1) Tibial plafond fractures involve injuries to both the bone and soft tissues of the distal tibia. They require anatomical reduction, stable fixation, and early mobilization to achieve the best outcomes. 2) Several surgical approaches can be used including anteromedial, anterolateral, and posterolateral. Small fragment plates and screws are typically used for internal fixation. Meticulous soft tissue management and wound closure are important. 3) While most patients experience some pain, many are able to return to work. Arthrosis is detected in about 50% of cases, but arthrodesis is rare. Outcomes improve over time, and patients should not be rushed into reconstruction without allowing for further

1. Tibial Plafond/Pilon Fractures
2/2/2011

2. The Spectrum of Fracture

3. The Spectrum of
Soft Tissue Injury

4. Relative Success
vs
Dismal Failure

5. The Soft Tissue Injury!!
Red Blisters
Clear Blisters
Open
Fracture

6. Terrible Injuries
“Excellent Results” are rarely achieved
Fair-Good results are the norm
Outcomes are impossible to predict
Treatment complications must be avoided

7. Bone Soft Tissue

8. 2 yrs.
Unusually good!

9. Tibial Plafond Fractures
Fair to Good Results Are the Norm
1991 - anterior B-3 fracture

10. Fair to Good Results Are the Norm
6 months 3 years

11. Fair to Good Results Are the Norm
8 years
Ankle score - 80
Works as a laborer

12. 5 years - no pain
Case 1 ankle score 95

13. 6.5 yrs - miserable -
Case 2 ankle score 45

14. Case 1 Case 2

15. Avg. age 35-40
Rare in children and elderly patients
Males 3 x more common
3-9% of all tibia fractures
Associated injuries 25-50%
Increased incidence – Air Bags!!!
Burgess et al JT 1995
Lower extremity
injuries in drivers
of air-bag equipped
automobiles
Save lives yes, but devastate the foot and ankle

16.  Multiply injured patients with and without
foot injuries ( 24 and 12 month follow ups)
 Dramatic differences in pain, function and
health related quality of life

17. Ankle Soft Tissues
Thin skin
Absent muscle
and adipose tissue
Lack of deep veins
Particularly
vulnerable!

18. The soft tissues over the
anteromedial tibia are vulnerable

19. Dense trabecular structure
of distal tibia

20. Bone is viscoelastic
Axial load is rapid
Shift in stress strain curve
Tremendous energy release

21. Displacement
Rapid axial load
Note the greater
energy under
the curve!!
Slow rotational load
Load
Stress strain curves for rapid vs. slow rate of loading

22. Rotational ankle fractures
are different - good prognosis and
few complications
with standard techniques

23. Dense trabecular structure
Thin soft tissues
Axial Loading
Typical fracture pattern
Severe soft tissue injury

24. Reudi and Allgower - 1969

26. Is this a tibial plafond fracture?
Does it belong in 43?

27. Plafond yes!!
C-2?
Or
C-3?

28. Four principles “stood the test
of time”
 Anatomical reduction
 Stable internal fixation
 Atraumatic technique
 Early pain-free mobilization
“Precise reconstruction of
articular surfaces is the goal,
and is always preferred to
tolerable malalignment”.

29. These Principals Illustrated for
Fractures of the Tibial Plafond

30. Ill-Advised
 Extensive surgical
approaches
 Fracture stripping
 Prolonged tourniquet times
 Bulky implants
Increased
soft tissue
injury
A recipe for disaster }

31. Limb Threatening Complications

32. McFerran et al JOT 1992
21pts (40%) with major complications
require 77 additional operations
Wyrsch et al JBJS 1996
3/18 amputations in closed fractures
Teeney and Wiss CORR 1993
37% infection and 26% fusion in Type 3’s
Cases
Treated
1980’s
Early
1990’s

33. Delays until surgery
Spanning ex fix part of most
protocols
Percutaneous and limited
approaches

34.  Spanning ex fx
 Marsh et al JBJS 1995 – 43 cases 0%
 Wyrsch et al JBJS 1996 – 20 cases 5 %
 External fixation same side
 Court Brown et al JOT 1999 – 24 cases 4%
 Tornetta et al JOT 1993– 26 cases 7%
 Delayed plating
0-10%
 Patterson and Cole JOT 2001 – 22 cases 0%
 Sands et al CORR 1998– 64 cases 6 %
 Sirkin et al JOT 1999 - 48 cases 6%

35. 1. Spanning articulated fixation with
percutaneous or limited approaches to the
articular surface and screw fixation
2. Percutaneous plating
3. Standard plating through open approaches
after long delays for soft tissue recovery

36.  Spanning fixator for three months
 A large monolateral frame fixed into the
talus and calcaneus
 Relatively earlier approaches to reduce the
articular surface percutaneously

37.  Suited for all tibial plafond fractures
 Ideal for very comminuted cases
 Contraindicated with ipsilateral talus or
calcaneus fractures
 Beware diaphyseal extension or severe open
fractures which might delay healing

38. Articulated Advantages
 Span the zone of
injury
 Fixator applied
first
 Same technique all
cases
 One step surgery
 Largely
percutaneous

39. Target the neck
of the talus
posterior
os calcis
FIXATOR TECHNIQUE - Same for all cases!

40. Technical tips
Talar pin
parallel to
top of talus

41. Depth of insertion – Hindfoot pins must
capture the entire talus and calcaneus
Canale view Harris view

42. Technical tips
Position of pins Assembled fixator
Keep the pins in the same plane!

43. Center the talus on two views
The articular surface can not be reduced if the talus
Is not repositioned

44. Axial CT scan critical for pre op planning
The more you use limited approaches
the more planning that is required

45. Limited or percutaneous approaches
and use of reduction aids

46. Reduction forceps based
on anterolateral incision –
Watch out for SPN!

47. Open approaches when necessary
based on major anterior fracture line
Direct approaches - no stripping

48. Percutaneous reduction sequence
visualized flouroscopically

51. 2 year follow up

52.  Never plated
 Treat with
fixator
 Bone graft less
than 10%

53. ROM
Splinting
Wt. Bearing

54. ~ 3 months after injury
Outpatient clinic
Calcaneal screw typically
loose
Often use SLC for another
month

55.  Uses medial sub cutaneous border
 Needs pre contoured plate
 Locking may offer advantages
 Ideal for a select group of fractures
 Non articular distal tibia
 Limited articular involvement
 Build back articular block through limited
approaches

56. Distal ttiibbiiaa wwiitthhoouutt aarrttiiccuullaarr
iinnvvoollvveemmeenntt

57. Reduction: Ligamentotaxis
 External fixator
 Femoral distractor
 Manual traction
 Well placed clamps

58. Femoral distractor
=

59. If Injured, Repair the Fibula

60. Pre-size and bend plate
Or use precountoured plate

61. Anatomy:
Medial face
• Rotation
• Curve

62. Incision

63. SubQ Tunnel

64. Insert plate

65. Confirm placement

66. Stab……Drill, Tap, Screw

67. Post-op

68. 4 months

72. AAnnootthheerr eexxaammppllee iinn aa
mmoorree ccoommpplleexx ffrraaccttuurree

74. 5 months

75.  Indicated to treat the range of tibial plafond
fractures
 Temporary spanning fixation and long
delay to definitive surgery
 Several different open approaches

76. 1st Stage: Temporary Fixation
 application of spanning external fixator,
 ORIF of the fibula,
 as soon after presentation as possible,
 stabilize the fracture while allowing the
soft tissue swelling to resolve,
Interim:
 ice, elevation, pre-operative plan,
 TIME to allow swelling to resolve,
2nd Stage: Definitive Fixation
 ORIF tibia, removal of external fixator,

77. “Traveling Traction”
Half Pins
Transfixation
Pin

78.  Ice, elevation,
 CT scan,
 crutch training,
 Pre-operative plan,
 TIME to allow
swelling to resolve,

79.  Fibula
 posterolateral approach
when an anteromedial
approach to the tibia is
planned,
 maximize the width of the
skin bridge,

80.  Fibula
 Implants:
 Metaphyseal fracture
 1/3 tubular plate,
 large screw,

81.  Fibula
 Implants:
 Metaphyseal fracture
 1/3 tubular plate,
 large screw,

82.  Fibula
 Implants:
 diaphyseal fracture
 3.5 LC – DCPlate
 Rationale:
 cortical bone,
 highest energy fractures,
 slower healing,

83.  Extensile Anteromedial Approach:
 “Workhorse”,
 Anterolateral Approach:
 gaining in popularity,
 Posterolateral Approach:
 recently proposed,

84. Anteromedial Approach
 Superficially:
 minimum 7 cm skin bridge,
 begin ½ finger breath lateral to crest
over the anterior compartment,
 continue parallel to Anterior Tibialis
tendon,
 towards the talonavicular joint,
 Post-operative soft tissue
complications

85. Anteromedial Approach
 Superficially:
 begin ½ finger breath lateral to crest
over the anterior compartment,
 continue parallel to Anterior Tibialis
tendon,
 towards the talonavicular joint,
 maintaining a 7 cm skin bridge,
Medial
talonavicular joint
medial

86. Anteromedial Approach
 Deep dissection:
 carried out medial to Anterior Tibialis
tendon,
 longitudinal arthrotomy,
 gentle elevation of tendons and
neurovascular bundle,
medial

88. Anteromedial Approach
 Deep dissection:
 remain medial to Anterior Tibialis
tendon,
 longitudinal arthrotomy,
 gentle elevation of tendons and
neurovascular bundle,
medial

89. Articular Reduction:
 largest and least displaced articular fragments
first,
 reduced fragments held with:
 K-wires (1.2 or 1.6mm),
 pointed reduction forceps,
 lag screws,
 reduce articular bloc to shaft,
 definitive fixation,

90. DON’T make medial a incision !!!
 the incision ends up directly over
the plate,
 difficult to close,
 increased wound complications,
 deep infection,
 soft tissue loss,
 free flap only bailout,
 burn bridges later reconstruction,
Not This Incision !!

91. Make This Incision !!

92. Anterolateral Approach
 Indications:
 open medial wound,
 displaced Chaput fragment,
 lateral articular comminution,
 Advantage:
 plate coverage,
 uninjured skin,
 Caution
 Superficial peroneal nerve

93. Anterolateral Approach
 Deep Dissection:
 through superior and inferior retinaculae,
 interval between toe extensors and fibula,
 elevate muscles off interosseous
membrane,
 Caution
 Superficial peroneal nerve

94. Anterolateral Approach
 Deep Dissection:
 through superior and inferior
retinaculae,
 interval between toe extensors and
fibula,
 elevate muscles off interosseous
membrane,
 Caution
 Superficial peroneal nerve

95. Posterolateral Approach
 Advantages
 a single incision for ORIF
of the tibia and fibula,
 FHL is positioned
between the skin and the
implants in case of post-op
wound complication,
 Disadvantages
 limited access to anterior
articular fracture fragments,
 prone position,
 sural nerve at risk,

96. Implants:
 Small Fragment Plates
 cloverleaf shaped plate,
 distal radius “T” plates,
 1/3 tubular plates,
 3.5 LC-DCP,
 Screws
 3.5 cortical/4.0
cancellous,
 cannulated: 4.0/4.5

97. Implants:
 Small Fragment Plates
 cloverleaf shaped plate,
 distal radius “T” plates,
 1/3 tubular plates,
 3.5 LC-DCP,
 Screws
 3.5 cortical/4.0
cancellous,
 cannulated: 4.0/4.5

98. Bone Graft
 support articular
fragments,
 augment healing,
 fill cancellous defects,
 ICBG,
 Allograft,
 Synthetic
 Calcium putties,

99. Meticulous Wound
Closure
 meticulous closure,
 1-0 vicryl for capsule,
 2-0 vicryl for
subcutaneous tissue,
 3-0 nylon for skin,
 Allgower’s modification
of the Donati stitch,
Allgöwer stitch modified by
ADllognöawtier stitch modified by Donati

100.  Summary: Tibial Plafond Fractures
 Represent both a bony and soft tissue injury,
 AO Principles:
 Anatomic articular reduction,
 stable fixation,
 early mobilization of patient and limb.
 several approaches to the tibia can be safely used,
 internal fixation is accomplished with small fragment
implants,
 meticulous soft tissue closure,

101. Results

102.  Most have some pain
 Most return to work
 Detectable arthrosis - 50%
 Arthrodesis rare

103. Pain Analysis
50% - no/minimal pain
35% - pain with weight bearing
15% - continuous
Marsh et al. JBJS 1995

104.  Sands et al CORR 1998 - 2-4 years after
injury
 Delayed plating
 Pollak et al JBJS 2003 – average 3.2 years after injury
 Plating and external fixation
 Marsh et al JBJS Feb 2003 – 5-11 years after
injury
 Spanning external fixation

105. SF-36: Plafond vs Aged Matched Norms
5-11 years after injury (Marsh et al JBJS Feb
100
80
60
40
20
0
PF* PR* BP* GH VT SF RE MH
Plafond
Norm
03)
Significantly
different

106. Ankle Osteoarthritis Scale:
Plafond 5-11 Years after Injury
1.2
1
0.8
0.6
0.4
0.2
0
Pain Disability Mean
Plafond
Norm

107. 20
18
16
14
12
10
8
6
4
2
0
Grade 0 Grade 1 Grade 2 Grade 3
# of
patients

108. 25/33 rated their ankle good or
excellent
Motion avg. 75% opposite
Only 2/37 late arthrodesis 5.4%

109. Reasonable
evidence
that patients
improve
for a long
time!
Do not be too
quick to offer
reconstruction!
 Sequential Ankle Score: 67 at 24 mo, 86 at 92
mo (p.004)
 Time to maximal healing: 2.4 yr (9 mo-5 yr)

110. 1986 - 24 yo Male

111. 1 year

112. 7 years

113. 14 years
 Works light labor
 Prefers high top boots
 Occasional pain
 Ankle score 80

114. Excellent results are only rarely achieved
Most have some ankle pain
Can not run or play sports
Measurable effect on general
health status
70% with moderate or severe
arthrosis

115. Fair to Good Results Are the Norm
Most rate their outcome as good or
excellent
Arthrodesis rate only ~ 5%
Most feel they improve for years

116. Summary and
Conclusions

117.  High energy fractures with severe
associated soft tissue injury
 Unpredictable outcomes
 Keep complications – 10% or less
 Results:
Generally not great
But if you stay out of trouble not awful

118. Long lasting effect on patient health related
quality of life and a greater effect on ankle
pain and function
Arthrosis common by 2 years after injury and
typical in the second five years. The clinical
significance is variable.
The variation in outcome is unpredictable
The severity of injury/quality of reduction
are important but better techniques to
understand this critical interaction are needed

119. Do not be quick to suggest arthrodesis based
on severity of injury or quality of
reduction
Patients improve for a long time and most
do not require arthrodesis
Complications must be avoided since they
produce bad outcomes and the extent
that we improve outcome with aggressive
surgery is at least unclear