In dislocated fractures, endosteal circulation is always disrupted and extraosseous blood supply has a dominant role in fracture healing. The skin receives significant blood supply from the underlying fascia by way of small perforating arteries (Tolhurst et al. The posterior tibial artery supplies extraosseous branches to the area of the medial malleolus and the posterior aspect of the tibial metaphysis just proximal to the tibial plafond (Borrelli et al. The anterior and posterior tibial arteries together divide into numerous extraosseous branches around the distal tibia. High-energy trauma is usually required to break the articular surface of the tibia and the overlying metaphysis.īlood supply to the distal tibia is provided by the three main systems: (1) the epiphyseal-metaphyseal (2) the nutrient (arteria nutricia tibiae) and (3) the periosteal (Nelson et al. Citation1994) and 17% through the fibula (Lambert Citation1971). Between 80 and 90% of the load is transmitted through the tibial plafond to the dome of the talus (Calhoun et al. Under physiological conditions, the ankle joint sustains peak loads of almost four times the body weight (Procter & Paul Citation1982). The tibia articulates distally with the talar dome, forming a congruent saddle-shaped weight-bearing surface. In a study from Scotland (Court-Brown Citation1996), 6% of pilon fractures were open. After diaphyseal fractures, the highest incidence of open fractures of the tibia and fibula occur in the tibial plafond. (Rüedi & Allgöver Citation1969, Ayeni Citation1988). These fractures are relatively rare, accounting for only 3% to 10% of all fractures of the tibia and fewer than 1% of all fractures of the lower extremity. Healing potential of the bone loss in distal tibia was at least equally good as in other locations of the tibia.ĭistal tibial fractures are difficult to treat and often result in permanent disability. A staged method using antibiotic beads and subsequent autogenous cancellous grafting proved to be effective in the treatment of tibial bone loss. Osteoinduction with rhBMP-7 was found to accelerate fracture healing and to shorten the sick leave. Fracture displacement could be better controlled with initial temporary external fixation than with early definitive fixation, but it had no significant effect on healing time, functional outcome or complication rate. The following risk factors for delayed healing after external fixation were identified: post-reduction fracture gap of <3 mm and fixation of the associated fibula fracture. The specific questions to be answered were: What are the risk factors for delayed union associated with two-ring hybrid external fixation? Does human recombinant BMP-7 accelerate healing? What is the role of temporary ankle-spanning external fixation? What is the healing potential of distal tibial bone loss treated with a staged method using antibiotic beads and subsequent autogenous cancellous grafting compared to other locations of the tibia? Additionally, 23 open tibial fractures with significant < 3 cm bone defect that were treated with a staged method in 2000–2004 were retrospectively evaluated. ![]() For this purpose, prospective data collection of tibial pilon fractures was carried out in 1998–2004, resulting in 159 fractures, of which 83 were treated with external fixation. The aim of the present study was to find out the factors that affect fracture union in tibial pilon fractures. ![]() External fixation is commonly used, but the method often results in delayed union. Copyright 2018 by the American Academy of Orthopaedic Surgeons.Distal tibial fractures are rare and difficult to treat because the bones are subcutaneous. Proper application of these recently adopted techniques may be instrumental in achieving aseptic union of pilon fractures. These techniques include early (ie, “immediate”) fixation, upgrading, primary arthrodesis, staged sequential posterior and anterior fixation, acute shortening, and transsyndesmotic fibular plating. Recently validated techniques further diminish the risk of soft-tissue and osseous sepsis. Even with proper timing, favorable host factors, and expert surgical technique, restoration of function and avoidance of complications are not always achievable. Surgical intervention must be performed with respect for the exceedingly vulnerable soft-tissue envelope and with a properly executed technique. ![]() Patients often present with considerably comminuted fracture patterns and notable soft-tissue compromise. Fractures of the distal tibial plafond (ie, pilon) comprise a broad range of injury mechanisms, patient demographics, and soft-tissue and osseous lesions.
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