Tibial shaft and pilon fractures with associated syndesmotic injury: a matched cohort evaluation
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To determine the outcomes of pilon and tibial shaft fractures with syndesmotic lesions compared to similar fractures without syndesmotic lesions.
Retrospective case-control study.
Level 1 trauma center.
All patients over a 5-year period (2012-2017) with tibial stem or pilon fractures with concomitant syndesmotic injury and a control group without syndesmotic injury matched for age, OTA/AO fracture classification and the Gustilo-Anderson classification of open fractures.
Preoperative or intraoperative diagnosis of a syndesmotic lesion with reduction and fixation of both the fracture and the syndesmosis.
Primary Outcome Measure:
Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with combined syndesmotic injury and tibial shaft or pilon fracture compared with those without syndesmotic injury.
A total of 30 patients, including 15 tibial shaft fractures and 15 pilon fractures, had associated syndesmotic lesions. The matched control group included 60 patients. The incidence of syndesmotic lesions in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic lesion group had more neurological lesions (23.3% vs. 8.3%, P=0.02), more vascular lesions not requiring repair (30% vs. 15%, P=0.13), and a higher rate of compartment syndrome (6.7% versus 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with syndesmotic injury (36.7% versus 13.3%, P = 0.04). Fifty percent of the syndesmotic lesion group underwent unplanned reoperation with significantly more unplanned reoperations (50% versus 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs 8.3% P=0.047) and a higher amputation rate (26.7% vs 3.3% P=0.002) while that the non-union rate was similar (17.4% versus 16.7% P = 0.85).
Although syndesmotic lesions with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combination injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should arouse clinical suspicion to assess a syndesmotic lesion.
Level of evidence:
Prognostic level III. See instructions to authors for a full description of levels of evidence.