Tibio-talar antegrade nailing for distal tibial fractures. An innovative way to save lower limb in the context of very severe 43C fractures of the tibial pilon.

Tibio-talar antegrade nailing for distal tibial fractures. An innovative way to save lower limb in the context of very severe 43C fractures of the tibial pilon. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tibio-talar antegrade nailing for distal tibial fractures. An innovative way to save lower limb in the context of very severe 43C fractures of the tibial pilon. Jonathan Curado, Alexis Laudat, Raphaelle Mansuy, Franck Dujardin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6190623/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: 43C type fractures are rare but challenging situations. This work aimed to present the results of an innovative surgical technique for this type of trauma: antegrade tibio-talar nailing. Methods: This retrospective and monocentric study included patients operated in a level 1 trauma center between May 2013 and July 2022 for antegrade tibio-talar nail. This procedure was indicated for 43C type fractures of the tibial pilon. The usual treatment plan was a two steps procedure: the first step was conducted with external fixation and soft tissues management for the damage control. The second step was initiated after soft tissues full recovery and consisted in a tibio-talar nailing with bone graft if necessary. A usual tibial nail hardware was used to fix the skeleton. The main evaluation criteria were bone consolidation. Complications were collected and are exposed. Amputation or death were considered as a failure. Results Six patients were included and reached full bone consolidation. They could walk at final follow-up. Many infections were observed, and 2 patients had a chronic osteomyelitis with acceptable pain and organized continuous follow-up. Conclusions Antegrade tibio-talar nailing is a rare surgical indication, helping lower limb salvage in high energy traumatology. It is an acceptable surgical technique for very comminuted 43C type fractures, associated with soft tissue damages. More studies should be conducted to correctly evaluate the results in a larger scale. Level of evidence IV tibial pilon fracture nail traumatology ankle Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction In high energy traumatology, a comminuted distal tibial fracture (43C according to the OTA/AO classification( 1 , 2 )) is a regular diagnostic. This type of trauma represents only 3 to 10% of ankle fracture( 3 ) and is the result of a sinking effect of the talus in the pilon articular surface. These lesions are difficult to treat, and the best way to manage them is still debated. Many theories surround this topic and none of them presents better functional result( 4 – 7 ). The functional prognostic in this fracture type is poor and tends to worsen with an open fracture( 3 , 8 ). In this context, infection and nonunion can conduct the patients to a very complex situation( 9 ). Costa and al( 10 ) demonstrated a benefit of intra medullary fixation on recovery and costs in distal tibia fractures. Many authors suggest retrograde ankle arthrodesis nailing to treat these fractures but tend to sacrifice sub talar joints, even if they’re healthy. According to the fact that most of these patients are young, retrograde nailing would be a good acute option but invasive for the hind-foot future and all foot kinematics( 11 , 12 ). Considering all those numbers and facts, it appears to us that purposing antegrade tibio talar nailing as a surgical treatment was a reasonable option. Hasan and al( 13 ) purposed this procedure as a limb salvage for elderly. Here, it is explored as a salvage procedure for any patient and more important for young patients involved in tragical high energy accidents. For this surgical possibility, patients with an intact fibula were not considered. In fact Luk and al( 14 ) already demonstrated that when the fibula is not fractured, the tibial pilon tends to be less comminuted and appears more like a type B fracture in the OTA/AO classification. The surgical technique and clinical results will be exposed on a short series of patients that received this treatment. The main evaluation criteria is bone healing according to radiographic and clinical evaluation. Materials and methods This study was an observational, retrospective and monocentric study. All patients who suffered from a comminuted tibial pilon fracture, classified as 43C in OTA/AO (Fig. 1 ) were included, when major soft tissue contusion was diagnosed and who underwent surgery for an antegrade tibio – talar nailing procedure, between May 2013 and July 2022. This surgery was indicated in the rare cases with serious articular damages, comminuted fracture, soft tissue impairment in usually active patients. Bone lesions were classified based on radiographic initial check-up at the emergency department. Major soft tissue contusion was defined as a skin condition that prevents the use of internal osteosynthesis, apart from external fixation, in the acute situation. All patients were operated in a level 1 trauma center. All cases were included for this cohort review. According to the rare indication of this surgery, no patient was excluded for the analysis. This surgery was never indicated if the patient was minor, nore could understand clearly and agree with the treatment plan. All patients with an intact fibula were not included. The primary endpoint was bone consolidation according to radiographic and clinical follow-up. Major complications like amputation or death were considered as a failure. The surgical procedure The usual surgical technique was conducted as a two steps procedure. The first step was a damage control phase, aiming to excise all necrotic soft tissues, wash the scars and close them. To control bone damages, an external fixation (EF) was set up under fluoroscopic control and fracture was reduced as anatomically as possible (Fig. 2 ). When bone was contaminated or too comminuted, antibiotic-charged bone cement was used to replace the skeleton. After a minimum of 2 weeks and being sure that soft tissues are completely healed, the second step consisted in an infrapatellar tibial antegrade nailing according to the 2 steps nailing procedure described by Roussignol et al( 15 ) combined with a minimal direct anterior ankle approach for pilon reduction, preparation of the articular surfaces and bone grafting (Fig. 3 ). The infrapatellar approach was extended from the patellar tip to the tibial tubercle. A trans ligamentar approach was performed to expose the pre spinal surface. Taking care to protect all soft tissues, a trocar was used for bone trepanation and insert the guide wire. The anterior ankle approach was then performed and aimed to stir up the talus, pass the guide wire through the tibiotalar joint and ream the future location of the tibio-talar nail (TTN). After reaming, the appropriate nail was placed, locked proximally with 2 screws and distally, in the talus with 2 other screws. This anterior approach was also used to remove free bone fragments, preparation of the articular surfaces by removing cartilage and proceed for a bone autograft, taken at the iliac crest. Autograft was used as an augmentation to maximize bone healing. Complementary screws were positioned if needed to fix bigger bone fragments (malleoli) or the autograft. Incisions were then closed and drained to minimize the risk of post operative hematoma. The fractured fibula was repaired with a locked plate, performed by a lateral approach according to soft tissue management, and at least 5 cm laterally from the anterior approach. The post operative period The usual follow-up planning for nailing was applied with clinical control at 2 weeks post operative to check the surgical incisions, and then clinical and radiological controls at 6 weeks, 12 weeks, 6 months and a year after the procedure. Patients were regularly monitored for pain and weight-bearing avoidance over a 6-week period. The use of a mechanical aid (crutches, walker) was also noted. A first radiographic check was organized at 45 days and progressive weight-bearing was allowed if no hardware failure and bone healing was observed. All open fractures were post operatively treated with 48 hours of probabilistic antibiotherapy. The statistical analysis Due to the small number of patients, the statistical analysis consists of descriptive statistics. Quantitative data are expressed as averages and standard deviations, or medians and quartiles. Categorical data is presented in the form of frequencies and percentages. Ethical committee agreement This study was approved by the local ethical committee and patients were informed and gave their consent for data collection. Results The cohort During the inclusion period, the department treated 248 patients for tibial pilon fractures. Six patients for TTN were identified between May 2013 and July 2022 (Table 1 ). Four of them were men (66%), with a median age of 45,7 years old (20 to 71). The right side was concerned in 3 patients and the left side in 3. All cases were performed on a comminuted distal tibial fracture (Fig. 1 ), classified as a 43C OTA/AO fracture. Four of them were involved in high heights fall and 2 of them in a low energy trauma. This traumatism was an open fracture in 5 of the 6 cases. A neurological deficit was associated in one case but originated by a fracture on the third lumbar vertebra. No vascular lesions were associated in those cases. Two of the 6 patients were treated in a context of poly fractured lesions: the first case presented a displaced lumbar fracture that needed a posterior vertebral arthrodesis and a distal radius fracture that was fixed. The second case had a distal radius fracture and a femoral shaft fracture that were fixed in the first step procedure. It must be underlined the prevalence of psychiatric illnesses in these patients (66% of them in this work, all of them with a high energy trauma). Table 1 Case’s Summary – (M : Male, F: Female; R: Right, L:Left; OTA/AO : XX; G-A : Gustilo – Andersen classification; EF: External Fixation; DCA: Debridment, wound Closure, Antibiotics) Age at surgery Sex Side OTA/OA G-A Initial treatment Soft tissues management Follow Up (months) 1 37 M R 43C3 II EF DCA 92 2 51 M L 43C2 I 0 DCA 24 3 71 F L 43C3 0 0 0 31 4 19 F L 43C3 II EF DCA 101 5 20 M R 43C1 II EF DCA 51 6 66 M R 43C3 II EF DCA 136 Bone healing results Only one patient achieved bone healing at the 6 weeks follow-up. Three of the 6 patients achieved bone healing at the 6 months follow-up, and 2 at the 12 months follow-up. The average duration to radiographic and clinic bone consolidation was approximately 7 months. Return to walking and weight bearing was achieved for 2 patients at 6 weeks with crutches, 2 patients at 3 months, and the other 2 patients at 6 months. The average duration before complete weight bearing was 3,5 months. Nevertheless, all patients achieved a radiographic bone healing and were able to walk without pain for 30 minutes at least at last follow-up (Fig. 4 ). Complications All patients presented signs of infection in their follow-up. Four patients presented an acute deep infection observed in the first 6 weeks. The first patient developed infection signs on his EF, treated with a “one stage revision” with EF removal, debridement, antibiotics and TTN. One of them had a superficial skin infection, treated by local care. The 2 other patients needed an iterative surgery for debridement, Antibiotics and Implant Retention (DAIR). They both cured after this procedure. All acute cases were followed for more than 2 years and are now free of any infection. The two last patients developed a chronic infection which was not cured at last follow-up (> 24 months). One of them reported pain at last follow-up but located at the proximal end of the nail probably occurring a pandiaphysitis. The second patient had a chronical leakage on medial ankle incision, pain-free and refused any further surgical procedure. At 9 years of follow up, one patient needed a complementary sub talar arthrodesis which was performed by direct lateral approach and fixed by 2 calcaneo-talar screws. No radical surgery as amputation was needed and no death was observed. Discussion Tibial pilon fractures are usually associated with poor functional outcomes( 16 ) and a high rate of complications. Context is the main issue concerning tibial pilon fractures: usually a high-energy trauma for young patients, where the prognostic is related to soft tissues, and low-energy trauma for the elderly. This work purposes an efficient and universal surgical treatment for this rare traumatic occurrence. Hasan and al( 13 ) analyzed this TTN procedure for elderly and showed good results. This work pretends to introduce the idea that this surgical procedure can be applied for any patient and helps to recover an acceptable function for daily living. It appears as a safe procedure even if complication’s rate remains high. However, to our knowledge, Hasan and al didn’t assess the rate of complications related to high-energy trauma and soft-tissue contusion in a relatively young population. For the 43C type fractures, a global complication rate is reported between 10 and 55%( 17 , 18 ). Any major complication can lead to radical decision as a trans tibial amputation( 19 ). Wynes and al( 20 ) alerted on the interest for post traumatic vascular status assessment. This could help to reduce the risk of soft tissue-related complications and infections, avoiding any internal fixation in the case of vascular lesion. In multi tissular lesions, the Major Extremity Trauma Research Consortium even purposed trans tibial amputation to be considered as a primary treatment( 21 ). In this work, a high rate of post-operative infections was observed. Nevertheless, Zhang and al( 22 ) had also pointed out that the high infection rate developed for this type of trauma. Purcell and al( 23 ) demonstrated that syndesmotic injuries, found in types 43C, are a risk factor for infections. According to this, Murawski and al( 24 ) suggested that addition of intrawound vancomycin powder at the time of definitive fixation could reduce gram-positive deep infections at a low financial cost. Tang and al( 6 ) exposed the idea that distal tibia and fibula had to be considered as a 4 columns structure. When performing an internal fixation, it might necessitate a strong fixation on each of these columns. This procedure depends on the soft tissues and vascular status. This theory is debated( 4 ). Furthermore, in our opinion, internal fixation is a technical challenge that is not always feasible. The complexity of the lesions requires the use of long plates, which expose the patient to the risk of pseudarthrosis, infection and wound disunion. Some other possibilities can be discussed concerning the treatment. It is widely accepted that 43C types aren’t suitable for non-operative treatment. EF represents a better option when talking about comminuted fractures with soft tissue damages( 25 , 26 ). EF offers many possibilities from simple plan to circular constructions (Ilizarov model( 27 , 28 )). The circular model can even allow progressive correction or bone growth. They have the advantage to be less invasive and “soft tissues-friendly” and give comparable functional results with internal fixation( 29 ). In this study, the usual treatment was a 2 steps surgery with hybrid fixation representing the first step, helping to manage the soft tissues and, when favorable, plate the fibula. Hybrid fixation was preferred because of its high stability and comfort to monitor soft tissues. The second step consisted in a TTN, associated with a small anterior approach, helping for nailing, bone excision and autograft. It was only deplored the difficulty encountered to achieve a stable fixation of the talus during the surgery. This difficulty could be overcome by reflecting on a dedicated device for TTN. Many authors( 30 – 32 ) defend retrograde ankle arthrodesis nailing as a good option for comminuted fractures in the elderly. Good results are achieved in terms of bone consolidation. But it seems difficult to sacrifice hind-foot joints for young and active patients. When aiming for a better function preservation, it appeared logical to try TTN, moreover in the case of young people. This work didn’t focus on functional recovery, but all patients can walk without crutches after 12 months. Two of them present acceptable sequalae pain, treated occasionally with paracetamol. It must be noted that most of these fractures occur in patients with a psychiatric disability. In this work, 2 of them jumped from high height trying to commit suicide and 2 had a diagnostic of schizophrenia. This aspect was underlined by Chiu and al( 30 ) in the elderly but it seems that it can be applied to a reasonable proportion part of “tibial pilon” population. This study is burdened by one main weakness: its retrospective cohort design gives a poor level of proof. This technique was defined by Hasan and al( 13 ) for elderly patients. Thus, the strength of this study lies in the fact that it describes an unusual surgical technique which aims to save lower limb in major traumatic situations, not just in an elderly population. Young patients with higher functional demands and aesthetic concerns seem to be an eligible population for that kind of surgical technique. It is technically demanding and must be carried out by trained traumatologists. In conclusion, TTN appears like a pertinent option when treating a tibial pilon (43C type) fracture even if soft tissues are damaged. This procedure needs to be performed at a higher scale to properly evaluate the results and the complications rate, but this pilot study has encouraging results. Declarations Funding No funding was needed to lead this work. Author Contribution JC wrote the main manuscript and collected the data AL wrote the main manuscriptRM collected the dataFD drafted the manuscript Conflicts of interest JC is an educational consultant for Viatris and Healthcare Events. AL and RM have no conflict of interest. FD is an educational consultant for G4 association. References Swiontkowski MF, Sands AK, Agel J, Diab M, Schwappach JR, Kreder HJ. Interobserver Variation in the AO/OTA Fracture Classification System for Pilon Fractures: Is There a Problem? J Orthop Trauma. oct 1997;11(7):467. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. janv 2018;32 Suppl 1:S1–170. Mair O, Pflüger P, Hanschen M, Biberthaler P, Crönlein M. Treatment strategies for complex ankle fractures-current developments summarized in a narrative review. Ann Transl Med. 25 oct 2023;11(11):387. Bakan ÖM, Vahabi A, Özkayın N. Management of complex pilon fractures: Is it necessary to fix all the columns in AO/OTA type 43-C fractures? Injury. déc 2023;54(12):111153. Ahmed ASA, Singer MS, El Bigawi HA. Neglected Tibial Pilon Fractures: Can Arthrodesis Be Avoided? J Orthop Trauma. juill 2018;32(7):369–75. Tang X, Tang PF, Wang MY, Lü DC, Liu MZ, Liu CJ, et al. Pilon fractures: a new classification and therapeutic strategies. Chin Med J (Engl). juill 2012;125(14):2487–92. Dujardin F. EM-Consulte. 2013 [cité 9 déc 2024]. Fractures totales du pilon tibial: Complete fractures of the tibial pilon. Disponible sur: https://www.em-consulte.com/article/850524/fractures-totales-du-pilon-tibial-complete-fractur Mair O, Pflüger P, Hoffeld K, Braun KF, Kirchhoff C, Biberthaler P, et al. Management of Pilon Fractures-Current Concepts. Front Surg. 2021;8:764232. Brauns A, Lammens J. The challenge of the infected pilon tibial non-union: treatment with radical resection, bone transport and ankle arthrodesis. Acta Orthop Belg. juin 2020;86(2):335–41. Costa ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, et al. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess Winch Engl. mai 2018;22(25):1–148. Araujo-Monsalvo VM, Toledo-Romo MF, Rodríguez-Castro GA, Vázquez-Escamilla J, Domínguez-Hernández VM, Meneses-Amador A, et al. Comparative study of two retrograde locked intramedullary nail designs for ankle arthrodesis: A finite element analysis. Proc Inst Mech Eng [H]. févr 2024;238(2):198–206. Evers J, Lakemeier M, Wähnert D, Schulze M, Richter M, Raschke MJ, et al. 3D Optical Investigation of 2 Nail Systems Used in Tibiotalocalcaneal Arthrodesis: A Biomechanical Study. Foot Ankle Int. mai 2017;38(5):571–9. Hasan YO, Bourget-Murray J, Page P, Penn-Barwell JG, Handley R. Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient. Eur J Orthop Surg Traumatol Orthop Traumatol. févr 2024;34(2):847–52. Luk PC, Charlton TP, Lee J, Thordarson DB. Ipsilateral Intact Fibula as a Predictor of Tibial Plafond Fracture Pattern and Severity. Foot Ankle Int. 1 oct 2013;34(10):1421–6. Roussignol X, Sigonney G, Potage D, Etienne M, Duparc F, Dujardin F. Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series. Orthop Traumatol Surg Res OTSR. févr 2015;101(1):89–92. Middleton SD, Guy P, Roffey DM, Broekhuyse HM, O’Brien PJ, Lefaivre KA. Long-Term Trajectory of Recovery Following Pilon Fracture Fixation. J Orthop Trauma. 1 juin 2022;36(6):e250–4. Sameer M, Kc B, V S. Fixation Of Tibial Pilon Fractures Based On Column Concept:A Prospective Study. Acta Orthop Belg [Internet]. déc 2017 [cité 13 nov 2024];83(4). Disponible sur: https://pubmed.ncbi.nlm.nih.gov/30423663/ Borrelli J, Ellis E. Pilon Fractures: Assessment and Treatment. Orthop Clin. 1 janv 2002;33(1):231–45. Luo X, Wang W, Wang Z, Ma F. Below-knee amputation following internal fixation of a complex open Pilon fracture: A case report. Asian J Surg [Internet]. 30 sept 2024 [cité 13 nov 2024]; Disponible sur: https://www.sciencedirect.com/science/article/pii/S1015958424020487 Wynes J, Kirksey L. Assessing Vascular Status and Risk of Latent Ischemia with Ankle Fracture: A Case Report and Algorithm for Treatment. J Foot Ankle Surg. 1 mai 2014;53(3):353–5. Major Extremity Trauma Research Consortium (METRC). Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation (OUTLET). J Bone Joint Surg Am. 1 sept 2021;103(17):1588–97. Zhang J, Lu V, Zhou AK, Stevenson A, Thahir A, Krkovic M. Predictors for infection severity for open tibial fractures: major trauma centre perspective. Arch Orthop Trauma Surg. nov 2023;143(11):6579–87. Purcell KF, Bergin PF, Russell GV, Graves ML, Jones LC, Spitler CA. Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment. J Orthop Trauma. 1 mars 2022;36(3):157–62. Murawski CD, Mittwede PN, Wawrose RA, Belayneh R, Tarkin IS. Management of High-Energy Tibial Pilon Fractures. J Bone Joint Surg Am. 19 juill 2023;105(14):1123–37. Quinnan SM. Definitive Management of Distal Tibia and Simple Plafond Fractures With Circular External Fixation. J Orthop Trauma. nov 2016;30 Suppl 4:S26–32. Giannoudis VP, Ewins E, Taylor DM, Foster P, Harwood P. Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study. Strateg Trauma Limb Reconstr. 2021;16(2):86–95. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop. janv 1989;(238):249–81. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop. févr 1989;(239):263–85. Legg PI, Malik-Tabassum K, Ibrahim YH, Dhinsa BS. Post-Operative Outcomes of Circular External Fixation in the Definitive Treatment of Tibial Plafond Fractures: A Systematic Review. Cureus. avr 2022;14(4):e24204. Chiu YC, Wu CH, Tsai KL, Jou IM, Tu YK, Ma CH. Primary Arthrodesis with Retrograde Hindfoot Nail for Elderly Patients with Tibia Pilon Fractures and Psychiatric Illness. J Am Podiatr Med Assoc. 2024;114(3):22–048. DeGenova DT, Hill ZP, Hoffman AD, Taylor AR, Dues B, Faherty M, et al. Does the Subtalar or Tibiotalar Joint Need Fused in Primary Retrograde Tibiotalocalcaneal Nailing for Fragility Ankle Fractures? Foot Ankle Spec. 10 mai 2024;19386400241249583. Tarkin IS, Fourman MS. Retrograde Hindfoot Nailing for Acute Trauma. Curr Rev Musculoskelet Med. sept 2018;11(3):439–44. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6190623","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":434587925,"identity":"26a9651a-7ca8-491c-8cfe-4ba2266dd282","order_by":0,"name":"Jonathan Curado","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIiWNgGAWjYDCCA2CSmYGxAUiBCH4QP6GAWC0HgYQkiJFgQIQWMABpMQCL4NHCd/vwM+mKGms55vbeg58/7rDLMz6/OvHDAwMGeX6xA1i1SJ5LM5M8cyzdmLHnXLLEwTPJxWY33m6WADrMcObsBKxaDM7wsEk2sB1ObJyRYyBxsI05cduNsxtAWhIMbuPT8g+sxfjHwbb6xM0zzm7+QVBLYxtYixnQlsOJG/h7t+G1RfIMm7FlYx/IL2fMLM62HU+ccYN3m0WCgQROv/CdYX54s+GbtZxhe4/xjcq26sT+/rObb/6osJHnl8auBQ4MG2AsCbBKCfzKQUAezuI/QFj1KBgFo2AUjCgAAPjZZ+6DZlcHAAAAAElFTkSuQmCC","orcid":"","institution":"Centre Hospitalier Universitaire de Rouen","correspondingAuthor":true,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Curado","suffix":""},{"id":434587926,"identity":"3dd878a6-2ec3-405c-b9e1-d7d47a76abf2","order_by":1,"name":"Alexis Laudat","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Rouen","correspondingAuthor":false,"prefix":"","firstName":"Alexis","middleName":"","lastName":"Laudat","suffix":""},{"id":434587927,"identity":"e30c2e89-8ce1-4ae0-829a-eff9e97a319b","order_by":2,"name":"Raphaelle Mansuy","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Rouen","correspondingAuthor":false,"prefix":"","firstName":"Raphaelle","middleName":"","lastName":"Mansuy","suffix":""},{"id":434587928,"identity":"d47667f4-efe2-4244-ae7d-e1a18b0507a9","order_by":3,"name":"Franck Dujardin","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Rouen","correspondingAuthor":false,"prefix":"","firstName":"Franck","middleName":"","lastName":"Dujardin","suffix":""}],"badges":[],"createdAt":"2025-03-09 22:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6190623/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6190623/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80045510,"identity":"1abdcf16-6c4c-4836-9592-b5b67f1ba3b3","added_by":"auto","created_at":"2025-04-07 09:43:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":51953,"visible":true,"origin":"","legend":"\u003cp\u003eExample of a 43C fracture treated in this small patients’ cohort.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6190623/v1/06e7b9b238b7d5834d397da7.jpg"},{"id":80045508,"identity":"64d5cbb4-c876-4c4e-8dff-a4a621865336","added_by":"auto","created_at":"2025-04-07 09:43:58","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":53870,"visible":true,"origin":"","legend":"\u003cp\u003eTemporary external fixation example after the first step surgical procedure.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6190623/v1/dd52d781c842521f11ae49a1.jpg"},{"id":80046553,"identity":"bac09255-2bb6-4a85-b79b-d46bacb8a2ca","added_by":"auto","created_at":"2025-04-07 09:51:59","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":39553,"visible":true,"origin":"","legend":"\u003cp\u003eFinal tibio-talar nailing using fibula and internal malleolus as an autograft.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6190623/v1/e691f368b90073177039fc05.jpg"},{"id":80045507,"identity":"2bb239b8-5173-4a33-92c7-eae63af284b6","added_by":"auto","created_at":"2025-04-07 09:43:58","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":58535,"visible":true,"origin":"","legend":"\u003cp\u003eResult after hardware removal, showing good bone healing.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6190623/v1/e33b1a84349e50e962419569.jpg"},{"id":80494704,"identity":"d008e2e0-cd82-4c02-a2be-0e6dbac292e0","added_by":"auto","created_at":"2025-04-13 22:53:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726231,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6190623/v1/efe6da3b-174c-4e32-b1d6-bee71e1dab22.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tibio-talar antegrade nailing for distal tibial fractures. An innovative way to save lower limb in the context of very severe 43C fractures of the tibial pilon.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn high energy traumatology, a comminuted distal tibial fracture (43C according to the OTA/AO classification(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)) is a regular diagnostic. This type of trauma represents only 3 to 10% of ankle fracture(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and is the result of a sinking effect of the talus in the pilon articular surface. These lesions are difficult to treat, and the best way to manage them is still debated. Many theories surround this topic and none of them presents better functional result(\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The functional prognostic in this fracture type is poor and tends to worsen with an open fracture(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In this context, infection and nonunion can conduct the patients to a very complex situation(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCosta and al(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) demonstrated a benefit of intra medullary fixation on recovery and costs in distal tibia fractures. Many authors suggest retrograde ankle arthrodesis nailing to treat these fractures but tend to sacrifice sub talar joints, even if they\u0026rsquo;re healthy. According to the fact that most of these patients are young, retrograde nailing would be a good acute option but invasive for the hind-foot future and all foot kinematics(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsidering all those numbers and facts, it appears to us that purposing antegrade tibio talar nailing as a surgical treatment was a reasonable option. Hasan and al(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) purposed this procedure as a limb salvage for elderly. Here, it is explored as a salvage procedure for any patient and more important for young patients involved in tragical high energy accidents. For this surgical possibility, patients with an intact fibula were not considered. In fact Luk and al(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) already demonstrated that when the fibula is not fractured, the tibial pilon tends to be less comminuted and appears more like a type B fracture in the OTA/AO classification.\u003c/p\u003e \u003cp\u003eThe surgical technique and clinical results will be exposed on a short series of patients that received this treatment. The main evaluation criteria is bone healing according to radiographic and clinical evaluation.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study was an observational, retrospective and monocentric study. All patients who suffered from a comminuted tibial pilon fracture, classified as 43C in OTA/AO (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were included, when major soft tissue contusion was diagnosed and who underwent surgery for an antegrade tibio \u0026ndash; talar nailing procedure, between May 2013 and July 2022. This surgery was indicated in the rare cases with serious articular damages, comminuted fracture, soft tissue impairment in usually active patients. Bone lesions were classified based on radiographic initial check-up at the emergency department. Major soft tissue contusion was defined as a skin condition that prevents the use of internal osteosynthesis, apart from external fixation, in the acute situation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAll patients were operated in a level 1 trauma center. All cases were included for this cohort review. According to the rare indication of this surgery, no patient was excluded for the analysis. This surgery was never indicated if the patient was minor, nore could understand clearly and agree with the treatment plan. All patients with an intact fibula were not included.\u003c/p\u003e \u003cp\u003eThe primary endpoint was bone consolidation according to radiographic and clinical follow-up. Major complications like amputation or death were considered as a failure.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe surgical procedure\u003c/h2\u003e \u003cp\u003eThe usual surgical technique was conducted as a two steps procedure. The first step was a damage control phase, aiming to excise all necrotic soft tissues, wash the scars and close them. To control bone damages, an external fixation (EF) was set up under fluoroscopic control and fracture was reduced as anatomically as possible (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). When bone was contaminated or too comminuted, antibiotic-charged bone cement was used to replace the skeleton.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter a minimum of 2 weeks and being sure that soft tissues are completely healed, the second step consisted in an infrapatellar tibial antegrade nailing according to the 2 steps nailing procedure described by Roussignol et al(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) combined with a minimal direct anterior ankle approach for pilon reduction, preparation of the articular surfaces and bone grafting (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The infrapatellar approach was extended from the patellar tip to the tibial tubercle. A trans ligamentar approach was performed to expose the pre spinal surface. Taking care to protect all soft tissues, a trocar was used for bone trepanation and insert the guide wire. The anterior ankle approach was then performed and aimed to stir up the talus, pass the guide wire through the tibiotalar joint and ream the future location of the tibio-talar nail (TTN). After reaming, the appropriate nail was placed, locked proximally with 2 screws and distally, in the talus with 2 other screws. This anterior approach was also used to remove free bone fragments, preparation of the articular surfaces by removing cartilage and proceed for a bone autograft, taken at the iliac crest. Autograft was used as an augmentation to maximize bone healing. Complementary screws were positioned if needed to fix bigger bone fragments (malleoli) or the autograft. Incisions were then closed and drained to minimize the risk of post operative hematoma. The fractured fibula was repaired with a locked plate, performed by a lateral approach according to soft tissue management, and at least 5 cm laterally from the anterior approach.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe post operative period\u003c/h3\u003e\n\u003cp\u003eThe usual follow-up planning for nailing was applied with clinical control at 2 weeks post operative to check the surgical incisions, and then clinical and radiological controls at 6 weeks, 12 weeks, 6 months and a year after the procedure.\u003c/p\u003e \u003cp\u003ePatients were regularly monitored for pain and weight-bearing avoidance over a 6-week period. The use of a mechanical aid (crutches, walker) was also noted. A first radiographic check was organized at 45 days and progressive weight-bearing was allowed if no hardware failure and bone healing was observed. All open fractures were post operatively treated with 48 hours of probabilistic antibiotherapy.\u003c/p\u003e\n\u003ch3\u003eThe statistical analysis\u003c/h3\u003e\n\u003cp\u003eDue to the small number of patients, the statistical analysis consists of descriptive statistics. Quantitative data are expressed as averages and standard deviations, or medians and quartiles. Categorical data is presented in the form of frequencies and percentages.\u003c/p\u003e\n\u003ch3\u003eEthical committee agreement\u003c/h3\u003e\n\u003cp\u003e This study was approved by the local ethical committee and patients were informed and gave their consent for data collection.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThe cohort\u003c/h2\u003e \u003cp\u003eDuring the inclusion period, the department treated 248 patients for tibial pilon fractures. Six patients for TTN were identified between May 2013 and July 2022 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Four of them were men (66%), with a median age of 45,7 years old (20 to 71). The right side was concerned in 3 patients and the left side in 3. All cases were performed on a comminuted distal tibial fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), classified as a 43C OTA/AO fracture. Four of them were involved in high heights fall and 2 of them in a low energy trauma. This traumatism was an open fracture in 5 of the 6 cases. A neurological deficit was associated in one case but originated by a fracture on the third lumbar vertebra. No vascular lesions were associated in those cases. Two of the 6 patients were treated in a context of poly fractured lesions: the first case presented a displaced lumbar fracture that needed a posterior vertebral arthrodesis and a distal radius fracture that was fixed. The second case had a distal radius fracture and a femoral shaft fracture that were fixed in the first step procedure. It must be underlined the prevalence of psychiatric illnesses in these patients (66% of them in this work, all of them with a high energy trauma).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCase\u0026rsquo;s Summary \u0026ndash; (M : Male, F: Female; R: Right, L:Left; OTA/AO : XX; G-A : Gustilo \u0026ndash; Andersen classification; EF: External Fixation; DCA: Debridment, wound Closure, Antibiotics)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge at\u003c/p\u003e \u003cp\u003esurgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSide\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOTA/OA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG-A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInitial treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSoft tissues\u003c/p\u003e \u003cp\u003emanagement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFollow Up\u003c/p\u003e \u003cp\u003e(months)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43C3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43C2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43C3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43C3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43C1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43C3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBone healing results\u003c/h3\u003e\n\u003cp\u003eOnly one patient achieved bone healing at the 6 weeks follow-up. Three of the 6 patients achieved bone healing at the 6 months follow-up, and 2 at the 12 months follow-up. The average duration to radiographic and clinic bone consolidation was approximately 7 months.\u003c/p\u003e \u003cp\u003eReturn to walking and weight bearing was achieved for 2 patients at 6 weeks with crutches, 2 patients at 3 months, and the other 2 patients at 6 months. The average duration before complete weight bearing was 3,5 months.\u003c/p\u003e \u003cp\u003eNevertheless, all patients achieved a radiographic bone healing and were able to walk without pain for 30 minutes at least at last follow-up (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eComplications\u003c/h3\u003e\n\u003cp\u003eAll patients presented signs of infection in their follow-up. Four patients presented an acute deep infection observed in the first 6 weeks. The first patient developed infection signs on his EF, treated with a \u0026ldquo;one stage revision\u0026rdquo; with EF removal, debridement, antibiotics and TTN. One of them had a superficial skin infection, treated by local care. The 2 other patients needed an iterative surgery for debridement, Antibiotics and Implant Retention (DAIR). They both cured after this procedure. All acute cases were followed for more than 2 years and are now free of any infection.\u003c/p\u003e \u003cp\u003eThe two last patients developed a chronic infection which was not cured at last follow-up (\u0026gt;\u0026thinsp;24 months). One of them reported pain at last follow-up but located at the proximal end of the nail probably occurring a pandiaphysitis. The second patient had a chronical leakage on medial ankle incision, pain-free and refused any further surgical procedure.\u003c/p\u003e \u003cp\u003eAt 9 years of follow up, one patient needed a complementary sub talar arthrodesis which was performed by direct lateral approach and fixed by 2 calcaneo-talar screws.\u003c/p\u003e \u003cp\u003eNo radical surgery as amputation was needed and no death was observed.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTibial pilon fractures are usually associated with poor functional outcomes(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and a high rate of complications. Context is the main issue concerning tibial pilon fractures: usually a high-energy trauma for young patients, where the prognostic is related to soft tissues, and low-energy trauma for the elderly.\u003c/p\u003e \u003cp\u003eThis work purposes an efficient and universal surgical treatment for this rare traumatic occurrence. Hasan and al(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) analyzed this TTN procedure for elderly and showed good results. This work pretends to introduce the idea that this surgical procedure can be applied for any patient and helps to recover an acceptable function for daily living. It appears as a safe procedure even if complication\u0026rsquo;s rate remains high. However, to our knowledge, Hasan and al didn\u0026rsquo;t assess the rate of complications related to high-energy trauma and soft-tissue contusion in a relatively young population.\u003c/p\u003e \u003cp\u003eFor the 43C type fractures, a global complication rate is reported between 10 and 55%(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Any major complication can lead to radical decision as a trans tibial amputation(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Wynes and al(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) alerted on the interest for post traumatic vascular status assessment. This could help to reduce the risk of soft tissue-related complications and infections, avoiding any internal fixation in the case of vascular lesion.\u003c/p\u003e \u003cp\u003eIn multi tissular lesions, the Major Extremity Trauma Research Consortium even purposed trans tibial amputation to be considered as a primary treatment(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this work, a high rate of post-operative infections was observed. Nevertheless, Zhang and al(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) had also pointed out that the high infection rate developed for this type of trauma. Purcell and al(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) demonstrated that syndesmotic injuries, found in types 43C, are a risk factor for infections. According to this, Murawski and al(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) suggested that addition of intrawound vancomycin powder at the time of definitive fixation could reduce gram-positive deep infections at a low financial cost.\u003c/p\u003e \u003cp\u003eTang and al(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) exposed the idea that distal tibia and fibula had to be considered as a 4 columns structure. When performing an internal fixation, it might necessitate a strong fixation on each of these columns. This procedure depends on the soft tissues and vascular status. This theory is debated(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Furthermore, in our opinion, internal fixation is a technical challenge that is not always feasible. The complexity of the lesions requires the use of long plates, which expose the patient to the risk of pseudarthrosis, infection and wound disunion.\u003c/p\u003e \u003cp\u003eSome other possibilities can be discussed concerning the treatment. It is widely accepted that 43C types aren\u0026rsquo;t suitable for non-operative treatment. EF represents a better option when talking about comminuted fractures with soft tissue damages(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). EF offers many possibilities from simple plan to circular constructions (Ilizarov model(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)). The circular model can even allow progressive correction or bone growth. They have the advantage to be less invasive and \u0026ldquo;soft tissues-friendly\u0026rdquo; and give comparable functional results with internal fixation(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the usual treatment was a 2 steps surgery with hybrid fixation representing the first step, helping to manage the soft tissues and, when favorable, plate the fibula. Hybrid fixation was preferred because of its high stability and comfort to monitor soft tissues. The second step consisted in a TTN, associated with a small anterior approach, helping for nailing, bone excision and autograft. It was only deplored the difficulty encountered to achieve a stable fixation of the talus during the surgery. This difficulty could be overcome by reflecting on a dedicated device for TTN.\u003c/p\u003e \u003cp\u003eMany authors(\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) defend retrograde ankle arthrodesis nailing as a good option for comminuted fractures in the elderly. Good results are achieved in terms of bone consolidation. But it seems difficult to sacrifice hind-foot joints for young and active patients. When aiming for a better function preservation, it appeared logical to try TTN, moreover in the case of young people. This work didn\u0026rsquo;t focus on functional recovery, but all patients can walk without crutches after 12 months. Two of them present acceptable sequalae pain, treated occasionally with paracetamol.\u003c/p\u003e \u003cp\u003eIt must be noted that most of these fractures occur in patients with a psychiatric disability. In this work, 2 of them jumped from high height trying to commit suicide and 2 had a diagnostic of schizophrenia. This aspect was underlined by Chiu and al(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) in the elderly but it seems that it can be applied to a reasonable proportion part of \u0026ldquo;tibial pilon\u0026rdquo; population.\u003c/p\u003e \u003cp\u003eThis study is burdened by one main weakness: its retrospective cohort design gives a poor level of proof. This technique was defined by Hasan and al(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) for elderly patients. Thus, the strength of this study lies in the fact that it describes an unusual surgical technique which aims to save lower limb in major traumatic situations, not just in an elderly population. Young patients with higher functional demands and aesthetic concerns seem to be an eligible population for that kind of surgical technique. It is technically demanding and must be carried out by trained traumatologists.\u003c/p\u003e \u003cp\u003eIn conclusion, TTN appears like a pertinent option when treating a tibial pilon (43C type) fracture even if soft tissues are damaged. This procedure needs to be performed at a higher scale to properly evaluate the results and the complications rate, but this pilot study has encouraging results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was needed to lead this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJC wrote the main manuscript and collected the data AL wrote the main manuscriptRM collected the dataFD drafted the manuscript\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJC is an educational consultant for Viatris and Healthcare Events.\u003c/p\u003e\n\u003cp\u003eAL and RM have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFD is an educational consultant for G4 association.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSwiontkowski MF, Sands AK, Agel J, Diab M, Schwappach JR, Kreder HJ. Interobserver Variation in the AO/OTA Fracture Classification System for Pilon Fractures: Is There a Problem? J Orthop Trauma. oct 1997;11(7):467.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. janv 2018;32 Suppl 1:S1\u0026ndash;170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMair O, Pfl\u0026uuml;ger P, Hanschen M, Biberthaler P, Cr\u0026ouml;nlein M. Treatment strategies for complex ankle fractures-current developments summarized in a narrative review. Ann Transl Med. 25 oct 2023;11(11):387.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakan \u0026Ouml;M, Vahabi A, \u0026Ouml;zkayın N. Management of complex pilon fractures: Is it necessary to fix all the columns in AO/OTA type 43-C fractures? Injury. d\u0026eacute;c 2023;54(12):111153.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed ASA, Singer MS, El Bigawi HA. Neglected Tibial Pilon Fractures: Can Arthrodesis Be Avoided? J Orthop Trauma. juill 2018;32(7):369\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang X, Tang PF, Wang MY, L\u0026uuml; DC, Liu MZ, Liu CJ, et al. Pilon fractures: a new classification and therapeutic strategies. Chin Med J (Engl). juill 2012;125(14):2487\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDujardin F. EM-Consulte. 2013 [cit\u0026eacute; 9 d\u0026eacute;c 2024]. Fractures totales du pilon tibial: Complete fractures of the tibial pilon. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.em-consulte.com/article/850524/fractures-totales-du-pilon-tibial-complete-fractur\u003c/span\u003e\u003cspan address=\"https://www.em-consulte.com/article/850524/fractures-totales-du-pilon-tibial-complete-fractur\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMair O, Pfl\u0026uuml;ger P, Hoffeld K, Braun KF, Kirchhoff C, Biberthaler P, et al. Management of Pilon Fractures-Current Concepts. Front Surg. 2021;8:764232.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrauns A, Lammens J. The challenge of the infected pilon tibial non-union: treatment with radical resection, bone transport and ankle arthrodesis. Acta Orthop Belg. juin 2020;86(2):335\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosta ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, et al. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess Winch Engl. mai 2018;22(25):1\u0026ndash;148.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAraujo-Monsalvo VM, Toledo-Romo MF, Rodr\u0026iacute;guez-Castro GA, V\u0026aacute;zquez-Escamilla J, Dom\u0026iacute;nguez-Hern\u0026aacute;ndez VM, Meneses-Amador A, et al. Comparative study of two retrograde locked intramedullary nail designs for ankle arthrodesis: A finite element analysis. Proc Inst Mech Eng [H]. f\u0026eacute;vr 2024;238(2):198\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvers J, Lakemeier M, W\u0026auml;hnert D, Schulze M, Richter M, Raschke MJ, et al. 3D Optical Investigation of 2 Nail Systems Used in Tibiotalocalcaneal Arthrodesis: A Biomechanical Study. Foot Ankle Int. mai 2017;38(5):571\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasan YO, Bourget-Murray J, Page P, Penn-Barwell JG, Handley R. Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient. Eur J Orthop Surg Traumatol Orthop Traumatol. f\u0026eacute;vr 2024;34(2):847\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuk PC, Charlton TP, Lee J, Thordarson DB. Ipsilateral Intact Fibula as a Predictor of Tibial Plafond Fracture Pattern and Severity. Foot Ankle Int. 1 oct 2013;34(10):1421\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoussignol X, Sigonney G, Potage D, Etienne M, Duparc F, Dujardin F. Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series. Orthop Traumatol Surg Res OTSR. f\u0026eacute;vr 2015;101(1):89\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiddleton SD, Guy P, Roffey DM, Broekhuyse HM, O\u0026rsquo;Brien PJ, Lefaivre KA. Long-Term Trajectory of Recovery Following Pilon Fracture Fixation. J Orthop Trauma. 1 juin 2022;36(6):e250\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSameer M, Kc B, V S. Fixation Of Tibial Pilon Fractures Based On Column Concept:A Prospective Study. Acta Orthop Belg [Internet]. d\u0026eacute;c 2017 [cit\u0026eacute; 13 nov 2024];83(4). Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/30423663/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/30423663/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorrelli J, Ellis E. Pilon Fractures: Assessment and Treatment. Orthop Clin. 1 janv 2002;33(1):231\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo X, Wang W, Wang Z, Ma F. Below-knee amputation following internal fixation of a complex open Pilon fracture: A case report. Asian J Surg [Internet]. 30 sept 2024 [cit\u0026eacute; 13 nov 2024]; Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/S1015958424020487\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/S1015958424020487\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWynes J, Kirksey L. Assessing Vascular Status and Risk of Latent Ischemia with Ankle Fracture: A Case Report and Algorithm for Treatment. J Foot Ankle Surg. 1 mai 2014;53(3):353\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMajor Extremity Trauma Research Consortium (METRC). Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation (OUTLET). J Bone Joint Surg Am. 1 sept 2021;103(17):1588\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang J, Lu V, Zhou AK, Stevenson A, Thahir A, Krkovic M. Predictors for infection severity for open tibial fractures: major trauma centre perspective. Arch Orthop Trauma Surg. nov 2023;143(11):6579\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePurcell KF, Bergin PF, Russell GV, Graves ML, Jones LC, Spitler CA. Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment. J Orthop Trauma. 1 mars 2022;36(3):157\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurawski CD, Mittwede PN, Wawrose RA, Belayneh R, Tarkin IS. Management of High-Energy Tibial Pilon Fractures. J Bone Joint Surg Am. 19 juill 2023;105(14):1123\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinnan SM. Definitive Management of Distal Tibia and Simple Plafond Fractures With Circular External Fixation. J Orthop Trauma. nov 2016;30 Suppl 4:S26\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiannoudis VP, Ewins E, Taylor DM, Foster P, Harwood P. Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study. Strateg Trauma Limb Reconstr. 2021;16(2):86\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIlizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop. janv 1989;(238):249\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIlizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop. f\u0026eacute;vr 1989;(239):263\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLegg PI, Malik-Tabassum K, Ibrahim YH, Dhinsa BS. Post-Operative Outcomes of Circular External Fixation in the Definitive Treatment of Tibial Plafond Fractures: A Systematic Review. Cureus. avr 2022;14(4):e24204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiu YC, Wu CH, Tsai KL, Jou IM, Tu YK, Ma CH. Primary Arthrodesis with Retrograde Hindfoot Nail for Elderly Patients with Tibia Pilon Fractures and Psychiatric Illness. J Am Podiatr Med Assoc. 2024;114(3):22\u0026ndash;048.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeGenova DT, Hill ZP, Hoffman AD, Taylor AR, Dues B, Faherty M, et al. Does the Subtalar or Tibiotalar Joint Need Fused in Primary Retrograde Tibiotalocalcaneal Nailing for Fragility Ankle Fractures? Foot Ankle Spec. 10 mai 2024;19386400241249583.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarkin IS, Fourman MS. Retrograde Hindfoot Nailing for Acute Trauma. Curr Rev Musculoskelet Med. sept 2018;11(3):439\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"tibial pilon fracture, nail, traumatology, ankle","lastPublishedDoi":"10.21203/rs.3.rs-6190623/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6190623/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives:\u003c/h2\u003e \u003cp\u003e43C type fractures are rare but challenging situations. This work aimed to present the results of an innovative surgical technique for this type of trauma: antegrade tibio-talar nailing.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis retrospective and monocentric study included patients operated in a level 1 trauma center between May 2013 and July 2022 for antegrade tibio-talar nail. This procedure was indicated for 43C type fractures of the tibial pilon. The usual treatment plan was a two steps procedure: the first step was conducted with external fixation and soft tissues management for the damage control. The second step was initiated after soft tissues full recovery and consisted in a tibio-talar nailing with bone graft if necessary. A usual tibial nail hardware was used to fix the skeleton. The main evaluation criteria were bone consolidation. Complications were collected and are exposed. Amputation or death were considered as a failure.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix patients were included and reached full bone consolidation. They could walk at final follow-up. Many infections were observed, and 2 patients had a chronic osteomyelitis with acceptable pain and organized continuous follow-up.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAntegrade tibio-talar nailing is a rare surgical indication, helping lower limb salvage in high energy traumatology. It is an acceptable surgical technique for very comminuted 43C type fractures, associated with soft tissue damages. More studies should be conducted to correctly evaluate the results in a larger scale.\u003c/p\u003e\u003ch2\u003eLevel of evidence\u003c/h2\u003e \u003cp\u003eIV\u003c/p\u003e","manuscriptTitle":"Tibio-talar antegrade nailing for distal tibial fractures. An innovative way to save lower limb in the context of very severe 43C fractures of the tibial pilon.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-07 09:43:54","doi":"10.21203/rs.3.rs-6190623/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"08749c15-7475-4922-abf8-35f5a2f8b28f","owner":[],"postedDate":"April 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-13T22:53:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-07 09:43:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6190623","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6190623","identity":"rs-6190623","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}