Surgical treatment of fractures of the posterior edge of the distal epimetaphysis of the tibia

The article presents and substantiates the problem of treating fractures of the ankles and the posterior edge of the distal epimetaphysis of the tibia. The features of transosseous osteosynthesis using pin-and-rod external fixation devices in the treatment of patients with various types of complex fractures of the ankle joint are shown. An analysis of the treatment outcomes of 118 patients with fractures of the posterior edge of the distal epimetaphysis of the tibia was carried out.

Surgical treatment of fractures of the tibial posterior edge distal epimetaphysis

The problem of treatment of fractures of edge posterior of the tibia is shown in this article. The aspect of osteosynthesis with the use of apparatus of external fixation in patients with different types of fractures of edge posterior of the tibia are shown. The analysis of treatment of 118 patients with fractures of the edge posterior of the tibia is performed.

Among the large group of pronation-eversion fractures of the distal articular part of the leg bones, fractures of the posterior edge of the tibia occupy a special place. This is due to the anatomical and biomechanical features of the limb segment. Features of such fractures include: polyfragmentary nature of the damage (fractures of the external malleolus or fibula along the diaphysis, often the internal malleolus, damage to the distal tibiofibular syndesmosis), damage to the capsule and ligaments of the ankle joint (deltoid, tibiofibular ligaments), significant violations of congruence in the supratalar joint, in most cases, there is very significant damage to the supporting surface of the tibia, difficulties in ensuring reposition and adequate stable fixation during the period of consolidation of fragments and fusion of the soft tissues of the joint. It should be especially noted that with such fractures, at the time of injury, a large fragment of the posterior edge of the tibia is formed, which is displaced proximally, causing gross violations of congruence in the supratalar joint with the formation of dislocation or subluxation of the foot posteriorly or posteriorly and outward.

Complications of this type of injury are the development of contractures and deforming arthrosis of the ankle joint, as well as combined post-traumatic flatfoot, which significantly impairs the function of the lower limb. Such complications, according to the literature, reach 20-37% [5, 7, 10, 11].

Conservative treatment of displaced fractures of the malleolus and posterior edge of the tibia is ineffective and is not currently used. Indications for conservative treatment may include fractures without displacement, without disruption of congruence in the supratalar joint, subject to dynamic (including x-ray) control of the limb.

Early surgical treatment of fractures of the posterior edge of the tibia is the method of choice in order to achieve reduction and ensure stable fixation of the fracture [2, 4, 6, 9, 12]. In this case, the most optimal is transosseous osteosynthesis according to Ilizarov [1, 3, 8]. Transosseous osteosynthesis techniques make it possible, in the vast majority of cases, to provide closed, gentle reduction with the elimination of all types of displacement and restoration of congruence in the supratalar joint without additional surgical trauma and circulatory impairment of the damaged limb segment.

Materials and research methods

In the Department of Traumatology for Adults of the Scientific Research - State Autonomous Institution of the Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan in 2000 - 2011. 124 patients were treated with fractures of the ankles and the posterior edge of the distal epimetaphysis of the tibia, subluxations and dislocations of the foot posteriorly or posteriorly and outward. There were 74 women, 50 men. Damage to the right ankle joint occurred in 68 patients, and to the left ankle joint in 56 patients.

In case of fractures of the ankles and the posterior edge of the tibia, the main complaints of patients were pain in the area of the damaged ankle joint, severe limitation of movements, and loss of limb support. In all cases there was evidence of previous trauma. As a rule, these are falls with the foot turned outward when the anterior part of the foot is positioned equinus. During clinical examination, there was swelling, deformation of the ankle joint, and severe pain on palpation. Active and passive movements are impossible or difficult, painful. In order to clarify the diagnosis, an X-ray examination of the ankle joint was performed in direct and lateral projections.

In the Traumatology Department of the Scientific Research Institute - now the Traumatology Clinic of the State Autonomous Institution of the Russian Clinical Hospital of the Ministry of Health of the Republic of Tatarstan - original configurations of external fixation devices based on the Ilizarov method have been developed and successfully used for the treatment of various types and types of complex fractures of the distal articular part of the tibia bones. The method of transosseous osteosynthesis and the configuration of the external fixation device that we have developed allows us to perform precise, gentle reduction of the fracture with the elimination of all types of displacements and provide stable fixation for the period of consolidation of bone tissue and fusion of the capsular-ligamentous apparatus of the ankle joint. At the same time, in most cases, the methods of transosseous osteosynthesis and the configuration of external fixation devices ensure a closed surgical intervention.

Transosseous osteosynthesis for fractures of the outer malleolus or fibula along the diaphysis, inner malleolus, posterior edge of the tibia, posterior or posterior and outward displacement of the foot.

The configuration of the external fixation device consists of ring and semi-ring supports of the Ilizarov set, interconnected by means of threaded rods, as well as a support of a movable repositioning unit, which is installed on the ring support of the device by means of threaded rods with brackets with the ability to move in three planes (Fig. 1).

Figure 1. Type of fracture and diagram of transosseous osteosynthesis using an external fixation device for fractures of the ankles and posterior edge of the tibia

On the operating table, after achieving anesthesia (as a rule, this is a conduction anesthesia), closed manual reduction of the fracture is performed with the elimination of gross displacement of fragments, subluxation or dislocation of the foot.

Two Schanz screws are inserted into the tibia from the medial side in the frontal and oblique sagittal planes 6-8 cm above the level of the ankle joint; a pin with a stop is passed through the heel bone from the outside, which are fixed in the ring and semi-ring supports of the external fixation apparatus. By moving along the pin with a stop, residual possible displacements of the foot in the supratalar joint are eliminated and conditions are created for repositioning the fragment of the posterior edge of the tibia, as well as eliminating damage to the tibiofibular syndesmosis. For the final reposition of the lateral malleolus (fibula) and to eliminate the rupture of the distal tibiofibular syndesmosis, a pin with an emphasis from back to front is passed through its distal fragment or a Schantz screw is inserted, which are fixed in the support of the movable repositioning unit. By moving the support along the rods in the distal direction, the final reposition of the fibula is achieved, while the fibula is installed coaxially with the tibia and, thus, conditions are created for eliminating the rupture of the distal tibiofibular syndesmosis. By moving a pin or a Schanz screw in the support of the repositioning unit, excess diastasis in the tibiofibular joint is eliminated. After repositioning the fibula and restoring the anatomy of the tibiofibular syndesmosis, a wire is passed through the displaced fragment of the posterior edge of the tibia from the outside, the free ends of which are fixed on brackets in the support of the second repositioning unit with the possibility of movement along the axis of the tibia. By moving along the threaded part of the brackets in the distal direction, reposition of the fragment of the posterior edge is achieved with the restoration of congruence in the supratalar joint. Osteosynthesis of the inner ankle is carried out with a knitting needle with a stop, the free end of which is brought out to the lateral surface of the lower leg and fixed to the bracket of the ring support of the device. The operation is completed with a control radiograph of the ankle joint in the frontal and lateral projections. The total treatment period in the device is 8 weeks. At the same time, taking into account the achieved reposition and stable fixation of the fracture, 4-5 weeks after the operation it is possible to remove the wire passed through the heel bone with partial dismantling of the device in order to begin early active movements in the ankle joint, which is the prevention of the development of stiffness and deforming arthrosis of the joint .

Transosseous osteosynthesis for fractures of the lateral malleolus or fibula along the diaphysis, posterior edge of the tibia, damage to the capsular-ligamentous apparatus of the ankle joint, posterior or posterior and outward displacement of the foot.

A feature of such fractures is partial or complete damage to the deltoid ligament, as well as the ligaments of the distal tibiofibular joint. The insertion of wires, insertion of Schanz screws into the tibia and calcaneus, fragments of the fibula, securing them to the supports of the apparatus and movable repositioning units is carried out according to the described method. After achieving reposition with the elimination of all types of displacements and restoration of congruence in the supratalar joint, by moving along a pin with a stop, passed through the heel bone, the foot is given a position of slight supination. This position ensures mutual approximation of the ends of the damaged deltoid ligament and creates conditions for its subsequent fusion. In cases of extensive ligament ruptures, which are clinically and radiologically defined as complete dislocations of the foot, we suture portions of the deltoid ligament to ensure fixation of the foot in the apparatus. The operation also ends with a control radiograph of the ankle joint in two standard projections. The treatment period in the external fixation device is 8 weeks.

Management of patients in the postoperative period.

After the operation, the need for hospital treatment ranges from 3 to 7 days and depends on the type of fracture, the severity of tissue damage, and the type of surgery. Low invasiveness of the intervention, high reliability and stability of fixation provide the possibility of early active management of patients who can get up and walk with the help of crutches from the first day after surgery. In cases of open interventions, surgical wound management is carried out according to general surgical rules. X-ray monitoring of the ankle joint is carried out before discharge from the hospital and then once a month with a mandatory examination of the patient in the department. The issue of removing pins and screws, dismantling and removing the device is decided individually, based on data from a clinical and x-ray examination of the patient.

After dismantling and removing the external fixation device, it is necessary to carry out the entire complex of restorative treatment, including full physiotherapeutic treatment, massage, physical therapy, as well as dosed, increasing load of the limb, which can be brought to full within 3-4 weeks. An early start of active movements in the ankle and foot joints is also necessary, which prevents the development of contractures and deforming osteoarthritis. We recommend that X-ray monitoring be carried out 1 week after removal of the device and then once every 1.5 months until complete recovery. An integrated approach to treatment ensures the best results in a short time. Realizes the patient's potential and leads to restoration of limb function. Restoration of working capacity, as a rule, occurs within 2-5 months after dismantling and removal of the external fixation device.

Results of treatment of patients with fractures of the posterior edge of the tibia.

An analysis of the treatment of 118 patients with fractures of the ankles and the posterior edge of the distal epimetaphysis of the tibia was carried out. The observation period ranged from 1 year to 11 years. The results were assessed based on clinical and radiological examination data, as well as assessment of health-related quality of life.

The comprehensive system for assessing treatment outcomes that we used included the following parameters: pain (absence, presence, degree of intensity), the ability to walk, load the limb, the patient’s activity with the restoration of the normal rhythm of life, restoration of work ability, attitude to sports (which was determined based on anamnesis); pain during palpation and performing active and passive movements in the ankle joint, deformation, condition of the muscles of the thigh and lower leg (presence or absence of atrophy), restoration of the limb axis, local vascular disorders (absence or presence of edema), results of measuring movement in the ankle joint in degrees, restoration of the arches of the feet. X-ray examination assessed the quality of reposition of fractures of the distal epimetaphysis of the leg bones, fusion of fragments, the state of the X-ray joint space of the ankle joint, and the absence or presence of osteoporosis. The results of treatment of fractures of the posterior edge of the distal epimetaphysis of the tibia are shown in Table 1.

Table 1.

Results of treatment of fractures and fracture-dislocations of the talus

№	Type of fracture	Evaluation of treatment outcomes				Total
№	Type of fracture	Exc.	Chorus.	Satisfied	Unsatisfactory	Total
1	Fractures of the posterior edge of the distal epimetaphysis of the tibia	40	54	24	—	118

As follows from the data in the table, for fractures of the ankles and the posterior edge of the distal epimetaphysis of the tibia, out of 118 cases of damage, the results were assessed as excellent in 40 (33.9%), good in 54 (45.8%), satisfactory in 24 (20. 3%) cases; No unsatisfactory outcomes were noted. The satisfactory treatment results obtained in 24 cases were associated with the development of limitation of movements and deforming arthrosis of the ankle joint, which led to dysfunction of the lower limb, a decrease in activity and the usual rhythm of life of the victims. In all cases, permanent disability was not noted.

An analysis of the results of treatment of patients with fractures of the posterior edge of the distal epimetaphysis of the tibia showed that the outcomes depend on the type and severity of the injury, the quality and accuracy of reposition with restoration of the anatomy of the ankle joint. Satisfactory results were obtained for large-fragmented fractures of the posterior edge with damage to more than 1/3 of the supporting articular surface of the tibia, which was determined by the severity of the injury with massive damage to the articular cartilage, as well as the capsular-ligamentous apparatus of the ankle joint.

Thus, an analysis of the results of treatment of 118 patients with fractures of the posterior edge of the distal epimetaphysis of the tibia showed good repositioning capabilities of transosseous osteosynthesis with external fixation devices. Excellent and good outcomes were noted in 94 (79.7%) of 118 cases of injury. The positive results obtained in most cases allow us to consider this method of treatment as the method of choice for fractures of the posterior edge of the distal epimetaphysis of the tibia.

AND ABOUT. Pankov, I.V. Ryabchikov, V.R. Nagmatullin

Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan

Pankov Igor Olegovich - Doctor of Medical Sciences, Chief Researcher of the Research Department, Head of the Clinic of the Traumatology Center

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Tibia fracture

A tibial fracture is one of the most common fractures in adults. Often, the outcome of treatment for these fractures is often lack of union and curvature of the bone.

Typically, when the tibia is damaged, the fibula also breaks. This bone does not bear the weight of the body, being only a place of muscle attachment. Therefore, its installation in the correct position and fixation during surgery is not required, which sometimes surprises patients.

More rare in prevalence, but much more severe in consequences, are tibial plateau fractures.

The tibial plateau is the flat part of the proximal end of the tibia that contributes to the functioning of the knee joint.

The focus of treatment for plateau fractures is to restore as much smoothness as possible to the damaged articular surface.

There are a huge number of varieties of these fractures with splitting, depression, deformation of the articular platform.

Intra-articular fractures often lead to arthrosis of the joint and impaired movement; therefore, they require the most careful and responsible approach on the part of the doctor.

There are several generally accepted approaches to the treatment of tibia fractures. In the past, treatment consisted of long-term fixation of the limb in a cast or skeletal traction.

The main disadvantage of these methods is a significant decrease in the patient’s quality of life during treatment, the development of stiffness in the joints, and cases of non-union are not uncommon.

Some fractures are initially unstable and it is not possible to achieve accurate reduction with conservative treatment methods in these cases without surgery.

At the present stage of development, traumatologists around the world use surgical methods for treating such injuries.

This is facilitated by the development of increasingly advanced fixatives, as well as the development of innovative materials for their production.

All this significantly reduced the risks of surgical intervention. The operation allows the patient to stand on his feet the very next day, does not require additional immobilization in a cast, and also allows for more accurate comparison of fragments and restoration of limb length.

Various types of fixators are used to treat fractures. Lockable rods are used for fractures of the diaphysis and will allow you to achieve the desired effect with minimal skin incisions.

Plates are most often used for fractures in the joint area. Modern plates can also be inserted into the fracture zone subcutaneously through microincisions.

With this minimally invasive approach, nutrition in the fracture zone is not disrupted, thereby the likelihood of complications is sharply reduced, and, importantly, an excellent cosmetic effect is achieved.

The absolute indication for surgery is open fractures. In such cases, at the first stage we stabilize the fracture using external fixation devices. Once the wounds have healed, in the second stage we remove the device and perform final fixation with a rod.

Once the fracture has healed, you can consider removing the metal fixator, although this is not necessary. In some cases, the metal fixator can cause discomfort and a feeling of pain. Typically, rods and plates from the tibia are removed no earlier than after a year, if there are radiological signs of fracture consolidation.