Preserving the Bone Envelope: A Prospective Observational Study of Closed Reduction and Ilizarov Circular Fixation for Open and Closed Distal Tibial Fractures.

Abstract

Distal tibial fractures are challenging injuries because of limited soft-tissue coverage, frequent high-energy mechanisms and the potential for soft-tissue compromise. Extensive surgical exposure may further disturb the local soft-tissue and biological environment. Ilizarov circular external fixation permits stable fixation with limited exposure of the fracture site. This prospective observational study evaluated fracture union, bone and functional outcomes and complications following closed or indirect reduction and Ilizarov circular external fixation in patients with open and closed distal tibial fractures and was conducted in the Department of Orthopaedics, Mymensingh Medical College Hospital, Bangladesh from 15 March 2018 to 15 March 2024. Forty skeletally mature patients with distal tibial fractures were treated with an Ilizarov circular external fixator. Fracture reduction was performed by closed or indirect manipulation under C-arm fluoroscopic guidance. Twenty patients had closed fractures and 20 had open fractures. Among the open fractures, 6 were Gustilo-Anderson Grade I, 9 Grade II and 5 Grade IIIA. Clinical and radiological outcomes were assessed during follow-up. Bone and functional outcomes were classified using the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. There were 30 male patients (75.0%) and 10 female patients (25.0%), with a mean age of 28 years. The right tibia was involved in 28 patients (70.0%) and the left tibia in 12(30.0%). Road traffic accidents accounted for 28 injuries (70.0%), falls from height for 8(20.0%) and physical assault for 4(10.0%). The mean interval from injury to Ilizarov fixation was 5 days. All 40 fractures united during follow-up. The mean time to radiological union was 17.12 weeks (range, 14-20 weeks). The mean duration of external fixation was 195 days (range, 180-210 days). The mean follow-up was 12 months (range, 6-15 months), with a minimum follow-up of 6 months after frame removal. According to ASAMI bone criteria, 24 patients (60.0%) had excellent results, 12(30.0%) good results and 4(10.0%) fair results. No poor bone result was recorded. Functional results were excellent in 18 patients (45.0%), good in 16(40.0%), fair in 4(10.0%) and poor in 2(5.0%). Pin-tract infection occurred in 16 patients (40.0%), involving 20 wires. Most infections were managed with local wound care and oral antibiotics. Eight patients (20.0%) required exchange of loose wires. No limb-length discrepancy was recorded during follow-up. In this prospective single-center series, closed or indirect reduction followed by Ilizarov circular external fixation was associated with a high observed rate of fracture union and predominantly favorable bone and functional outcomes in open and closed distal tibial fractures. The technique provided stable fixation while limiting direct surgical exposure of the fracture site. The findings support Ilizarov circular fixation as a useful treatment option in appropriately selected distal tibial fractures, particularly when preservation of the soft-tissue envelope is an important consideration. Comparative studies with larger samples and standardized functional outcome measures are required to determine its relative effectiveness against other fixation methods.