mono-LCP ORIF one in case of a multi-plane displaced tibial pilon fracture.

Conclusions

Choosing the right approach for each fracture pattern is important to get the best possible visualization and therefore to obtain anatomical reduction of the tibial articular surface and create a stable fixation construct. The quality of fracture reduction, in terms of joint congruence, as well as the restoration of fracture length, alignment and rotation, is the key to treating a C1-C2 tibial pilon fracture. In conclusion, new devices combined with multiple surgical techniques will help orthopedic surgeons to best manage this difficult type of fracture and reduce the rate of complications.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

MP (first author): mainly wrote this manuscript and performed the acquisition, analysis and interpretation of data; LC, AA (corresponding authors): mainly performed the conception and design of this study. All Authors read and approved the final manuscript.

Ethical consideration

The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki. Written informed consent was obtained from each patient for study participation and data publication.

History

Received: March 23, 2024

Accepted: November 26, 2024

Figures and tables

Figure 1.43-C2 distal tibial fracture, displacing the ankle into a valgus position (A); CT scan shows an important comminution of the anterior wall, a discontinuity of the posterior distal diaphysis and a free antero-lateral fragment still attached to the fibula through the antero-inferior tibio-fibular ligament (B).

Figure 2.Post-operative X-ray: the Chaput fragment is stabilized by a lag screw, the medial column fragment is fixed by a medial anatomic LCP, placing the distal screws as shaping a shelf along the articular dome, and anterior column with an antero-lateral anatomic LCP, throw which the posterior cortex is cought and reduced.

Figure 3.43-C1 distal diaphyso-epiphysial tibial fracture (A); a 3-D CT scan shows an obliquely longitudinal displacement of the pilon with a 2 cm ascent of the huge medial fragment along with the talus (B).

Figure 4.Post-operative X-ray: osteosynthesis is obtained with a long medial anatomic LCP along the “stressed” side and supporting the contralateral one with a pre-bent straight plate.

References

1. Mair O, Pflüger P, Hoffeld K. Management of pilon fractures-current concepts. Front Surg. 2021; 8:764232. DOI
2. Zelle BA, Dang KH, Ornell SS. High-energy tibial pilon fractures: an instructional review. Int Orthop. 2019; 43:1939-1950. DOI
3. Bear J, Rollick N, Helfet D. Evolution in management of tibial pilon fractures. Curr Rev Musculoskelet Med. 2018; 11:537-545. DOI
4. Luk PC, Charlton TP, Lee J. Ipsilateral intact fibula as a predictor of tibial plafond fracture pattern and severity. Foot Ankle Int. 2013; 34:1421-1426. DOI
5. Saad BN, Yingling JM, Liporace FA. Pilon fractures: challenges and solutions. Orthop Res Rev. 2019; 11:149-157. DOI
6. Dujardin F, Abdulmutalib H, Tobenas AC. Total fractures of the tibial pilon. Orthop Traumatol Surg Res. 2014; 100:S65-S74. DOI
7. Newman SD, Mauffrey CP, Krikler S. Distal metadiaphyseal tibial fractures. Injury. 2011; 42:975-984. DOI
8. Topliss CJ, Jackson M, Atkins RM. Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg Br. 2005; 87:692-697. DOI
9. Chen H, Cui X, Ma B. Staged procedure protocol based on the four-column concept in the treatment of AO/OTA type 43-C3.3 pilon fractures. J Int Med Res. 2019; 47:2045-2055. DOI
10. Leonetti D, Tigani D. Pilon fractures: A new classification system based on CT-scan. Injury. 2017; 48:2311-2317. DOI
11. Grose A, Gardner MJ, Hettrich C. Open reduction and internal fixation of tibial pilon fractures using a lateral approach. J Orthop Trauma. 2007; 21:530-537. DOI
12. Stapleton JJ, Zgonis T. Surgical treatment of tibial plafond fractures. Clin Podiatr Med Surg. 2014; 31:547-564. DOI
13. Erichsen JL, Andersen PI, Viberg B. A systematic review and meta-analysis of functional outcomes and complications following external fixation or open reduction internal fixation for distal intra-articular tibial fractures: an update. Eur J Orthop Surg Traumatol. 2019; 29:907-917. DOI
14. Harris AM, Patterson BM, Sontich JK. Results and outcomes after operative treatment of high-energy tibial plafond fractures. Foot Ankle Int. 2006; 27:256-265. DOI
15. Carbonell-Escobar R, Rubio-Suarez JC, Ibarzabal-Gil A. Analysis of the variables affecting outcome in fractures of the tibial pilon treated by open reduction and internal fixation. J Clin Orthop Trauma. 2017; 8:332-338. DOI
16. Bonato LJ, Edwards ER, Gosling CM. Patient reported health related quality of life early outcomes at 12 months after surgically managed tibial plafond fracture. Injury. 2017; 48:946-953. DOI
17. Borens O, Kloen P, Richmond J. Minimally invasive treatment of pilon fractures with a low profile plate: preliminary results in 17 cases. Arch Orthop Trauma Surg. 2009; 129:649-659. DOI
18. Penny P, Swords M, Heisler J. Ability of modern distal tibia plates to stabilize comminuted pilon fracture fragments: is dual plate fixation necessary?. Injury. 2016; 47:1761-1769. DOI
19. Yoon SJ, Yeo ED, Jung KJ. Evaluating the efficacy of tension band wiring fixation for chaput tubercle fractures. J Clin Med. 2023; 12:5490. DOI
20. Dietz SO, Müller-Bongartz F, Rommens PM. The small-fragment double plate osteosynthesis in C1 to C3 fractures of the tibial pilon. Z Orthop Unfall. 146:240-245. DOI
21. Rammelt S, Bartoníček J, Kroker L. Pathoanatomy of the anterolateral tibial fragment in ankle fractures. J Bone Joint Surg Am. 2022; 104:353-363. DOI
22. Kroker L, Neumann AP, Beyer F. Ankle fractures involving the anterolateral distal tibia: medium-term clinical results of 50 cases. Eur J Trauma Emerg Surg. 2023; 49:941-949. DOI
23. Kubiak EN, Beebe MJ, North K. Early weight bearing after lower extremity fractures in adults. J Am Acad Orthop Surg. 2013; 21:727-738. DOI
24. Howard JL, Agel J, Barei DP. A prospective study evaluating incision placement and wound healing for tibial plafond fractures. J Orthop Trauma. 2008; 22:299-305. DOI
25. Kottmeier SA, Madison RD, Divaris N. Pilon fracture: preventing complications. J Am Acad Orthop Surg. 2018; 26:640-651. DOI
26. Vicenti G, Bizzoca D, Nappi VS. The impact of lag screw in the healing time of distal tibia fractures treated with minimally invasive plate osteosynthesis: a randomized clinical trial. Injury. 2020; 51:S80-S85. DOI
27. Thordarson DB. Complications after treatment of tibial pilon fractures: prevention and management strategies. J Am Acad Orthop Surg. 2000; 8:253-265. DOI
28. Oexeman S, Ward KL. Understanding the arterial anatomy and dermal perfusion of the lower extremity with clinical application. Clin Podiatr Med Surg. 2020; 37:743-749. DOI
29. Schulz AP, Fuchs S, Simon L. Severe fracture of the tibial pilon: results with a multidirectional self-locking osteosynthesis plate utilizing a two-stage procedure. Eur J Trauma Emerg Surg. 2008; 34:391-396. DOI
30. Calori GM, Tagliabue L, Mazza EW. Tibial pilon fractures: which method of treatment?. Injury. 2010; 41:1183-1190. DOI
31. Vicenti G, Bizzocca D, Scialpi L. Malunions and nonunions following tibial malleolar and tibial plafond fractures: current concepts. Lo Scalpello. 2020; 34DOI
32. Korkmaz A, Ciftdemir M, Ozcan M. The analysis of the variables, affecting outcome in surgically treated tibia pilon fractured patients. Injury. 2013; 44:1270-1274. DOI
33. Dickson KF, Montgomery S, Field J. High energy plafond fractures treated by a spanning external fixator initially and followed by a second stage open reduction internal fixation of the articular surface – preliminary report. Injury. 2001; 32:SD92-98. DOI
34. Barış A, Çirci E, Demirci Z. Minimally invasive medial plate osteosynthesis in tibial pilon fractures: longterm functional and radiological outcomes. Acta Orthop Traumatol Turc. 2020; 54:20-26. DOI
35. Lau TW, Leung F, Chan CF. Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop. 2008; 32:697-703. DOI
36. Elnewishy A, Elkholy M, Hamada A. Comparing minimally invasive percutaneous plate osteosynthesis with interlocking intramedullary nail fixation for the management of adult extra-articular distal tibial fractures: a comprehensive systematic review and meta-analysis. Cureus. 2023; 15:E49214. DOI
37. Vidović D, Matejčić A, Ivica M. Minimally-invasive plate osteosynthesis in distal tibial fractures: results and complications. Injury. 2015; 46:S96-S99. DOI
38. Ballal A, Rai HR, Shetty SM. A prospective study on functional outcome of internal fixation of tibial pilon fractures with locking plate using minimally invasive plate osteosynthesis technique. J Clin Diagn Res. 2016; 10:RC01-4. DOI
39. Galante VN, Vicenti G, Corina G. Hybrid external fixation in the treatment of tibial pilon fractures: a retrospective analysis of 162 fractures. Injury. 2016; 47:S131-S137. DOI
40. Abd-Almageed E, Marwan Y, Esmaeel A. Hybrid external fixation for arbeitsgemeinschaft für osteosynthesefragen (AO) 43-C tibial plafond fractures. J Foot Ankle Surg. 2015; 54:1031-1036. DOI