PubMed · 11000091
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P J Skoll, D A Hudson. 2000. Hands off!. https://doi.org/10.1054/bjps.2000.3422
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Anatomic reduction of displaced fractures is limited by the chosen surgical approach and intraoperative visualization. Preoperative Computed Tomography (CT) enhances the analysis of the fracture pattern and provides accurate spatial relationships. Computer Assisted Surgery (CAS) was introduced to increase the accuracy of specific surgical procedures. CAS systems can be used for implant placement or osteotomies in intact bone or reduced situations prior to obtaining the CT data, as differentiation into different datasets related to specific fragments is not yet possible. We present a model that allows "virtual" controlled reduction, providing computer assistance during the fracture reduction. Prior to clinical application, the accuracy of the process of virtual reduction must be proven in an experimental setting. An in vitro fracture model with two body fragments and a motion tracking system for three-dimensional (3D) control (accuracy 0.1 mm and 0.1 degrees ) was used. Two methods were employed: direct visualization and reduction by the examiner, and "virtual" reduction, performed solely with the use of a computer image, in which the examiner lacks any direct visualization of the fragments. The results of this very simplified "fracture" model indicate that the overall difference between direct and virtual controlled reduction was very small. A significant difference of 0.3 mm (0-1.8 mm) was seen for the residual displacement represented by the Euclidean distance (p < 0.01), whereas the difference in the residual angulation was not significant (p > 0.05). The methods tested revealed that virtual controlled reduction is nearly as accurate as direct visualization. Reduction control utilizing a motion tracker system reveals accurate 3D information in this simplified reduction setup, and is now used as a standard setup for analyzing realistic fracture models.
Soft tissue complications, skin slough, and superficial infection lead to deeper infection and amputation. By avoiding these complications, it is expected that better results can be obtained. Two techniques are available to do this. The first is to limit incisions and use external fixation to obtain stability. Even in these cases, care must be taken with the soft tissues. The second is a staged reconstruction, whereby stage one allows soft tissue stabilization. To this end, the fibula is plated, and transarticular external fixation is performed; this maintains anatomic length, preventing soft tissue contraction and permitting edema resolution. The second stage, formal tibial open reduction and internal fixation, is performed with plates and screws when operative intervention is safe. These methods appear to be equally effective in reducing major soft tissue complications. Surgeons should treat these complex fractures with the method with which they are most comfortable. Surgeons who feel comfortable with techniques of internal fixation are best qualified to perform open reductions. Surgeons who have experience with percutaneous fixation and hybrid external fixator application should use this method. Surgeons with limited or minimal experience with pilon fractures should consider fibula fixation and transarticular external fixation followed by transfer to an orthopedic trauma surgeon for definitive management.