Distal tibia fractures with intraarticular extension can occur following a variety of injury mechanisms. Some injuries occur from a bending or axial load, whereas others may result from a twisting mechanism. The latter, which commonly demonstrate a spiral oblique pattern, are known to be associated with posterior malleolar fractures.1,2 Unfortunately, the literature does not differentiate well between distal tibia fractures that represent typical pilon fractures and those that have larger malleolar fracture from a rotational injury. Both injury types can accurately be described as intraarticular distal tibia fractures, but the associated ligamentous and soft tissue damage are dissimilar.
The use of an intramedullary nail (IMN) with supplemental fixation for simple or partial articular distal tibial fractures is not new.3–6 The treatment of these complex injuries has been facilitated by advancements in surgical technique and the available orthopaedic implants. Alternative means for tibial nail insertion, use of small and minifragment plates and screws, and the development of less invasive techniques have emerged. In addition, contemporary intramedullary nails now have both more, and more distal, interlocking bolt options. Angular stable interlocking bolts have also been introduced, which may improve fixation in short or compromised distal tibial segments.7
The use of an IMN for simple pilon fractures has multiple advantages. Although the soft tissue envelope is always considered, percutaneous or minimally invasive techniques for reduction and fixation of simple articular injuries can often be performed earlier than a formal open approach can be. Treatment of these injuries with an IMN results in minimal periosteal disruption to the distal tibia, a location prone to soft tissue complications. Limited soft tissue dissection may also benefit healing. In the setting of an open fracture, use of an IMN keeps a surface implant from being placed on the bone, which may decrease the risk of infection.
Biomechanically, a tibial IMN positioned in line with the mechanical axis of the tibia allows the implant to act, in most instances, as a load sharing implant. In addition, the stiffness and strength of the nail can be modulated by IMN diameter and the use of additional screws through or around the nail. A recent biomechanical investigation compared the use of a tibial IMN to a standard medial distal tibial plate for fixation of a simulated simple intraarticular distal tibia fracture after lag screw fixation of the articular fracture line. The study found that the IMN performed better under axial loading conditions but mixed results were seen under the 2 torsional loading conditions.8
Fixation of some intraarticular distal tibia fractures with an IMN may therefore be biomechanically and clinically advantageous. The clinical literature on this technique is not robust and, as noted, is comprised of potentially dissimilar injuries.
Multiple studies have described the treatment of distal tibia fractures with intraarticular extension. Robinson et al reported on 63 distal metaphyseal tibia fractures; 20 fractures had a concurrent or simple fracture extension into the ankle joint described as either medial or posterior malleolar fracture. The authors reported that fixation of the malleolus was performed with cancellous screws only if the malleolar fracture displaced with tibial nailing, which occurred in a total of 7 fractures. The authors reported no clinical or radiographic complications related the presence of a malleolar fracture, regardless of the presence of fixation.3 Konrath later described 28 patients with diaphyseal tibia fractures with distal intraarticular involvement. Twenty patients were available for follow-up; 12 patients had shaft fractures that were not contiguous with the ankle fracture, whereas 8 patients had fractures that extended into the tibial plafond but were less than 5 mm displaced. The authors reported that 16 patients had the intraarticular component of their fracture addressed before the nailing procedure. The authors reported no complications and uneventful healing of all distal fracture extensions.4
Nork et al reviewed 36 distal tibia fractures treated with an intramedullary nail. Ten fractures had simple intraarticular displacement and were treated with percutaneous screw fixation of the articular block before nail placement. Although the study did not directly compare the 2 groups, no complications were noted that related to those fractures with intraarticular extension.6 Another mixed study reported by Kruppa et al evaluated 105 distal tibia fractures treated with an IMN and included 31 intraarticular injuries. Again, no data specific to the intraarticular injuries were collected but the study did note that malunion occurred in 23.8% of study patients; nonunion occurred in 19% and was associated with open fractures, wound complications, and fibular fixation.9
In a comparative study, Ristiniemi compared IMN fixation to external fixation of both extraarticular and intraarticular distal tibia fractures. The authors noted articular fixation in the IMN group was performed in 9 patients with a 4-mm cannulated screw, but the study did not differentiate the radiographic or functional outcomes of the intraarticular cohort from the remainder of the patients. Although both interventions yielded similar functional results, external fixation was associated with a greater number of secondary interventions.10
Katsenis et al recently reported on 50 intraarticular distal tibia fractures. Fixation of the articular fracture extension was performed in 37 of 50 fractures before nail placement with 4-mm cancellous screws. Immediate partial weight bearing (up to 50%) and routine dynamization were performed in all cases. Final coronal and sagittal plane deformity was reported to be less than 4 degrees in all cases and average less than 1 degree. Functional outcome scores and range of motion were measured in all patients with minimum 3-year follow-up. The authors reported outcome scores similar to reported lower extremity injury norms and return to work/previous level of activity in almost all patients.11
Finally, a recent study of simple pilon fractures treated with tibial IMN reviewed the technique in 31 patients, 23 of which were available for follow-up and studied. Twenty patients had addition screw fixation of the plafond. The study described many of the relevant variables in distal tibia fixation, including fibular fixation, number of distal interlocking bolts placed in the nail and technique used for tibial nail placement. The authors also provided information regarding their postoperative protocol, noting all patients were nonweight bearing for 6 weeks followed by partial weight bearing and full weight bearing at 10 weeks. Radiographic alignment and union results were reported, but no functional measurements were provided. The authors concluded by noting that IMNs can be successfully used to treat simple pilon fractures but that experienced hands are required to successfully execute this technique.12
Initial Injury Evaluation
A complete assessment of the soft tissue envelope and neurovascular status of the lower limb is imperative. Open injuries require tetanus and antibiotic prophylaxis, and surgical debridement and irrigation. Standard antero-posterior (AP) and lateral radiographs of the tibia/fibula and the ankle should be performed before plaster is applied (Figs. 1A–C). The limb should be reduced, stabilized, and consideration given to a preoperative CT scan if definitive fixation is anticipated at the time of initial surgical intervention. If provisional external fixation is to be placed initially, a CT scan can be obtained following provisional stabilization at the surgeon's discretion. Consideration should be given to proximity of Schantz pin placement to the fracture site and plan for definitive fixation.
Meticulous evaluation of the CT scan is essential to successful management of any intraarticular distal tibia fracture. Advanced imaging will not only define the location, type, and displacement of the articular injury but will help dictate the surgical approach and type of fixation needed (Figs. 2A–C). Minimally displaced intraarticular fractures may be amenable to percutaneous reduction and fixation strategies; areas of articular impaction, fractures with interposed osseous debris, and some displaced fractures may require an open surgical approach.
Reduction and Fixation of the Tibial Plafond
Priority is given to anatomic reduction and stable fixation of the distal tibial articular surface before reduction of the extraarticular component of the tibial fracture and intramedullary nail placement. This approach ensures that the nail does not displace the intraarticular fracture(s), whereas the nail is being placed. If reduction of a more proximal tibial fracture component aids in reduction of the articular surface, such as in a spiral fracture that is contiguous with a segment of the tibial plafond, this can be performed in conjunction with the initial management of the articular surface (Fig. 3).
Percutaneous fixation of the joint surface can be performed when fractures are minimally or nondisplaced. Pointed reduction forceps can be placed through limited incisions in the skin to reduce and compress fracture lines that involve the joint surface. Screws can then be placed using lag technique or by using partially threaded lag screw(s) (Fig. 4A). Solid or cannulated screws can be used. Percutaneous fixation of the joint is based on CT information. Screw placement must be as close to perpendicular as possible to every fracture line and as close to the joint surface as possible. Juxtaarticular fixation provides both maximum compression at the joint surface but also allows the IMN to be placed as far as possible into the distal tibial metaphyseal block. The perfect talar lateral fluoroscopic image is primarily utilized to ensure that distal tibial hardware does not violate the concave tibial plafond. Oblique fluoroscopic images show the position and length of screws that are not perpendicular to the standard AP, mortise, or lateral view of the ankle.
Some injuries are not amenable to percutaneous techniques. Specifically, markedly displaced injuries, zones of articular impaction that require a reduction, and situations where there is osseous debris that would prohibit anatomic articular reduction. The soft tissues of the lower limb dictate surgical timing when any open approach to the distal tibia is needed. Every effort should be made to use limited incisions or use multiple smaller incisions to appropriately reduce and fix the joint. Minifragment plate and screw devices can be used to support areas of comminution or support areas of impaction (Figs. 4B, C). If any portion of the plate will overlap the intramedullary depth of the tibial nail, the ability to fluoroscopically visualize the distal tibia and place multiple interlocking nail bolts must be considered.
Reduction and Fixation of the Tibial Shaft
Following articular reduction and fixation, restoration of tibial length, alignment, and rotation should be performed. Multiple techniques commonly used to achieve proper tibial reduction before IMN placement can be implemented.
Fixation of a concurrent fibula fracture has been shown to decrease the incidence of malalignment of distal tibia fractures treated with an IMN.13 Restoration of fibular anatomy also provides a stable lateral column in the setting of more unstable fracture patterns. If an anterolateral or posterolateral incision must be used to address the plafond, the position of a surgical incision for the fibula should be carefully planned to reduce the risk of wound complications. Finally, although stabilization of the fibula may aid in alignment, consideration should be given to recent work that has suggested that fibular fixation may increase the rate of tibial nonunion.9
Provisional percutaneous and/or external fixation devices can also play an important role when using an IMN for fixation of simple intraarticular distal tibia fractures. Less invasive reduction techniques limit disruption of the traumatized soft tissue envelope and preserve the periosteal blood supply. Percutaneous clamps can be placed to reduce fractures or hold minimally displaced extraarticular fractures. Likewise, an external fixator or universal distractor can be placed outside the standard path of the nail to provide added stability to the leg before the locked IMN is placed.
Isolated tibial pilon fractures are commonly treated with the patient in a supine position. Standard infrapatellar nail placement requires hyperflexion of the knee and fluoroscopic imaging of the extremity requires continued manipulation of the leg. Intramedullary nailing of distal tibia fractures with the leg in a semiextended position provides some advantages to the infrapatellar approach.14 When concurrent fixation of the tibial plafond is performed, this technique may also be advantageous. With the leg extended, the distal tibial articular surface can be addressed first and then nail placement can ensue without marked manipulation of the leg; a small bump is placed under the knee to begin nail placement. Fluoroscopic imaging of the distal tibia is also aided by a semiextended leg position. Standard AP and lateral images and oblique images are easily obtained by manipulation of the image intensifier alone.
Nail placement into the distal tibia should be performed carefully, so that the articular reduction and fixation is not disrupted. The ball-tipped guidewire should be placed to a point just beyond the desired location of the nail to ensure that the entire nail path is reamed. If a bend is placed in the guidewire initially, consideration should be given to using an exchange tube with placement of an unbent guidewire and rereaming of the most distal portion of the nail path before hardware placement. This technique will ensure that the nail has a completely reamed path and can be placed easily to the intended depth. Static locking bolts should be routinely used initially both proximally and distally in the nail to prevent fracture shortening or nail migration. Distal bolts are placed in as many positions as possible to improve distal fixation. Many contemporary nails provide fixed angle or threaded distal bolt options; this technology may improve distal fixation in short segments.
The treatment of simple intraarticular distal tibia fractures with an IMN may have both biologic and biomechanical advantages over standard open plate fixation techniques. Limited clinical data, specific to intraarticular injuries treated with an IMN, exist; larger and comparative studies are needed to more clearly define its role. Although potentially more technically demanding, the principles of anatomic joint reduction and restoration of limb length, alignment, and rotation remain unchanged.
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