Distal tibial fractures occur when the talus acts as a hammer, impacting and injuring the distal tibia [1]. These fractures remain a challenge for orthopedic surgeons because of their complex anatomy and difficult soft tissue conditions [2]. They account for approximately 1–10% of all lower extremity fractures [2]. The difficulty in management arises primarily due to the subcutaneous location of the tibia and its tenuous blood supply, which increases the risk of wound complications. The spectrum of injuries comprises low-energy spiral fractures as a result of simple falls on one end of the spectrum to high-energy injuries due to road traffic accidents or high falls [3]. Fractures that occur among the elderly that are of low energy are normally spiral and have limited soft tissue damage. Such cases also tend to experience fewer wound complications and decreased risks of infection after the surgery [4]. Conversely, at younger ages, fractures of the high-energy type tend to be caused by axial loading as the talus drives into the tibial plafond, causing articular comminution and devastating soft tissue injuries. The foot position on impact has a lot of effect on the fracture pattern [1, 4]. About 85% to 100% of distal tibial fractures have concomitant fibular fractures, which are important to repair to restore tibial alignment [3]. Most difficult are those fractures that are caused by high-energy trauma, and this prompts the question about whether the treatment is conservative or operative, the time of fixation, the type of implant used, and the mode of surgery [2]. Other comorbid conditions like diabetes, smoking, alcoholism, and vascular disease complicated the decision-making [3]. At first, the AO principles of open reduction and internal fixation (ORIF) were the gold standard. Nevertheless, the excitement died away because of high wound breakages, deep infections, and osteomyelitis in severe fracture patterns [1]. Consequently, the use of external fixation gained popularity in the 1990s and especially in intricate fractures with impaired soft tissues because it minimized the occurrence of septic complications that were caused by massive surgical exposures [1]. Unilateral systems were slowly phased out with the existence of hybrid fixators, which provided more stability and earlier weight bearing. Nevertheless, pin tract infection and secondary displacement, as well as stiffness of the ankle, were complications that restricted long-term results. Unless there is a stable fracture or the patient is medically unfit to undergo surgery, non-operative treatment is seldom indicated. Nonetheless, malunion, stiffness of the joints, and early secondary arthritis have been reported to be high as well as systemic complications of prolonged recumbency [5-7]. With a better understanding of soft tissue assessment, ORIF regained favor, particularly after classification systems such as Tscherne and AO grading helped surgeons decide appropriate timing for intervention [1]. While intramedullary nailing has been attempted, it poses difficulties in the distal tibia due to the hourglass canal shape and limited control of articular fragments. Several methods of plating have been discussed, such as medial, anterior, and cloverleaf plates [8]. Although medial plating is regarded as standard, there is a high risk of wound dehiscence because of it being subcutaneous, despite the use of current low-profile locking plates. Minimal invasive percutaneous plate osteosynthesis (MIPPO) has enhanced soft tissue results, and union is 80-100 percent, though angular malunions, failures of hardware, and articular mal-reductions are still present. The anterolateral approach has recently gained attention, with anatomically contoured locking compression plates designed for this surface [9]. This method provides better soft tissue coverage, potentially lowering wound complications compared to medial plating. Early studies suggest that anterolateral plating may represent a significant advancement in the surgical management of distal tibial fractures.

This prospective study was conducted in the Department of Orthopedics, Osmania Medical College and Hospital, Hyderabad, Telangana. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in the vernacular language. Inclusion criteria 1. Distal tibial fractures of (AO types A–C). 2. Aged 18 years and above 3. Males and Females 4. Medically fit for anesthesia and surgery 5. Signed the written consent Exclusion criteria 1. Open fractures with gross contamination 2. Pathological fractures 3. Polytrauma patients are not fit for surgery 4. Cases with poor soft tissue conditions A total of 20 patients with distal tibial pilon fractures were included based on the inclusion and exclusion criteria. Patients were selected after thorough clinical evaluation and radiographic assessment in anteroposterior and lateral views. Treatment Groups Non-operative management was considered only for: Non-displaced fractures confirmed radiographically. Displaced fractures where surgery was contraindicated due to comorbidities or poor general condition. These cases were treated with a long leg plaster cast, with strict radiographic monitoring. Axially loaded fractures with metaphyseal and articular displacement were excluded from this category. Operative management was performed for displaced pilon fractures, particularly those with intra-articular extension. Surgical decision-making was guided by age, mechanism of injury, fracture pattern, comorbidities, and soft tissue status. The objectives were anatomic reduction of the articular surface, restoration of alignment and length, stable fixation, and early mobilization. Operative Procedure Fibula fixation: When indicated, the fibula was fixed first to restore length and alignment. The posterolateral Henry’s approach was used. Reduction was achieved under fluoroscopic guidance and fixed with one-third tubular or semi-tubular plates using 3.5 mm cortical screws proximally and distally. Fixation of the tibia: Most cases received the anterolateral approach, which provides an adequate visualization of the tibial plafond. Caution was observed to recognize and preserve the superficial peroneal nerve. The articular fragments were sequentially abridged (posterolateral-posteromedial-central-anterior-anterolateral) and temporarily stabilized using K-wires after the exposure. Fixation was definitively achieved with the use of a 3.5 mm anterolateral distal tibia locking compression plate (LCP) with either open reduction or the minimally invasive percutaneous plate osteosynthesis (MIPPO) method, based on the type of fracture. The AO type A fractures were commonly treated using MIPPO, and AO type B and C fractures were treated using open reduction. The fixation was determined by fluoroscopy. Irrigation of wounds, closed in layers over a suction drain, and a sterile dressing was applied. Postoperative Protocol: A Short leg plaster cast was applied immediately after surgery. Drain was removed after 48 hours; active ankle and knee mobilization exercises were started concurrently. Non-weight-bearing ambulation with walker support began after drain removal. The cast was later changed to a removable splint for night use. Sutures were removed on the 12th postoperative day, following which patients were discharged. Follow-up was done at 6, 10, and 16 weeks, and monthly thereafter in cases of delayed union. Partial weight bearing was initiated once radiological signs of union were seen; full weight bearing was allowed after fracture consolidation. Outcome Measures: Functional and radiological outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, Kaikkonen ankle score, and Teeny-Wiss radiological scoring system Statistical analysis: All the available data were refined, segregated, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 26 in Windows format. The continuous variables were recorded as mean, standard deviation, frequency, and percentage. Categorical variables were calculated using Student's t-test for differences between the means of two groups and Fisher's Exact test for differences between two groups. The values of p (<0.05) were considered significant.

Table 1 presents the baseline demographic and injury characteristics of the study. A critical analysis of the able shows that in the 20 cases with distal tibial pilon fractures, the majority belonged to the younger age group 20 – 25, with 50% of cases, followed by 36 – 50 years, with 35% and 15% were above the age of 50 years. This shows that diaphyseal tibial pilon fractures are common in young individuals, mostly due to high-energy trauma. Males were predominant cases in this, with 85% of fractures occurring in males. Road traffic accidents were the leading cause of fractures, 80% of cases, followed by falls, which accounted for 20% of cases. The laterality of fractures appears to be distributed equally on both sides, with 55% of cases on the left side and 45% cases on the right side. Table 1: Baseline Demographic and Injury Characteristics of the Study Cohort (N=20) Characteristic Category Number of Patients Percentage (%) Age Group (years) 20- 35 10 50.0 36- 50 7 35.0 51 - 65 3 15.0 Sex Male 17 85.0 Female 3 15.0 Mechanism of Injury Road Traffic Accident (RTA) 16 80.0 Fall 4 20.0 Affected Side Right 9 45.0 Left 11 55.0 Table 2 depicts the Fracture Classification and Reduction Radiological (Teeny & Wiss). The table shows that radiological evaluation of the reduction of fracture was rated on the Teeny and Wiss basis. Type B fractures were the most common of all (10 cases, 50%), then Type A (7 cases, 35%) and Type C (3 cases, 15%). There were 20% anatomic reductions, and most of them (60%) showed good reductions. Reduction was seen as fair in 20% of the patients, and notably, none was determined as poor. The highest percentage of anatomic or good reductions was reported in Type A fractures, with Type B fractures having a greater distribution of fair reductions, but were more common. The solitary poor reduction was in a Type A fracture, and this emphasizes that even less complicated fractures can pose intraoperative technical issues. On the whole, these findings highlight the point that, when performed with great attention and care in surgery, most pilon fractures can be effectively reduced, even though Type B and C types are more challenging. Table 2: Fracture Classification and Quality of Radiological Reduction (Teeny & Wiss) Fracture type Anatomic Good Fair Poor Type A 2 (10%) 4 (20%) 1 (5%) 0 (0.0%) Type B 0 (0.0%) 7 (35%) 3 (15%) 0 (0.0%) Type c 2 (10%) 1 (5%) 0 (0.0%) 0 (0.0%) Total 4 (20%) 12 (60%) 4 (20%) 0 (0.0%) Table 3 shows the final follow-up (Mean 9 months) Functional Outcomes among the cohort. A mean follow-up of nine months was assessed using functional outcomes. Among 20 patients, 25% had excellent outcomes, and 60% had good outcomes, which indicates that most of them were able to restore satisfactory functions. Equitable results were observed in 10 percent of patients, with only 5 percent being rated poor. Fracture type distribution showed that Type A fractures had an excellent and good recovery rate, and no further results displayed poor recovery. The most common type was Type B fractures, which had largely good results, with two cases with fair results. Type C fractures, although less common, had good results with one excellent and two good outcomes. Such results suggest that fracture type and complexity have an impact, but proper fixation and rehabilitation may result in positive recovery in the majority of patients. Table 3: Functional outcomes at final Follow-up (Mean duration 9 Months) Fracture type Excellent Good Fair Poor Type A 2 (10.0%) 4 (20.0%) 0 (0.0%) 1 (5.0%) Type B 2 (10.0%) 6 (30.0%) 2 (10.0%) 0 (0.0%) Type C 1 (5.0%) 2 (10.0%) 0 (0.0%) 0 (0.0%) Total 5 (25.0%) 12 (60.0%) 2 (10.0%) 1 (5.0%) Table 4 shows the AOFAS Score Distribution among the cases of the study. Functional status was measured in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) score. The mean score was 76 (range: 40–90). Out of the cohort of the study, one-fifth of patients scored excellent (90-100), and half scored good (75-89). In 25% of patients, there was a fair result (50-74), and in one case, the result was poor (<50). Such distribution indicates that close to 70% of the patients had good to excellent recovery by final follow-up, which is consistent with the clinical and radiological outcomes. Nevertheless, a group of patients still underwent functional limitations, which demonstrates the multifaceted nature of pilon fracture management and the impact of related complications on long-term care. Table 4: American Orthopedic Foot and Ankle Society (AOFAS) score distribution AOFAS Category Score range Number of patients Percentage Excellent 90 – 100 4 20.0 Good 75 – 89 10 50.0 Fair 50 – 74 5 25.0 Poor < 50 1 5.0 Mean score range 76 (40 – 90) Table 5 shows Fracture Union Outcomes in the cohort. There were positive rates of union with 19/20 patients (95%) uniting their fractures in the average period of 12 to 24 weeks. The non-union was found only in one patient (5%), and further intervention was required. These findings demonstrate the usefulness of surgical fixation methods like LCP plating in the accomplishment of solid union, even of intra-articular fractures. The average union length is in accordance with the reported timeframes on the healing of tibial pilon fractures in the past, indicating that early mobility procedures did not hinder recovery. The fact that the rate of union is high also highlights the efficacy of existing fixation techniques in restoring the continuity of bone whilst permitting functional rehabilitation. Table 5: Fracture Union Outcomes Outcome Number of patients Percentage Mean Time to Union (Weeks) Union Achieved 19 95.0 12 – 24 Non-Union 1 5.0 - Table 6 shows Postoperative Complications in the cohort of the study. One out of six patients (30%) had at least one postoperative complication. The prevalent one was the dehiscence or infection of the superficial wound, which was seen in 20% of cases. One patient had flap necrosis (5%), and another had implant failure (5%), and both patients needed further surgery. One patient recorded a non-union (5%), and this is in line with the outcomes of union obtained before. Notably, no tendon exposure and no deep infection were present. The overall complication rate seems to be rather high, yet the majority of them were mild and could be addressed with the help of proper interventions. The results highlight the difficulty in the treatment of a pilon fracture because of its small soft tissue envelope and high-energy impact, which explains the necessity of particularly attentive surgical practice and constant attention in the postoperative period. Table 6: Postoperative Complications Observed in the Study Cohort (N=20) Complication Number of Cases Percentage (%) Superficial Wound Dehiscence / Infection 4 20.0 Flap Necrosis 1 5.0 Implant Failure 1 5.0 Non-Union 1 5.0 Tendon Exposure 0 0.0 Deep Infection 0 0.0 Total Patients with ≥1 Complication 6 30.0

The current study was done to analyze results and complications after surgical treatment of distal tibia pilon fracture with anterolateral locking compression plate (LCP) fixation among 20 adult participants. We found that these fractures are most frequently observed in young and active men, and the most frequent cause of these fractures is the high-energy trauma, like road traffic accidents, which is in line with epidemiological outcomes of pilon fractures globally [10, 11]. The fact that the age group of 20-35 years received the highest number of injuries indicates the high socio-economic cost of these injuries. Radiological results by assessing the Teeny and Wiss criteria proved that 80% of cases showed anatomic or good reductions, only 20% showed fair outcomes, and none showed poor outcomes. Such outcomes demonstrate the efficacy of anterolateral plating in achieving stable fixation and satisfactory alignment even in complex fracture patterns. Similar observations have been made by other studies in this field, which found that the anterolateral approach provides excellent visualization of the distal tibia, allowing for more precise reduction and restoration of articular congruity [12, 13]. It is important to note that Type B fractures were also associated with a higher percentage of fair outcomes, which must be explained by the fact that partial articular injury is more difficult to accomplish in practice, as reported by Rueidi and Allgower in their classical work and subsequent literature [1]. Functional outcome results at a mean follow-up of nine months showed that 85% of the patients recorded excellent or good results, and only one patient reported poor outcomes. This is in agreement with the other research that has shown locking plates to offer rigid fixation, early mobilization, and positive functional recovery [14, 15]. Our mean AOFAS score was 76, which is in the range of other similar series, but the variability remains because of fracture types, severity of soft tissue injury, and rehabilitation procedures [16]. Notably, the majority of the patients recovered to satisfactory functioning, although a substantial proportion of patients (30%) continued to report fair to poor functional status, which underscores the long-term effects of pilon fractures and the complexity of the issues in restoring full functionality. The union rates were good, 95% of them were united within 12-24 weeks, similar to the union periods recorded for surgically treated pilon fractures [17, 18]. The observed single case of non-union can be explained by the fact that fracture configuration and biological factors are complex. The high rates of union in this series indicate that LCP fixation gives sufficient stability to allow bone healing and functional rehabilitation. There were 30% cases of postoperative complications, mostly superficial wound infections (20%). The occurrence of this complication is within the expected range, as pilon fractures are characterized by the fact that the soft tissue is most often compromised because of the high-energy mechanism [19]. No deep infections were reported, which highlights the significance of the appropriate attention to the work with the soft tissue envelope and steps of surgery in stages where necessary. Flap necrosis and implant failure were rare but significant complications that required secondary intervention. The results are comparable with those of other researchers who have indicated that the surgical technique, proper handling of the soft tissues, and close monitoring of the patients after the surgery are important aspects to reduce complications [20, 21]. Overall, our results show that anterolateral LCP fixation is a reliable method for distal tibial pilon fractures, providing satisfactory radiological reduction, functional recovery, and union rates. However, despite advances in surgical techniques, the high incidence of complications and variability in long-term function underline the complex nature of these fractures. Larger prospective studies with longer follow-up are warranted to further optimize management strategies.

This present study demonstrated that the surgical approach of the distal tibia pilon fracture using anterolateral locking compression plate fixation is a reliable intervention method with regard to fracture healing, radiological restoration, and functional outcome. Most of the patients in our study had excellent to good functional outcomes, and there was a high union rate of 95% in 12 -24 weeks. Despite the favorable results, there were complications such as superficial wound infections, flap necrosis, and implant failure, which is an indication that there are inherent difficulties in the treatment of high-energy distal tibial fractures. In general, anterolateral plating is a safe procedure that remains effective provided it is done with a proper and careful surgical technique and followed by close attention. Post-surgical long-term follow-up is essential.

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