title: 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.
abstract: Early open reduction and internal fixation (ORIF) with plates and screws for plafond injuries caused by skiing initially reported by Ruedi and Allgower proved inadequate for the treatment of high-energy motor vehicle accident type injuries. The purpose of our study was to review our treatment protocol using a spanning external fixator placed semi-emergently medially across the joint and a later staged ORIF of just the articular surface to achieve and maintain anatomic reduction.
  
  
  METHODS
  We preformed a retrospective study of 35 patients with 37 highly comminuted severe (OTA 43-B3 and -C3 or Ruedi type II or III) tibial plafond fractures treated by a single surgeon. All patients were treated with an initial spanning unilateral external fixator and subsequent ORIF. Radiographs were examined for: classification, number of pieces of the tibial dome, evidence of ground-glass comminution (more than three pieces <2mm in size on CT), anatomic reduction, alignment, and presence/absence of arthritis.
  
  
  RESULTS
  Evidence of ground glass comminution existed in 26/37 patients (70%). Following ORIF, articular reduction was perfect (0-1mm displacement) in 29/36 (81%), imperfect (1-3mm) in 6/36 (17%) and poor (>3mm) in 1/36 (3%) cases. Joint alignment was anatomical in 35/37 (96%), with 15 degree anterior angulation in one patient and 5 degree valgus angulation in another patient. Radiographic arthritis was present in 10/36 patients (28%) at latest follow-up. Joint distraction at time of reduction was present in 27/37 patients (73%). A total of 25/37 patients (65%) had no post-operative complications, while 3/37 (8%) had a joint infection requiring one patient to have hardware removed. A total of 4/37 (11%) showed loss of reduction at latest follow-up. A total of 3/37 (8%) had a secondary arthrodesis; A total of 1 (3%) had a primary arthrodesis; 1 (3%) diabetic man had a below-knee amputation after a failed arthrodesis.
  
  
  CONCLUSIONS
  We treat severe tibial plafond fractures with a spanning external fixator at the time of injury, wait between 10 and 21 days to allow for soft tissue healing, and then perform a limited ORIF of the articular surface with canulated screws. In a group of high-energy plafond fractures, we achieved 81% good to excellent results with this protocol. We conclude that use of a spanning external fixator with delayed ORIF compares favorably with the literature.
authors.affiliation: Department of Orthopaedics, Tulane University Health Science Center, 1430 Tulane Avenue, SL32, New Orleans, LA 70112, USA.
authors.forename: K F
authors.initials: KF
authors.lastname: Dickson
authors.forename: S
authors.initials: S
authors.lastname: Montgomery
authors.forename: J
authors.initials: J
authors.lastname: Field
mesh_terms: D000328:Adult; D016512:Ankle Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D001174:Arthrodesis / Q000379:methods; D016267:External Fixators; D005500:Follow-Up Studies; D005592:Fracture Fixation / Q000379:methods*; D005593:Fracture Fixation, Internal / Q000379:methods; D017102:Fracture Healing; D018460:Fractures, Comminuted / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008297:Male; D011183:Postoperative Complications; D011859:Radiography; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome