Abstract
Purpose
To conduct a systematic review and meta-analysis comparing physical function and complications following DIATF surgery with external fixation (EF) or open reduction internal fixation (ORIF).
Method
A search was conducted using PubMed, Embase, Cochrane CENTRAL, Open Grey and Orthopaedic Proceedings. Studies with a level of evidence of I–III on patients (≥ 18 years) with DIATFs operated on with either EF or ORIF were included. A total of 3814 studies were identified. The Cochrane Risk of Bias Tool for randomised controlled trials and the ROBINS-I tool for nonrandomised studies were used to assess risk of bias.
Results
Nine studies with 478 patients, 271 ORIF and 197 EF met the inclusion criteria. The mean follow-up ranged from 12 to 38 months. The meta-analysis showed a higher incidence of superficial wound infections (RR = 2.94, 95% CI 1.62–5.34, p = 0.0004) and malunions (RR = 2.62, 95% CI 1.27–5.43, p = 0.009) in the EF group compared to the ORIF group. Also worse physical function was associated with the EF group. However, the overall evidence was low.
Conclusion
This systematic review is the first to report on physical function following DIATF surgery. In general, decreased physical function was reported. The meta-analysis showed lower incidence of superficial wound infection and malunion rates in the ORIF group. Heterogeneity was low. In conclusion, this review reports lower complication rates following ORIF for DIATF. The overall evidence was limited, and therefore, the authors cannot recommend ORIF to be superior to EF treatment for DIATF. More multi-centre studies with larger sample sizes are needed to assess long-term physical function and complications following DIATF surgery.
Level of evidence
Level 1.
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References
Tarkin IS, Marcantonio A, Pape HC, Clare MP (2008) An update on the management of high-energy Pilon fractures. Injury 39(2):142–154. https://doi.org/10.1016/j.injury.2007.07.024
Sirkin M, Sanders R (2001) The treatment of pilon fractures. Orthop Clin North Am 32(1):91–102
Egol KA, Wolinsky P, Koval KJ (2000) Open reduction and internal fixation of tibial pilon fractures. Foot Ankle Clin 5(4):873–885
Patterson MJ, Cole JD (1999) Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma 13(2):85–91
Watson JT, Moed BR, Karges DE, Cramer KE (2000) Pilon fractures. Treatment protocol based on severity of soft tissue injury. Clin Orthop Relat Res 375:78–90
Lomax A, Singh A, Jane NM, Senthil CK (2015) Complications and early results after operative fixation of 68 pilon fractures of the distal tibia. Scott Med J 60(2):79–84. https://doi.org/10.1177/0036933015569159
Harris AM, Patterson BM, Sontich JK, Heather A, Vallier MD (2006) Results and outcomes after operative treatment of high-energy tibial plafond fractures. Foot Ankle Int 27(4):256–265
Van den Berg J, Monteban P, Roobroeck M, Smeets B, Nijs S, Hoekstra H (2016) Functional outcome and general health status after treatment of AO type 43 distal tibial fractures. Injury 47(7):1519–1524. https://doi.org/10.1016/j.injury.2016.04.009
Pollak AN, McCarthy ML, Bess RS, Agel J, Swiontkowski MF (2003) Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 85-A(10):1893–1900
De- Las-Heras-Romero J, Lledo-Alvarez AM, Lizaur-Utrilla A, Lopez-Prats FA (2017) Quality of life and prognostic factors after intra-articular tibial pilon fracture. Injury 48(6):1258–1263. https://doi.org/10.1016/j.injury.2017.03.023
Lewis J, Vint H, Pallister I (2013) Pilot study assessing functional outcome of tibial pilon fractures using the VSTORM method. Injury 44(8):1112–1116. https://doi.org/10.1016/j.injury.2013.02.019
Mauffrey C, Vasario G, Battiston B, Beazley J, Seligson D (2011) Tibial pilon fractures: a review of incidence, diagnose, treatment and complications. Acta Orthop Belg 77(4):432–440
Pugh KJ, Wolinsky R, McAndrew MP, Johnson KD (1999) Tibial pilon fractures: a comparison of treatment methods. J Trauma 47(5):937–941
Wang D, Xiang JP, Chen XH, Zhu QT (2015) A meta-analysis for postoperative complications in tibial plafond fracture: open reduction and internal fixation versus limited internal fixation combined with external fixator. J Foot Ankle Surg 54(4):646–651. https://doi.org/10.1053/j.jfas.2014.06.007
Moher D, Liberati A, Tetzlaff J, Altman DG (2009) The Prisma group. Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. BMJ 339:b2535
CEBM (Center for Evidence Based Medicine). http://www.cebm.net/. Accessed 17 Dec 2012
Rüedi T, Algöever M (1979) Fractures of the lower end of the tibia. Clin Orthop Relat Res 138:105–110
Gustilo RB, Anderson JT (1976) The prevention of infection in treatment of 1000 and 25 open fractures of long bones-retrospective and prospective analysis. J Bone Joint Surg Am 58(4):453–458
Hunt KJ, Hurwit D (2013) Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am. 95(16):e118(1–9). https://doi.org/10.2106/jbjs.l.01476.external frame versus internal locking plate for articular pilon fracture fixation. ISRCTN98152560. Protocol registration: https://doi.org/10.1186/ISRCTN98152560
International Clinical Trials Registry Platform. World Health Organisation. http://apps.who.int/trialsearch/
System for information on Grey Litterature in Europe. Open Grey. http://www.opengrey.eu
Topliss CJ, Jackson M, Atkins RM (2005) Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg Br 87(5):692–697
Catalogue SUDOC. Systeme Universitaire de Documentation. http://www.sudoc.fr/07047558X
Catalogue SUDOC. Systeme Universitaire de Documentation. http://www.sudoc.fr/176519319
Jouvineaux P, Ohl Xavier, Harisbourne A, Berrichi A, Labatut L, Simon P, Mainard D, Vix N, Dehoux E (2010) Distal tibia fractures: management and complications of 101 cases. Int Orthop (SICOT) 34(4):583–588. https://doi.org/10.1007/s00264-009-0832-z
Sterne JAC, Higgins JPT, Reeves BC (2016) On the behalf of the development group for ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions, version 7. http://www.riskofbias.info
Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration. www.cochrane-handbook.org
Higgins JPT, Thompson SG, Deeks JJ, Altman D (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560. https://doi.org/10.1136/bmj.327.7414.557
Jansen H, Fenwick A, Doht S, Frey S, Meffert R (2013) Clinical outcome and changes in gait pattern after pilon fractures. Int Orthop (SICOT) 37(1):51–58. https://doi.org/10.1007/s00264-012-1716-1
Djuardin F, Abdulmutalib H, Tobenas AC (2014) Total fractures of the tibial pilon. Orthop Traumatol Surg Res 100(1 suppl):s65–s74. https://doi.org/10.1016/j.otsr.2013.06.016
Kuo LT, Chi CC, Chuang CH (2015) Surgical interventions for treating distal tibial metaphyseal fractures in adults (review). Cochrane Database Syst Rev 3:CD010261. https://doi.org/10.1002/14651858.cd010261.pub2
Jösti J, Tiefenböck M, Winnisch M, Lang N, Hajdu S, Sarahrudi K (2017) Distal tibial fractures: evaluation of different fixation techniques. Wiener klinische Wohenschrift 129(5–6):164–168. https://doi.org/10.1007/s00508-015-0730-x
Binda T, Faluomi M, D’Angelo F, Cherubino P (2011) Tibial pilon fractures: results in the medium- to long-term. J Orthopaed Traumatol 12(suppl 1):s89–s123
Gülabi D, Toprak Ö, Sen C, Avci C, Bilen E, Saglam F (2012) The mid-term results of treatment for tibial pilon fractures. Ulus Travma Acil Cerrahi Derg. Sept 18(5):429–435. https://doi.org/10.5505/tjtes.2012.86094
Wang J, Song H, Dong Z, Wang H (2005) The treatment of mini-invasive external fixator for the distal tibial fracture. Chin J Orthop Trauma 7:786–787
Blauth M, Bastian L, Krettek C, Knop C, Evans S (2001) Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma 15(3):153–160
Angelen JO (1999) Early outcome of hybrid external fixation for fracture of the distal tibia. J Orthop Trauma 13:92–97
Bozkurt M, Ocguder DA, Ugurlu M, Kalkan T (2008) Tibial pilon fracture repair using ilizarov external fixation, capsuloligamentotaxis and early rehabilitation of the ankle. J Foot ankle Surg 47(4):302–306. https://doi.org/10.1053/j.jfas.2008.02.013
Minator Sajjadi M, Ebrahimpour A, Okhovatpour MA, Karimi A, Zandi R, Sharifzadeh A (2018) The outcomes of pilon fracture treatment: primary open reduction and internal fixation versus two-stage approach. Arch Bone Jt Surg 6(5):412–419
Cisneros LN, Gomez M, Alvarez C, Millan A, De Caso J, Soria L (2016) Comparison of outcome of tibial plafond fractures managed by hybrid external fixation versus two-stage management with final plate fixation. Indian J Orthop 50:123-13
Deivaraju C, Vlasak R, Sadasivan K (2016) Staged treatment of pilon fractures. J Orthop 12(suppl 1):s1–s6
Wang C, Li Y, Huang L, Wang M (2010) Comparison of two-staged ORIF and limited internal fixation with external fixator for closed tibial plafond fractures. Arch Orthop Trauma Surg 130(10):1289–1297. https://doi.org/10.1007/s00402-010-1075-6
Richards JE, Magill M, Tressler MA, Shuler FD, Kregor PJ, Obremskey WT (2012) External fixation versus ORIF for distal intra-articular tibia fractures. Orthopedics 35(6):e862–e867. https://doi.org/10.3928/01477447-20120525-25
Guo Y, Tong L, Li S, Liu Z (2015) External fixation combined with limited internal fixation versus open reduction internal fixation for treating Ruedi–Allgower type III pilon fractures. Med Sci Monit 21:1662–1667. https://doi.org/10.12659/msm.893289
Kuolouvaris P, Stafylas K, Mitsionis G, Vekris M, Mavrodontidis A, Xenakis T (2007) Long-term results of various therapy concepts in severe pilon fractures. Arch Orthop Trauma Surg 127(5):313–320. https://doi.org/10.1007/s00402-007-0306-y
Davidovich RI, Elkataran RJ, Romo S, Walsh M, Egol KA (2011) Open reduction with internal fixation versus limited internal fixation and external fixation for high grade pilon fractures (OTA type 43c). Foot Anke Int 32(10):955–961
Danoff JR, Saifi C, Goodspeed DC, Reid JS (2015) Outcome of 28 open pilon fractures with injury severity-based fixation (2015). Eur J Surg Traumatol 25(3):569–575. https://doi.org/10.1007/s00590-014-1552-7
Bacon S, Smith WR, Morgan SJ, Hasenboehler E, Philips G, Williams A, Ziran BH, Stahel PF (2008) A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: open reduction and internal fixation versus external Ilizarov fixation. Injury 39(2):196–202. https://doi.org/10.1016/j.injury.2007.09.003
Xiao R, Tang Q, Cai C (2005) Treatments of tibial pilon fractures with a combination of limited internal and external fixation. Chin J Repar Reconstr Surg 19(8):603–606
Sitnik A, Beletsky A, Schelkun S (2017) Intra-articular fractures of the distal tibia. Effort Open Rev. https://doi.org/10.1302/2058-5241.2.150047
Calori GM, Tagliabue L, Mazza E, deBellis U, Pierannunzii L, Marelli BM, Colombo M, Albisetti W (2010) Tibial pilon fractures: which method of treatment. Injury 41(11):1183–1190. https://doi.org/10.1016/j.injury.2010.08.041
White TO, Guy P, Cooke CJ, Kennedy SA, Droll KP, Blachut PA, O’Brien PJ (2010) The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures. J Orthop Trauma 24(12):757–763. https://doi.org/10.1097/bot.0b013e3181d04bc0
Borrelli J Jr, Ellis E (2002) Pilon fractures: assessment and treatment. Orthop Clin North Am 33(1):231–245
Jacob N, Amin A, Giotakis N, Narayan B, Nayagam S, Trompeter AJ (2015) Management of high-energy pilon fractures. Strateg Traum Limb Reconstr 10(3):137–147. https://doi.org/10.1007/s11751-015-0231-5
Helfet DL, Koval K, Pappas J, Sanders RW, DiPasquale T (1994) Intraarticular “pilon” fracture of the tibia. Clin Orthop Relat Res 298:221–228
Meng YC, Zhou XH (2016) External fixation versus open reduction and internal fixation for tibial pilon fractures. A meta-analysis based on observational studies. J Chin Trauma 19(5):278–282
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This study was funded by Syddansk Universitet.
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Erichsen, J.L., Andersen, P.I., Viberg, B. et al. 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 29, 907–917 (2019). https://doi.org/10.1007/s00590-019-02368-9
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DOI: https://doi.org/10.1007/s00590-019-02368-9