Immediate Weight-Bearing Protocol for the Determination of Ankle Stability in Patients With Isolated Distal Fibular Fractures.

OBJECTIVE: To evaluate an alternative protocol for allowing immediate weight-bearing (WB) as tolerated in a functional walking boot in patients with a medial clear space (MCS) of less than 4 mm on nonstressed initial radiographs with subsequent WB radiographs at 1-week follow-up to determine if this can differentiate stable from unstable distal fibular fractures. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS: Seventy-nine patients who sustained an isolated distal fibular fracture with an MCS less than 4 mm on initial non-weight-bearing radiographs during a 6-year period. INTERVENTION: Patients with MCS less than 4 mm on 1-week radiographs were treated nonoperatively. Patients with MCS greater than or equal to 4 mm were treated operatively. MAIN OUTCOME MEASUREMENTS: Medial clear space measurements on WB ankle radiographs at the time of radiographic bony union. RESULTS: Two of the 79 (2.5%) patients had an MCS greater than 4 mm at 1-week follow-up with WB radiographs and underwent operative fixation. The remaining 77 patients were treated nonoperatively. All 77 patients had an MCS less than 4 mm on WB radiographs at the time of radiographic healing. CONCLUSION: These results suggest that our immediate weight-bearing protocol may be an effective method for determination of functional ankle stability only in the setting of an isolated distal fibula fracture with MCS less than 4 mm. However, it should be cautioned that careful evaluation of WB radiographs for joint asymmetry and/or MCS widening is mandatory to avoid poor outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Is It Safe to Prep the External Fixator In Situ During Second-Stage Pilon Surgical Treatment?

OBJECTIVE: To evaluate the infection rate of our protocol of prepping the external fixator in situ during definitive second-stage pilon fracture open reduction internal fixation. DESIGN: Retrospective clinical investigation. SETTING: Academic Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Out of 229 patients with distal tibia fractures presenting to our institution from 1999 to 2014, 100 were treated in a 2-stage fashion utilizing this protocol. INTERVENTION: Prepping the external fixator into the surgical field during the second-stage/definitive open reduction internal fixation procedure. MAIN OUTCOME MEASUREMENT: The rates of deep and superficial infections after definitive fixation. RESULTS: The deep infection rate was 13%, and the superficial infection rate was 11%. CONCLUSIONS: Infection rates using this protocol are comparable to previously reported infection rates for two-stage surgical treatment of pilon fractures. This protocol provides the treating surgeon information about an alternative method to streamline definitive fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Distal tibia nonunions.

Although tibia metaphyseal nonunion is rare, its treatment is often complex. The merits of related management techniques are discussed. These techniques include: intramedullary nailing, fine wire fixation, and blade plate reconstruction, which is the method preferred by the authors.

Functional outcome after blade plate reconstruction of distal tibia metaphyseal nonunions: a study of 11 cases.

OBJECTIVES: To present the functional outcome of a cohort of 11 patients prospectively followed before and after blade plate reconstruction of a distal tibia metaphyseal nonunion. DESIGN: Prospective case series. SETTING: University hospital tertiary referral center. PATIENTS: Eleven patients with an average age of 48 years. Average duration of nonunion was 11 months. Patients had undergone an average of 3.1 procedures before the index surgery. Three patients had prior deep infections, and one patient had an active infection. INTERVENTION: A precontoured 4.5-mm cannulated blade plate was applied to the medial tibial surface through a posteromedial approach. Autograft was added in eight patients to fill bone voids. MAIN OUTCOME MEASURES: AOFAS scores were assigned to each patient preoperatively and at most recent follow-up. RESULTS: All patients healed their nonunions after the index surgery. Average time to radiographic union was 16 weeks. Average time to full weight bearing was 12 weeks. AOFAS scores improved in all patients from an average preoperative score of 29 to an average postoperative score of 89. The only complication was a deep infection, which was treated successfully with one irrigation and débridement and 6 weeks of intravenous antibiotics. CONCLUSION: Blade plate reconstruction of distal tibia metaphyseal nonunion is a safe and reliable method that results in a high union and low complication rate.