Functional Outcomes of Tillaux and Triplane Fractures with 2 to 5 Millimeters of Intra-Articular Gap

Abstract

Background: The treatment of transitional ankle fractures (Tillaux and triplane) is often dictated by the amount of displacement at the articular surface. Although >2 mm is a common indication for operative management, this practice has not been strongly supported by either the pediatric or adult literature. The purpose of this study was to determine whether operative treatment of transitional fractures with 2 to 5 mm of intra-articular gap leads to superior functional outcomes compared with cast management. Methods: A retrospective review of all patients treated for distal tibial fractures at a single institution between 2009 and 2017 was conducted. Computed tomographic images obtained after closed reduction were reviewed to identify patients with 2 to 5 mm of displacement (either gap or step-off) at the articular surface of the tibial plafond. Complications were classified according to the modified Clavien-Dindo system. Only patients with functional outcome data (Foot and Ankle Ability Measure [FAAM]) at a minimum of 2 years after treatment were included. Two multivariable linear regression models were developed using backward stepwise regression with either the FAAM Sports score or the Single Assessment Numerical Evaluation (SANE) Sports score as the dependent variables. Results: Fifty-seven patients (34 with triplane fractures and 23 with Tillaux fractures) with a mean follow-up of 4.5 years (range, 2.0 to 9.2 years) met inclusion criteria. Thirty-four patients were treated operatively, and 23 patients were treated with closed reduction and cast application. Nonoperative treatment, greater intra-articular gap, and presence of a grade-III complication were associated with worse functional outcomes in both multivariable regression models. A gap after closed reduction remained a negative predictor of functional outcome even in patients who were treated operatively. Patients who were treated nonoperatively and had ≤2.5 mm of gap had a significantly higher mean SANE Sports score at 90% than those patients with >2.5 mm of gap at 75% (p = 0.03). Conclusions: In Tillaux and triplane fractures with 2 to 5 mm of gap at the tibial plafond, a greater gap after closed reduction, nonoperative treatment, and complications were negative predictors of functional outcome at a mean follow-up of 4.5 years. Surgical management likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Clinical Outcomes in Pediatric Distal Tibia Triplanar Fractures Treated Surgically and Conservatively

“…In a retrospective study in 2020, Lurie et al reported that functional results were similar to surgical treatment when the intra-articular gap did not exceed 2.5 mm. The researchers concluded that surgery should be the treatment option for displacements exceeding 2.5 mm [ 3 ]. Computed tomography is required to make this precise measurement and identify the displacement in the joint and physis [ 14 ].…”

“…Direct radiographs, CT scans, clinical notes, and technical data (open reduction + internal fixation and closed reduction + plastering) and complications (loss of reduction, malunion, implant failure, additional procedure, deep or superficial infection, revision surgery, and leg length discrepancy due to premature physis closure) were recorded. A discrepancy of > 1 cm on radiography and tape measurement was defined as a leg length discrepancy (LLD), while a deformity of > 5 ° on anteroposterior and lateral radiographs was defined as angular deformity [ 3 ].…”

Paediatric Ankle Fractures: Guidelines to Management

“…Non-weight bearing for a period of 4 weeks post-fixation followed by gradual weight bearing is the recommended post-operative protocol. The outcomes of surgical fixation are very good and there is no risk of growth arrest as the child is usually closer to skeletal maturity [39][40][41].…”

“…All fractures with articular displacement > 2 mm are considered as displaced fractures and warrants perfect anatomical reduction and fixation [37,40,49]. Ertl et al in their series had reported poor functional outcomes in the long-term when the residual gap was more than 2 mm.…”

“…Ertl et al in their series had reported poor functional outcomes in the long-term when the residual gap was more than 2 mm. The importance of 2 mm cut-off was re-emphasized in the recent publication by Lurie et al in which they showed significantly worse outcome in patients who had > 2.5 mm fracture gap in the CT scan and treated non-operatively [40]. The need for open reduction should be judiciously decided on a case-to-case basis considering the fact that experience and surgical expertise of the operating surgeon plays a significant role in achieving a closed reduction or assisted closed reduction.…”