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Outcomes after tibial plafond fractures: does the treatment approach matter?
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posted on 28.02.2017by Bonato, Luke Joseph
Tibial plafond fractures are serious, complex injuries of the distal tibia. Tibial plafond fractures are associated with many complications, multiple different management approaches and poor outcomes. Different strategies have been described to manage tibial plafond fractures, with no clear consensus as to the best management approach reached. The tibial plafond fracture types and population presenting to Australian trauma centres is unknown. The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) database was used to retrospectively identify potential tibial plafond fractures from between September 2003 and July 2009. The VOTOR prospectively collects health related quality of life outcomes from patients at 6 and 12 months post injury. Tibial plafond fractures were confirmed by assessment of radiological records using the AO/OTA fracture classification system. There were 108 confirmed tibial plafond fractures, in 103 patients. Data was collected from the VOTOR database, hospital medical record and radiological records, to identify the patient demographics, mechanisms of injury, fracture management and long term outcomes. All identified patients were invited to take part in a clinical review. This study described the Australian experience of tibial plafond fractures. Most cases involved young
to middle aged men, in traffic or fall related incidents, many of which were compensable in nature. A high proportion were severe AO/OTA Type C fractures and almost one third of fractures were open injuries. The use of a two-stage approach to fracture management, with temporary external fixation was found to be widely used, with the preference for definitive fracture management being ORIF. Complications were identi1ied in the short term, largely related to soft tissue trauma and the management associated with superficial and deep infections, wound breakdown and repeat surgery for on-going wound management. Other identified complications included haemorrhage, compartment syndrome and superficial pin-site infections. Radiological outcomes were examined for all tibial plafond fractures, with an emphasis on time to radiological union, the onset of post-traumatic osteoarthritis and mal-union (angular deformities). Time to union was the key short term outcome and the median time to union was 141 days. The onset of post-traumatic osteoarthritic changes was present in 70% of all tihial plafond fractures. Tibial plafond fractures were associated with long-term tibial angular deformities. A detailed review of l2-month post injury patient reported outcomes including return to work, moderate to severe reporting of pain, physical and mental component scores was undertaken throughout this study. Moderate to severe pain was identified within 28% of tibial plafond fracture patients at 12 months post injury. Significantly lower physical component scores were identified compared with Australian population norms. The low return to work rate of 57% at 12 months, highlights the profound impact of tibial plafond fractures on patient's lives. Tibial plafond fractures present many management challenges in both the short and long-term, and were associated with a high degree of physical, social and psychological morbidity. Future research must continue to examine the factors associated with tibial plafond injuries and strive to improve the care of tibial plafond fracture patients.