Factors that Influence Soft-tissue Injury in Fractures of the Distal Tibia

Document Type : RESEARCH PAPER


1 Department of Plastic and Reconstructive Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain

2 Department of Orthopaedic Surgery; La Paz University Hospital-IdiPaz, Madrid, Spain


Background: Soft tissue injury associated with fractures of the distal tibia is a predictive factor for a poor prognosis.
The purpose of this study was to investigate factors associated with the need for a flap coverage after distal tibial
fracture, and whether there was a difference in functional outcomes between patients with flap coverage or no flap
coverage for a distal tibial fracture.
Methods: All fractures of the distal tibia treated in our department between 2010 and 2017 were reviewed. The
functional result was assessed using the SF-36 Quality of Life Questionnaire, the Visual Analog Scale (VAS) when
walking and the AOFAS scale (American Orthopedic Foot and Ankle Society).
Results: 132 distal tibia fractures were reviewed, of which 51 required soft tissue flap reconstruction, which was
associated with open fractures (p <0.001, OR 5.25), high energy trauma (p <0.001, OR 1.7)), the use of external fixation
(p <0.001, OR 12.5) and the presence of vascular alterations on the Angio-CT scan (p <0.001). No significant differences
were found in any of the scales that assessed the functional results between the group of patients who required soft
tissue flap reconstruction and the group of patients who did not.
Conclusion: We found that the need for a soft tissue flap was associated with the following parameters: open fracture, high
energy of trauma, presence of skin necrosis, the use of external fixation and the existence of vascular injury. In relation to
functional results, differences were not found between the group that needed coverage with a flap and the one that did not.
Level of evidence: III


1. Zelle BA, Dang KH, Ornell SS. High-energy tibial
pilon fractures: an instructional review. Int Orthop.
2. Rb G. Anderson JT. Prevention of infection in the
treatment of one thousand and twenty-five open
fractures of long bones: retrospective and prospective
analyses. J Bone Joint Surg Am. 1976; 58(4):453-8.
3. Dickson KF, Katzman S, Paiement G. The importance
of the blood supply in the healing of tibial fractures.
Contemp Orthop. 1995; 30(6):489.
4. Menck J, Bertram C, Lierse W. Sectorial
angioarchitecture of the human tibia. Cells Tissues
Organs. 1992; 143(1):67-73.
5. Tarkin IS, Sop A, Pape HC. High-energy foot and ankle
trauma: principles for formulating an individualized
care plan. Foot Ankle Clin. 2008; 13(4):705-23.
6. Zelle BA, Bhandari M, Espiritu M, Koval KJ, Zlowodzki
M, Evidence-Based Orthopaedic Trauma Working
Group. Treatment of distal tibia fractures without
articular involvement: a systematic review of 1125
fractures. J Orthop Trauma. 2006; 20(1):76-9.
7. Tarkin IS, Siska PA, Zelle BA. Soft tissue and
biomechanical challenges encountered with the
management of distal tibia nonunions. Orthop Clin
North Am. 2010; 41(1):119-26. 
8. Crist BD, Khazzam M, Murtha YM, Della Rocca GJ.
Pilon fractures: advances in surgical management. J
Am Acad Orthop Surg. 2011; 19(10):612-22.
9. Erichsen JL, Andersen PI, Viberg B, Jensen C, Damborg
F, Froberg L. A systematic review and meta-analysis
of functional outcomes and complications following
external fixation or open reduction internal fixation
for distal intra-articular tibial fractures: an update.
Eur J Orthop Surg Traumatol. 2019; 29(4):907-17.
10. Bear J, Rollick N, Helfet D. Evolution in management of
tibial pilon fractures. Curr Rev Musculoskelet Med.
2018; 11(4):537-45.
11. Molepo M, Barnard AC, Birkholtz F, Tetsworth K, Glatt
V, Hohmann E. Functional outcomes of the failed plate
fixation in distal tibial fractures salvaged by hexapod
external fixator. Eur J Orthop Surg Traumatol. 2018;
12. Scaglione M, Celli F, Casella F, Fabbri L. Tibial pilon
fractures treated with hybrid external fixator: analysis
of 75 cases. Musculoskelet Surg. 2019; 103(1):83-9.
13. Vaienti E, Schiavi P, Ceccarelli F, Pogliacomi F. Treatment
of distal tibial fractures: prospective comparative
study evaluating two surgical procedures with
investigation for predictive factors of unfavourable
outcome. Int Orthop. 2019; 43(1): 201-7. 
14. Dang KH, Ornell SS, Huynh RA, DeLeon JC, Pesek R,
Karia RA. Early clinical and radiographic outcomes of
a mini-fragment, low profile plating system in tibial
plafond fractures. Injury. 2019; 50(10):1773-80.
15. Silluzio N, De Santis V, Marzetti E, Piccioli A, Rosa
MA, Maccauro G. Clinical and radiographic outcomes
in patients operated for complex open tibial pilon
fractures. Injury. 2019; 50:S24-8.
16. Malige A, Yeazell S, Nwachuku C. Surgical fixation of
pilon injuries: a comparison of the anterolateral and
posterolateral approach. Arch Orthop Trauma Surg.
2019; 139(9):1179-85.
17. Misir A, Kizkapan TB, Yildiz KI, Uzun E, Ozcamdalli
M. Traction radiographs versus CT in the evaluation
of fracture morphology and consecutive treatment
decisions in OTA/AO 43C3 fractures. Injury. 2019;
18. Gates CB, Karthikeyan T, Fu F, Huard J. Regenerative
medicine for the musculoskeletal system based on
muscle-derived stem cells. J Am Acad Orthop Surg.
2008; 16(2):68-76.
19. Sirkin M, Sanders R, DiPasquale T, Herscovici Jr D.
A staged protocol for soft tissue management in
the treatment of complex pilon fractures. J Orthop
Trauma. 2004; 18(8):S32-8.
20. Krettek C, Bachmann S Pilon fractures. Part
2: Repositioning and stabilization technique
and complication management Chirurg. 2015;
21. LeBus GF, Collinge C. Vascular abnormalities as
assessed with CT angiography in high-energy tibial
plafond fractures. J Orthop Trauma. 2008; 22(1):16-22.
22. Attinger CE, Evans KK, Bulan E, Blume P, Cooper
P. Angiosomes of the foot and ankle and clinical
implications for limb salvage: reconstruction, incisions,
and revascularization. Plast Reconstr Surg. 2006;
23. Carbonell-Escobar R, Rubio-Suarez JC, Ibarzabal-Gil
A, Rodriguez-Merchan EC. Analysis of the variables
affecting outcome in fractures of the tibial pilon
treated by open reduction and internal fixation. J Clin
Orthop Trauma. 2017; 8(4):332-8.