Classification of long bone fractures AO (Association of Osteosynthesis)

Tibia fracture

Tibia fractures

The tibial bone, or tibia, is a long tubular bone located in the lower limb between the knee and foot. Tibial bone fractures are a fairly common occurrence, usually resulting from trauma or repeated overload on the bone.

In some cases, the only symptom of a minor fracture is pain in the lower leg while walking. In more severe cases, a bone fragment may protrude through the skin.

Recovery and healing times vary depending on the type and severity of the tibia fracture. Treatment of fractures should be carried out by specialists, and exercises performed by the patient independently at home can speed up recovery.

What is a tibial fracture?

According to the American Academy of Orthopedic Surgeons, the tibia is the most frequently fractured bone of all the long bones in the human body. Fractures also include cracks.

The tibia is one of the bones, along with the fibula, that form the skeleton of the lower limb.

The tibia plays a key role in the biomechanics of body movement, being:

• The larger of the two bones of the lower limb
• Responsible for maintaining body weight
• A necessary element for correct biomechanics of movements in the knee and ankle joints

A tibial fracture often occurs in combination with other types of damage to surrounding tissues: muscles and ligaments. To clarify the diagnosis, an examination by a doctor is always required.

Different types of tibial fractures

Depending on the cause and circumstances of the injury, the severity and type of fracture sustained may vary. The fracture can be transverse, which means the fracture line is located across the long axis of the bone, or oblique, in which case the fracture line will be at an angle.

Proximal fractures are those fractures that affect the upper part of the tibia. Fractures of the body of the tibia are located below.

The following types of fractures are typical for the tibia:

• Stable fracture . A stable fracture is a crack in the bone. In this case, the bone fragments maintain their normal, correct position. This type of fracture is called a nondisplaced fracture.
• Displaced fracture . In this case, a shift of bone fragments occurs relative to each other, the bone no longer represents a single whole. In such cases, surgical intervention is often required to correct the relative position of the fragments.
• Stress fractures. This type of fracture often occurs when there is increased stress on the bone. A fracture is a small, thin crack in the bone.
• Spiral fracture . This type of fracture occurs when the cause of the fracture is a twisting motion.
• Comminuted fracture . With this type of fracture, there may be three or more fragments.

When a bone fracture occurs, bone fragments can either remain under the skin or disrupt its integrity and end up outside. Open fractures are those fractures in which the ends of the fragments are visible. With closed fractures, the bone does not damage the bone covering, although damage to internal tissues may also occur.

Causes of tibia fractures

Long tubular bones in the human body are quite elastic, but there are many situations in which their fracture is possible. These are:

• Traumatic injuries: injuries from road accidents or falls
• Sports injuries, such as long-distance running
• Injuries from contact sports such as American football
• Osteoporosis, which makes bones more fragile than normal

Signs of a tibial fracture

• Local pain in one (in the case of a single fracture) or several (in the case of multiple fractures) areas of the tibia
• Edema of the lower limb
• Difficulty or inability to walk, stand, or lift weights
• Visible lower limb deformity or unequal leg lengths
• Bruising or other discoloration of the skin around the shin bone
• Changes in sensation in the foot area
• Protrusion of bone fragments through the skin with their characteristic tension

Establishing diagnosis

To make a diagnosis, the doctor first interviews the patient to clarify the patient's medical history and the circumstances of the injury. After this, an examination and other diagnostic tests will be performed to assess the extent of the damage and the presence of a fracture as such. This is important for choosing the most optimal treatment method.

Diagnostic tests may include:

• X-ray examination
• Computed tomography (CT scan), which provides a three-dimensional image of the bone
• Magnetic resonance imaging (MRI) to obtain detailed images of the muscles, ligaments and bones in the area of ​​injury. MRI scanning is often used in cases where other research methods have not been sufficient to make a diagnosis.

Continued: Treatment of tibial fractures

fracture, fracture of the tibia

Classification of long bone fractures AO (Association of Osteosynthesis)

With the goal of simplifying clinical diagnosis, strategically assessing the severity and prognosis of injury, and creating a "common language of concepts" among traumatologists, Maurice E. Muller created the AO classification of long bone fractures .

General provisions for the classification of bone fractures according to AO

In general terms, Müller suggests presenting fractures of all tubular bones in the human skeleton in the following form (see diagrams, drawings, tables).

AO/OTA numbering system with anatomical location of fractures of three bone segments

Proximal segment = 1, diaphyseal segment = 2, distal segment = 3

Alphanumeric structure of the AO Muller classification of long bone fractures for adults

Designation of the anatomical location of the fracture according to AO

The anatomical location of the fracture is indicated by two numbers: the first for the bone, the second for its segment (the ulna and radius, as well as the tibia and fibula, are regarded as one bone). The proximal and distal segments of the long bones are defined using a square whose sides are the same length as the widest part of the epiphysis (exceptions 31- and 44-).

Determining the type of fracture in long bone fractures in adults

The exceptions are fractures of the proximal segment of the humerus (11-), proximal segment of the femur (31-), bones (44-), subacetabular fracture (32-)

Diaphyseal fractures

Stages of diagnosing diaphyseal fractures

Classification of diaphyseal fractures into three groups

Segmental fractures

Stages of diagnosis of segmental fractures

Classification of segmental fractures into three groups

Particular provisions of the classification of bone fractures according to AO

Classification of humerus fractures according to AO (1)

Classification of forearm fractures: radius and ulna according to AO (2)

Classification of femur fractures according to AO (3)

Classification of tibia fractures: tibia and fibula according to AO (4)

Classification of ankle fractures according to AO (44)

Features of treatment and rehabilitation for fractures

Treatment of fractures in older people can be conservative or surgical. The decision is made by the attending physician, taking into account the location of the injury.

1. Radius. For a non-displaced fracture, a plaster splint is applied. When the bones are displaced, they are connected with knitting needles to ensure smooth fusion. During the rehabilitation period, a set of exercises is prescribed aimed at restoring mobility of the fingers and wrist.
2. Shoulder neck. If there is no displacement, a fixing bandage is sufficient for healing. For a complicated fracture, a plate is applied. The bones are returned to their anatomically correct position using the method of skeletal traction - fixation of damaged limbs using weights.
3. Brachial bone. A plaster cast is applied to the arm and secured with a bandage in a bent position at the elbow. Skeletal traction and surgery may be required if there is displacement.
4. Femoral neck. The conservative method of treating a femoral neck fracture is not enough. Refusal to undergo surgery is fraught with death (the probability of patient death within the first year after injury reaches 60%). The damaged joint is restored using metal spokes, pins, and plates. In case of total destruction due to progressive osteoporosis, endoprosthetics is performed - the affected joint is replaced with an artificial bone joint.
5. Femur. This area requires a special approach. The tissue in older people cannot heal properly without additional intervention. You will need to install an implant or parts that fix the bone tissue.
6. Tibia. The displacement is corrected during surgery - knitting needles and screws are installed on the bone. Plaster is applied on top.
7. Ankle. A plaster splint with a metal insert on the heel is placed on the ankle, which will allow you to move without relying on crutches.
8. Spine. Conservative treatment in a hospital involves complete rest for 1-3 months. The patient will need a special bed with the ability to adjust the height of the backrest and fixing tapes to secure the affected vertebrae.

It is important to understand not only how to treat a fracture in older people, but also how to speed up rehabilitation after an injury. Exercise therapy plays a key role in the recovery period. The doctor selects a set of exercises that are safe for the patient. It takes into account his age, the presence of concomitant diseases, the nature and location of the fracture.

To make recovery from fractures in older people faster, physiotherapy is included. Magnetic therapy is useful - the effect of magnetic fields on the affected areas of the body. This effect improves blood circulation, ensures the flow of oxygen and nutrients to bone tissue.

Journal "Trauma" Vol. 12, No. 2, 2011

Introduction

Intra- and periarticular fractures of the distal tibia account for about 1% among fractures of all locations and up to 9% among all fractures of the tibia [1].
The use of the term “pilon fracture” is due to the fact that pilon translated from French means “club” or “rammer”, and the mechanism of injury in these injuries is characterized by the impact of the talus block, like a club, on the distal tibia [2]. Errors in the diagnosis and treatment tactics of fractures of the distal leg bones remain quite common and cause a long period of disability, and in some cases lead to disability. One of the reasons for these failures is an inadequate approach to treatment when orthopedic traumatologists try to treat injuries such as ankle fractures. Currently, the standard approach to treatment is a tactic based on the AO classification (Fig. 1) [3, 4].

Purpose of the study: to present the features of treatment tactics for pilon injuries and their consequences.

Materials and research methods

The study was conducted based on the results of treatment of 2 groups of patients with closed injuries.

Group I consisted of 11 patients aged from 24 to 45 years (men - 8, women - 3), who underwent surgical interventions in the acute period of injury. Among the victims, type A fractures were noted in 5 cases, B - in 4 cases, C - in 2 cases.

Group II consisted of 9 patients aged from 28 to 60 years (men - 7, women - 2), who had persistent deformities that developed against the background of inadequate surgical tactics and disorders of reparative osteogenesis. The most common types of deformity were varus and antecurvatio.

Diagnostic measures in the first group necessarily included: assessment of the condition of soft tissues (presence and severity of edema), taking radiographs in two standard projections. CT was performed as indicated to assess the degree of bone damage, determine the number of main fragments and their displacement, as well as the severity of damage to the articular surface of the tibia.

When treating the consequences of injuries to develop treatment tactics, in addition to the types of studies used in acute cases, the following were carried out: ENMG, Doppler sonography, densitometry (if indicated), assessment of the condition of soft tissues to determine a rational surgical approach (presence, severity and extent of scar changes).

General principles of treatment

Fresh damage

The choice of treatment tactics is determined by the nature of the damage. Thus, for extra-articular fractures (type A), conservative treatment with simultaneous reduction and fixation with a plaster cast is acceptable. This type of treatment is preferable for patients with severe comorbidities. The possibility of using minimally invasive technologies should be considered as the method of choice for relatively simple fractures with minimal displacement of fragments (type A or type B). The absolute indications for surgical treatment for closed injuries are complex comminuted intra-articular fractures (type C) with displacement of fragments involved in the formation of the articular surface by 2 mm or more, unstable fractures of the metaphysis of the tibia. The key point regulating the time of surgical intervention is the condition of the soft tissues, and therefore in some cases it is justified to carry out surgical intervention delayed by 7–10–14 days.

The standard of surgical treatment for closed fractures is surgery performed from 2 approaches. Separate approaches are made to the fibula and tibia. The key points and objectives of the intervention are: restoration of segment length, axial relationships, integrity of the articular surface of the distal tibia, stable osteosynthesis.

The technology of standard surgical intervention involves the following sequence of actions:

1) reconstruction of the fibula and its stable osteosynthesis;

2) restoration of the articular surface of the tibia;

3) replacement of the resulting bone defect with a bone autograft;

4) fixation of tibial bone fragments using a bone plate as a support [3–5].

As an illustration, we provide the following clinical example.

Patient L.A.I., 36 years old, was admitted to the institute’s clinic on September 5, 2008.

He was injured on August 29, 2008, in a fall from a height of 2.5 m. He was treated for 7 days in the trauma department at his place of residence using bedside skeletal traction, then transferred to the institute. Locally - pronounced swelling of the right ankle joint with gross deformation and the presence of epidermal blisters on the back surface of the leg with extensive interstitial hematomas. Swelling and hematomas of the left foot.

An X-ray of the right shin including the ankle joint reveals a comminuted intra-articular fracture of the epimetadiaphysis of the tibia and a comminuted fracture of the fibula, which corresponds to a type C3 injury (Fig. 2). To clarify the severity of damage to bone structures, displacement of fragments and the severity of damage to the articular surface of the tibia, spiral tomography of the fracture zone was performed with 3D reconstruction (Fig. 3). An x-ray of the left foot reveals a comminuted intra-articular fracture of the calcaneus with outward subluxation and displacement of fragments.

During the preoperative preparation, decongestant therapy and skin sanitation were carried out. On September 8, 2008, an operation was performed: open reduction of bone fragments of the right leg, bone osteosynthesis. Due to the patient's categorical refusal to perform open reposition of the calcaneal bone fragments, a one-stage reposition was performed using a rod as a joystick (passed through the heel), followed by fixation in a plaster cast and removal of the rod (Fig. 4).

Features of surgery

The operation was performed using 2 approaches. First, from an approach in the projection of the posterior edge of the fibula, open reduction of fragments of the fibula was performed, stabilization with a 1/3 tubular plate LCP (2 + 2).

Then an anteromedial approach was performed (the distance between the approaches was at least 9 cm). When examining the area of ​​the tibia fracture, it was determined that there were multiple free small fragments that were removed. After comparing the fragments involved in articulation, preventive fixation of the inner malleolus with a part of the epiphysis of the tibia with pins was performed (Fig. 5). Then, external osteosynthesis was performed with an LCP plate, designed for fixation of these fractures, modeled according to the template (Fig. 6).

The postoperative course is smooth, healing by primary intention. In the postoperative period, he received complex medication and physiotherapeutic treatment. 4 months after surgery, healing of the fractures was observed, and the patient was allowed full weight-bearing on both lower extremities, which allowed him to return to his previous type of work. The patient is equipped with orthopedic insoles. Clinical and radiological examination revealed osteoarthritis of the right ankle joint.

Distinctive features of surgical tactics in the treatment of consequences of pilon injuries with the presence of deformities

Features of surgical interventions are determined by the following factors:

— the presence of persistent deformation of both bones of the leg, which developed against the background of disorders of reparative osteogenesis and inadequate load;

— the presence of metal fixators, often deformed and not performing their function;

— the presence of scarred skin, intimately fused to the underlying bone tissue;

- trophic disorders of the skin, mainly along the anterior internal surface of the lower third of the leg;

— the presence of neurodystrophic syndrome;

— the presence of severe regional osteoporosis, including that caused by a long period of non-weight-bearing of the limb.

Stages of surgical treatment (using the example of a healed fracture with residual deformation and the presence of metal fixators on both bones of the leg):

— removal of metal fixatives;

— corrective osteotomies of the fibula and tibia;

— restoration of the axial relationship of the fibula and tibia, preventive fixation;

— stable osteosynthesis of both bones of the leg, starting with the fibula;

— filling the resulting defects in the fibula and tibia with autologous bone and ceramic implants.

As an illustration, we provide the following clinical example.

Patient L.Yu.N., 48 years old, was admitted to the institute’s clinic on June 2, 2008, 5 months after the injury received on January 30, 2008, when he fell on the street.

Primary diagnosis (according to the presented extract from the medical history): closed comminuted intra-articular fracture of the distal epimetaphysis of the left tibia, fracture of the lower third of the fibula with displacement of fragments.

An operation was performed at the place of residence: open reduction, external osteosynthesis of fractures of both bones of the left leg with additional fixation with a plaster cast. After 3 months, the axial load was resolved, after which the development of deformation was noted, increasing as the load continued. At the time of admission, the following were noted: deformation of the lower third of the leg varus - 25°, antecurvatio - 27°, impaired support function of the limb and function of the ankle joint (Fig. 7, 8). When analyzing the radiographs, attention is drawn to the features of the performed osteosynthesis, namely the lack of adequate fixation of the distal epimetaphysis with the location of the plate along the anterior outer surface.

On June 19, 2008, 5.5 months after the injury, surgery was performed. From 2 approaches, after removing both plates, corrective osteotomies of the fibula and tibia were performed (at the apexes of the deformities), followed by normalization of the axial relationships. Then, external osteosynthesis of the fibula with a 1/3 LCP tubular plate and the tibia with an LCP “clover leaf” plate was performed (Fig. 9).

The postoperative course is smooth, healing by primary intention.

Currently, there is consolidation of fractures of the leg bones, restoration of the limb's ability to support, and the patient's return to his previous type of work.

There is a limitation of movements in the ankle joint (plantar/dorsal flexion: 30°/0/10°) due to post-traumatic osteoarthritis of the ankle joint (Fig. 10). The patient receives periodic courses of conservative therapy for osteoarthritis and uses orthopedic insoles.

Postoperative management of patients

The basic principles of managing patients of both clinical groups in the postoperative period are almost the same, however, the duration of each stage of rehabilitation and the features of drug correction are determined individually and are based on the severity of damage to bone and soft tissue structures, the severity of reparative processes, the condition of articulating surfaces (especially important when treating the consequences of fractures with long-term deformities). The complex of treatment measures must necessarily include: anti-inflammatory, decongestant, chondromodulatory and osteotropic therapy, physiofunctional treatment with mandatory monitoring of reparative osteogenesis. In the postoperative period, it is mandatory to take control radiographs 2, 6 and 12 weeks after surgery. Full axial load on the operated limb is allowed once fusion is achieved.

Treatment results

The results of treatment in all patients of both groups were assessed over a period of 4 months to 2 years. Fracture healing was observed in all patients, however, the average healing time among patients of the first group was 4 months, and in patients of the second group - 6.5 months, with a significant decrease in the function of the ankle joint in patients of the 2nd group with the development of osteoarthritis.

conclusions

1. Damage to the pilon refers to severe damage not only to osteochondral formations, but also to soft tissue structures.

2. Pilon injuries differ significantly from “trimalleolar” fractures according to the following criteria:

— mechanogenesis of injury (axial compression with significant force in case of pilon injuries, predominantly rotational mechanism in ankle fractures);

— localization and severity of damage to bone/cartilaginous and soft tissue formations;

— approaches to treatment and tactics of surgical intervention.

3. To achieve good treatment results, a thorough preoperative examination, planning of the sequence of surgical stages, anatomical reposition of fragments of articulating surfaces, stable osteosynthesis, replacement of bone defects, monitoring of the reparative process of bone tissue and soft tissue formations with individual rehabilitation are necessary.

Treatment of tibial pilon fractures

Pilon-type fractures, or intra-articular fractures of the distal metaepiphysis of the tibia, are often comminuted in nature and are accompanied by pronounced trophic disorders in the soft tissues in the area of ​​injury [1].

In the scientific literature regarding this type of injury, the following terms are recognized as interchangeable: “intra-articular fractures of the distal tibia”, “pilon fracture”, “plafond”, “intra-articular fracture tibia” [2].

Due to the variety of options for pilon fracture, there are different approaches to the treatment of this pathology. New fixators are being created, preoperative preparation, surgical techniques are being improved, the significance of classifications is being assessed, and a statistical analysis of the results of treatment of patients with intra-articular fractures of the distal metaepiphysis of the tibia is being conducted. At the moment, many works are being published on pilon fractures, which indicates the relevance of the topic and the unresolved problem of treating patients with this pathology.

French radiologist Er tienne Destot in 1911. introduced the term “tibial spine” into medical practice, reflecting a specific mechanism of injury in which an axial load acting through the talus bone led to destruction of the distal tibia. From French, “pilon” translates to “pestle,” which pharmacists used to crush pieces of drug solids in a cup to prepare medicine [2].

In 2005, S. J. Topliss et al. gave the following definition: “...pilon fractures are fractures involving the horizontal articular surface of the distal tibia with proximal extension of the fracture line.” According to S. Mauffrey (2011), this is “an anatomical region that includes the articular surface of the distal tibia. The proximal border runs 8-10 cm from the articular surface of the ankle joint, where the transition of the metaphysis into the diaphysis with its triangular configuration is formed."

I.P. Kondratyev (2014) gives a topographic-anatomical definition of the pilon zone: “The distal metaepiphysis of the tibia (“pilon”) is an irregularly shaped figure, the height of which is equal to its base” [1,3].

The incidence of pilon fractures is 7-10% of all skeletal trauma; 20-32.8% of intra-articular fractures of long tubular bones; 9% of tibial fractures and about 2% of lower extremity fractures. This pathology predominates among men (57-65%) of working age [4, 5].

According to Russian authors, among the causes of high-energy pylon fractures, the leading positions are occupied by falls from a height (44-49.1%) and road traffic accidents (20.4-27%). According to foreign authors, among the main causes of pylon fractures, road traffic accidents prevail over falls from height. Sometimes intra-articular fractures of the distal tibia occur due to low-energy trauma: for example, when playing sports or falling on the street in icy conditions, there are reports of a pilon fracture due to prolonged compression [1].

An intra-articular fracture of the distal metaepiphysis of the tibia is mainly part of a polytrauma, but can also be an isolated injury. However, in both cases, nearby anatomical structures are also damaged. The talofibular ligament complex is damaged 8 times more often than the integrity of the fibula is damaged. Quite often, an avulsion fracture of the lateral tibia (anterolateral, posterolateral) occurs, leading to functional diastasis with widening of the notch and instability in the ankle joint [3].

In the structure of polytrauma, a pilon fracture is part of a multiple injury in 54.6% of cases, and a combined injury in 45.4% of cases. Most often, this pathology is combined with traumatic brain injury - 26.9%, chest injury - 11.1% and foot injuries - 9.3%, less often - with injuries to the upper limb - 6.5%, spine - 5.5 % and hips - 4.6%. In 71.9%, this pathology is accompanied by the development of shock. According to foreign authors, pilon fractures can be combined with long-term compression syndrome of the pelvis and acetabulum, and contralateral injuries of the tibial plateau [1,6].

The variety of forms of intra-articular injuries of the distal tibia, as well as types of soft tissue damage, is the main problem in creating a unified working classification that determines the specific method and method of treatment [1-3,7].

The classifications most used in practice and science - TR Riiedi and M. Allgower (1969), JSC/ASIF, S. J. Topliss (2005) and X. Tang, DC Lu (2012) - are based on data from radiation methods studies: radiography or computed tomography. They reflect the anatomical characteristics of this pathology, which includes the location of the fracture and its direction, the number and degree of displacement of fragments [2, 3, 7, 8].

Mainly in the world, the classification of RB Gustilo, JT Anderson for open injuries and HG Tscheme, HJ are used to assess the degree of soft tissue traumatization. Oestem for closed ones. The classification by RB Gustilo, JT Anderson takes into account the characteristics of bone damage, the size of the wound, the degree of its contamination, as well as the presence of damage to blood vessels and nerves. There is a correlation between the degree of soft tissue damage and the likelihood of developing purulent-necrotic complications. The HG Tscheme, HJ Oestem classification divides closed soft tissue injuries into 4 degrees. Grade O: minimal soft tissue damage. I degree: superficial abrasion or contusion of soft tissues. II degree: deep damage to soft tissues with contusion of the skin and muscles. III degree: extensive contusion with crushing of the skin and soft tissues, compartment syndrome with probable damage to the great vessels and nerve trunks [1, 2, 9].

Classification SM Abdelgaid, M.A. Ahmed and EG Abdel-Mageed (2013) is a combination of the classification of fractures of the distal metaepiphysis of the tibia according to AO and soft tissue injuries according to the HG Tscheme and was developed for preoperative planning of a minimally invasive treatment method: MIPO (minimally plate invasive osteosynthesis), screws, AVF. It is based on the division of the skin into three zones (A, B, C), which are assessed according to the HG Tscheme, which is taken into account in minimally invasive osteosynthesis [10].

The accuracy and reproducibility of pilon fracture classification systems remain a matter of debate to date, FJ Muller, M Nerlich, (2010), RL. Noth (2011) report their imperfection and conditionality [7].

A conservative method of treating intra-articular fractures of the distal tibia, based on closed reduction followed by long-term immobilization with a plaster splint and a skeletal traction system, is currently advisable to use in patients with severe concomitant pathology or in cases where arthrodesis of the ankle joint is planned [ 1, 4, 7].

Today, surgical treatment of fractures of the distal metaepiphysis of the tibia, successfully used since 1950, has become the main one [5]. A study of long-term results of treatment of fractures of the distal metaepiphysis of the tibia showed that the surgical approach significantly improves the outcome of the disease. Surgical treatment options include internal and external osteosynthesis, but there is no universal method used for all types of pilon fractures. Surgical treatment of intra-articular fractures of the distal metaepiphysis of the tibia is based on basic principles: minimal trauma, maximum restoration of anatomy, stable fixation and early activation [1, 9,11].

T.R. Ruedi, M. Allgower in the 60s published the results of treating patients with pilon fractures using the open reduction and internal fixation (ORIF) technique. Excellent and good results were about 74% [1, 5, 9]. Other investigators have reported a large number of unsatisfactory results using the ORIF technique. The number of satisfactory outcomes prevails in the group with low-energy pilon fractures [12–14].

Quite often, unsatisfactory results of treatment of pilon fractures are associated with underestimation of the degree of damage to the soft tissues of the injured limb. The high percentage of complications with internal fixation initiated a scientific search for a solution to this problem. Studies have appeared that indicate a decrease in negative treatment results with internal fixation of comminuted fractures of the tibia in combination with external fixation. Thanks to this technique, the number of satisfactory outcomes in the case of comminuted burst fractures of the distal metaepiphysis of the tibia increased to 67-81%, the frequency of wound suppuration decreased to 8% [9,15].

According to some authors, in all cases where possible, the use of the MIPO concept—minimally invasive plate osteosynthesis—is indicated [1, 16, 17]. However, according to some authors, the advantages of the MIPO concept over ORIF are questionable. The lack of good visualization with the MIPO technique determines the high incidence of inaccurate reduction [18]. Also, a number of studies have reported that the use of the MIPO technique is associated with more complications than ORIF. Therefore, in all cases where possible, it is recommended to use the technique of open reduction and internal fixation [19]. According to M. Leonard et al. (2009), the use of a minimally invasive technique for the treatment of pilon fractures is possible for fractures of types I and II according to the Ruedi classification or 43B1, 43B2, 43C1, 43C2 according to the AO classification. In some cases, this technique can be used for fractures of AO 43B3 and 43C3. The use of the MIPO technique is not recommended for severe comminuted pilon fractures with soft tissue damage [5].

The choice of implant in the surgical treatment of intra-articular fractures of the distal tibia is an important condition for a positive result. Fixation with T- or L-plates and screws has been used for many years. A strong fixation is formed between the plate and the bone. To perform osteosynthesis with these fixators, it is necessary to severely expose bone fragments and bone, as well as to injure the surrounding soft tissues [20, 21].

The use of a monoaxial or polyaxial LCP plate (locking compression plates) eliminates direct contact of the plate with the bone. The polyaxial model of the LCP plate allows you to select the screw angle [19, 22, 23].

In 2007, DePuy Orthopedics, Inc. (Warsaw, California, US) released an implant called ALPS (“anatomic locked plating systems”). The peculiarity of this design is the combination of anatomical design with a hybrid (mono- and polyaxial) screw fastening technique. In the article by N. Tap et al. (2011) published clinical and functional results of treatment of 21 patients with a closed pilon fracture using medial and anterolateral ALPS plates. All results were regarded as good, with 15 patients returning to their previous work [24].

In 2006 I.A. Redko proposed an original method for the treatment of pilon fractures combined with fibula fractures, which consists in sequentially repositioning and fixing both damaged segments from one access using bone plates (patent for invention No. 2317787, Bulletin of Rospatent No. 6, 2008) [ 25].

J. Hong (2011) described a technique for surgical treatment of intra-articular fractures of the distal tibia with severe soft tissue damage using the “posteromedial anatomical plate” developed by him and his colleagues, which is an exact anatomical “imprint” of the posteromedial surface of the adult pilus. The studies included patients with open and closed fractures. 69.2% of patients had a fracture of the fibula. The postoperative period in all patients proceeded smoothly, without complications. Long-term results were assessed using the Ankle-Hindfoot scale from 12 to 43 months after surgery: excellent in 10 patients (38.5%), good in 13 (50.0%), good in 3 (11.5%). - satisfactory. Not a single patient experienced not only implant rejection, but also any discomfort associated with the posteromedial placement of the plate they developed [26].

One of the important principles of the concept of immersion osteosynthesis is the choice of optimal surgical access. Surgical access to a pilon fracture must meet several basic requirements: minimal trauma to soft tissues, the ability to perform adequate reduction and osteosynthesis.

The anteromedial approach is located 0.5 cm below the joint space, slightly medial to the tibialis anterior tendon, lateral to the medial malleolus, proximal to the medial edge of the dome of the talus. To maintain normal vascularization of soft tissues and prevent their ischemia, the distance between the approaches to the external ankle and the pilon should be at least 6-7 cm, but if necessary, the distance can be reduced to 5 cm [1,7,18,27].

An anterolateral approach to the pylon is performed between the extensor tendon of the fifth finger and the lateral malleolus, starting 0.5 cm distal to the joint space of the ankle joint and continuing proximally above the lateral part of the dome of the talus. The use of an anterior external approach is considered minimally traumatic for the surrounding soft tissues. However, some researchers believe that it is necessary to conduct retrospective multicenter studies that adequately assess the level of long-term postoperative complications [18, 28—30].

Both approaches can be used successfully and provide good functional results. However, intraoperative difficulties and complications in the postoperative period when performing the anterolateral approach are less common [1].

Many surgeons use a posterior approach. Performing this approach is technically simple, and placing the plate on the posterior surface of the tibia is safe due to the tibialis posterior muscle, which protects the adjacent tibial artery, vein and nerve [31]. L.F. Amorosa et al. (2009, 2010) recommend using a posteromedial or posterolateral approach in the surgical treatment of pilon fractures that occur under the combined influence of rotational and axial loads [32].

According to T. Bhattacharyya et al. (2006), the posterolateral approach is advisable to use only as an alternative, in cases where there is no other option [33]. J. Hong et al. (2011) believe that posteromedial access

fully meets the requirements for the treatment of pilon fracture. Its use is of particular importance in cases of severe soft tissue damage [26].

Due to the fact that pilon fractures are accompanied by significant damage to soft tissues and the use of immersion osteosynthesis can potentially cause unsatisfactory treatment results, the use of transosseous osteosynthesis does not lose popularity [9].

Difficulties in choosing the right tactics and method of treatment are often associated with the condition of the soft tissues in the fracture zone. From the moment of injury, edema forms in a short time, which leads to disruption of the trophism of surrounding tissues due to the development of interstitial hypertensive syndrome. Against the background of these local changes, the formation of hemorrhagic bullous dermatitis and even necrosis is possible, which significantly reduces the possibility of using surgical treatment. In such cases, it is recommended to use the Ilizarov apparatus [34].

This method is low-traumatic for soft tissues and in some cases allows for precise reposition of fragments, stably fixing them and beginning early rehabilitation [4, 34].

Absolute indications for the use of the concept of transosseous osteosynthesis using the Ilizarov apparatus include pilon fractures with significant soft tissue damage or a predisposition to the development of local trophic disorders.

Valid indications include: a high intra-articular fracture reaching the diaphysis of the tibia, significant loss of bone tissue at the transition of the diaphysis to the metaphysis, fragmentation of the intra-articular surface of the tibia, a crushed fracture of the fibula. Relative indications include cases when the Ilizarov method does not have any advantages over other methods of surgical treatment [9, 34].

The great advantage of using the transosseous osteosynthesis technique is the possibility of functional load on the operated limb, movements in the ankle, which stimulates fracture healing. The main disadvantages of transosseous osteosynthesis are the possibility of infectious complications, psychological discomfort of the constant presence of an external fixator, and the need to care for the device [1, 7, 9].

When a satisfactory position of the fragments is achieved and maintained, the hardware method of treatment remains the main one. The criteria for satisfactory position of fragments are as follows: restoration of the length and axis of the fibula and tibia has been achieved; 80% of the articular surface in the area of ​​the previously existing articular surface is congruent to the talus trochlea. If at least one of the criteria is absent, the position of the bone fragments is considered unsatisfactory. In such cases, open reduction is necessary.

The use of transosseous osteosynthesis as the initial and main method of treatment is limited by the timing of the formation of scar tissue in the interfragmental space. In this regard, after 15-30 days, the use of the ligamentotaxis mechanism is ineffective.

Currently, due to the high level of complications associated with the initial condition of the soft tissues, the concept of two-stage treatment of pilon fractures is widely used. In the acute period of injury, when there is significant swelling or unsatisfactory condition of the soft tissues, immobilization is performed by installing a skeletal traction system or an external fixation device, and at the second stage, final fixation is performed [15, 35].

To some extent, the two-stage protocol for treating a pilon fracture is a frequent case of the “damage control” concept applied locally [1].

The first stage is performed as early as possible from the moment of injury. At this stage, reposition and fixation of fragments occurs, as well as, if necessary, primary surgical treatment of wounds. The period of transition to the second stage of treatment for a pilon fracture, according to different authors, varies [1, 9].

Thus, RK Gupta et al. (2010) recommend moving to the second stage of treatment within 3-8 days. When a pilon is fractured in the surrounding soft tissues, the microcirculatory network of vessels is partially destroyed, and the pathophysiological chain of formation of local tissue hypoxia and acidosis is triggered. These changes are compensated within approximately 5-7 days. Additional trauma during this period in the form of surgery is fraught with the development of complications such as delayed consolidation or non-union of bone fragments, wound infection, osteomyelitis. FJ Muller, M. Nerlich (2010) report the optimal implementation of the second stage in the period 6-21 days from the moment of surgery, DB Thordarson (2000), JL Marsh et al. (2003), S. Mehta et al. (2011) - 5-14 days. M.V. Nierengarten et al. (2001) believe that final fixation should be performed only after a few weeks. RP Dunbar et al. (2007), MJ Gardner et al. (2008), P. L. Noth et al. (2011) indicate a period of 3 weeks. According to LKCannada (2010), no earlier than 4 weeks [7,36]. In fact, you cannot rely solely on the deadlines proposed by many authors. According to clinicians, the optimal time to perform the final stage of surgical treatment is the appearance of wrinkling on the skin (“a symptom of the appearance of wrinkles”) in the area of ​​the fracture, which indicates regression of pathological processes in the soft tissues [36]. The delay time allows not only to improve the condition of the soft tissues, but also to finally determine the access site and its size in compliance with the principle of minimal trauma to soft tissues. The second stage of surgical treatment of a pilon fracture can occur using both transosseous and immersion osteosynthesis options. In cases where restoration of the fractured articular surface of the tibia is not possible, primary arthrodesis of the ankle joint is performed. In some cases of minimally invasive surgical treatment of an intra-articular fracture of the distal metaepiphysis of the tibia, arthroscopic assistance is used to control the condition of the articular surface. However, there are also opponents of this procedure [37].

Treatment outcomes depend on many factors: age, bone tissue condition, general premorbid background (diabetes mellitus, cardiovascular pathology, long-term use of anticoagulants, reduced immunity), choice of treatment method. It must be remembered that over the age of 50 years, 50-55% of people develop osteopenia [1]. The nature of the fracture and the characteristics of soft tissue damage also affect the results of treatment. For example, the greatest likelihood of developing osteoarthritis and chronic pain is typical for comminuted intra-articular fractures [9, 34]. Unsatisfactory treatment results are observed in 10–54% of cases. In 6 - 8% of patients with this disease, persistent or long-term disability occurs due to the early development of post-traumatic deforming arthrosis (60 - 80%), joint deformation (12 - 20), contractures (29 - 50%), affected by pain syndrome [5]. This often becomes the reason for a repeated, more aggressive operation—arthrodesis of the ankle joint [34].

The results of surgical treatment of patients with pilon fractures are recommended to be assessed in the short and long term after surgery [1, 3, 5, 7]. In the first case, the criteria for assessing the outcome of treatment are the duration of treatment at the inpatient and outpatient stages, the nature of early postoperative complications (infection of surface tissues, necrosis and osteomyelitis), the timing of limiting the load on the operated limb [1 ,4, 9].

In the long-term period after surgery (a year or more), the outcome is assessed based on such criteria as the number and nature of complications that developed after the end of treatment. The degree of restoration of the function of the damaged limb as a whole is taken into account, as well as the need for repeated surgical interventions. The main criteria for the quality of treatment of an intra-articular fracture of the distal metaepiphysis of the tibia are: range of motion in the ankle joint, congruence of articular surfaces and stability of the ankle and subtalar joints [1, 4, 5].

Some characteristics can be assessed in isolation from others. For example, the range of motion in the ankle joint is assessed in different planes using the international SFTR method. The abbreviation means the following: S—movements in the sagittal plane, F—in the frontal plane, T—in the transverse (“transversal”) plane, R—rotational movements. The neutral position of the foot at the ankle joint is 90°. In a healthy ankle joint, the range of motion is as follows: S: 20° - 0° - 45°: dorsal - extension (20°), plantar - flexion (45°).

To determine the radiological stage of post-traumatic osteoarthritis, the classification of J. Kellegren and J. Lawrence (1957, 2002) is used, based on an assessment of the degree of narrowing of the joint space and the size of osteophytes [9].

The consequences of a pilon fracture, like any other disease, should be assessed using specially developed scales, tests and questionnaires. These methods make it possible to objectively assess the patient’s quality of life as a whole or to characterize in detail the area of ​​damage, disability or social limitations. It is most correct to use mixed scales to evaluate results, which include a questionnaire for the patient and data from a clinical examination [1].

The Olerud-Molander Ankle Score (OMAS), introduced in 1984, is one of the first scales to evaluate the results of surgical treatment of ankle fractures. This scale is actively used in our time. After some time, scoring scales appeared, such as Kaikkonen scale, Iowa Ankle Score, Maryland foot score systems. Currently, the most commonly used systems for long-term treatment outcomes are the Ankle/Foot scale, the modified Mazur scale and the SMFA scale [1, 4,17].

The American Orthopedic Foot and Ankle Society (AOFAS) in 1994 recommended a new classification that evaluates objective and subjective factors characterizing functional status, pain, and quality of anatomical reduction. The Ankle/Foot scale is characterized by ease of use, a sufficient level of validity and sensitivity. Treatment results are assessed depending on the sum of points from 0 to 100: 90 - 100 - excellent, 80 - 89 - good, 50 - 79 - satisfactory results [1, 9,16].

When assessing the results of treatment of intra-articular fractures of the distal tibia, specialists from the Westchester Medical Center of the University Hospital of New York use the modified Mazur score and the Short Form-36 Version 2.0 questionnaire. Both scales have a fairly high level of reliability, validity and sensitivity [1, 17].

One of the most used rating scales in medicine is the Short Form-36 (SF-36). It consists of 8 blocks containing 36 questions. Of these, 21 questions are aimed at clarifying the patient’s idea of ​​his physical health, and the remaining 15-0 are aimed at mental health. In other words, the SF-36 scale allows you to obtain an objective assessment of changes in the patient’s quality of life due to injury and the treatment provided for this. Due to the relevance and versatility of the SF-36 scale, it has undergone many changes during its existence, and its various versions have appeared [1].

The SF-36 Version 2.0 ques-tionnaire is very different from the SF-36. According to a comparative study by WT Obremskey et al. (2007), dedicated to the effectiveness of the Short Form-36 and SMFA scales, the SF-36 scale, despite its recognition, has its drawbacks: limitations in assessing the consequences of musculoskeletal injury. At the same time, the authors speak positively about the SMFA scale, which fully assesses the patient’s functional recovery and quality of life, considering it the method of choice when assessing long-term results of treatment of musculoskeletal injuries [1,16].

The results of a study on a comparative analysis of three scales—the Maryland foot score, the Ankle/Foot score, and the SF-36—were presented at the annual meeting of the Orthopedic Trauma Association in 2010. The study authors claim the reliability of all three scales. However, Tometta et al. indicate the need to abandon so many existing rating systems in favor of the Visual Analog Scale pain, since the dominant criterion noted by patients is pain. You should also pay attention to criteria such as the incidence of arthritis and range of motion, and several objective criteria, such as the absolute dominant criterion that patients use when assessing their condition [4, 7, 34].

Conclusion

Based on the analyzed data from domestic and foreign literature, it can be concluded that there is a continuing search for solutions to the problems of treating patients with intra-articular fractures of the distal metaepiphysis of the tibia. Most often, fractures of this location occur in men of working age and are the result of high-energy trauma. Currently, conservative treatment of patients with This pathology is rarely used.

The complex nature of the fracture determines the high probability of unsatisfactory long-term results. Developing an algorithm for choosing surgical treatment makes it possible to reduce these indicators. Surgical treatment of intra-articular fractures of the distal metaepiphysis of the tibia is based on basic principles: minimal trauma, maximum restoration of anatomy, stable fixation and early activation. The algorithm for choosing an operative technique is based on the condition of the soft tissues and the nature of the fracture. There are various methods of surgical treatment: ORIF, MIPO, transosseous osteosynthesis, combined technique, each of which is successfully used. The issue of creating a unified working classification for choosing surgical treatment in each specific case remains relevant.