Vo
lu
m
e
5,
Ju
ly
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
IMPROVEMENT OF THE TACTICS OF SURGICAL TREATMENT OF VICTIMS
WITH INTRA-ARTICULAR FRACTURES OF THE DISTAL METAEPIPHYSIS OF
THE TIBIA
Temurov Alisher Akmaljon ugli
assistant of the department.
Murodov Shoxrux ulug’bek ugli
clinical resident.
Nigmatullayev Muhammad Nurali ugli
clinical resident.
Tolmasov Mirjalol Mirzohid ugli
clinical resident
Abstract:
According to domestic and foreign literature, a large number of unsatisfactory
results (up to 40%) in the treatment of patients with intra-articular fractures of the distal
metaepiphysis of the tibia are associated with massive destruction of the articular surface of
the ankle joint. This leads to repeated surgical interventions aimed at correcting the
orthopedic consequences of the trauma.
Currently, there is no clear algorithm for preoperative planning and operative technique.
This is due to errors made during preoperative planning and surgical treatment.
For modern medicine, the problem of reducing the labor activity of patients with CRF and
leading to disability in 26% of cases is very important.
Key words:
fractures, distal metaepiphysis, catatravma,
Research objective.
Increasing the effectiveness of surgical treatment of patients with intra-
articular fractures of the distal metaepiphysis of the tibia.
The relevance of the diagnosis and treatment of patients with intra-articular fractures of the
distal metaepiphysis of the tibia is determined, first of all, by the large proportion of
unsatisfactory anatomical and functional results in this category of patients, according to
various authors, from 15 to 28%.
High-energy fractures of the distal metaepiphysis of the tibia are usually caused by a fall
from a height (catatravma) accompanied by a fall on straightened legs and are caused by
forces directed in the cranial direction along the axis of the tibia [4, 6, 9]. The second most
common cause of high-energy injuries under consideration is road traffic accidents [7, 2]. As
a rule, during a car accident, the ankle joint is affected by a combination of forces, including
compression, forced back flexion, and rotation [2.4]
Vo
lu
m
e
5,
Ju
ly
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
Materials and methods.
On this topic, at the clinical base of the Department of
Traumatology and Orthopedics of the DKTF, at the Samarkand branch of the Scientific and
Practical Medical Center of Traumatology and Orthopedics, examination and treatment of
patients with patellar instability are being carried out. From 2023 to 2025, an analysis of 126
patients' medical histories will be conducted: The majority of patients were men (97 victims
or 77%). Female individuals were significantly fewer - 29 clinical observations, which
constituted 23% of the study group. The age of the patients ranged from 19 to 64 years..
Table-1 Distribution of patients by age and sex.
Age
Sex
Total
Male
Female
Number
%
Number
%
Number
%
19 - 29
20
20,6
5
17,5
25
1
9,
8
30 - 39
37
38,2
3
10,3
40
3
1,
7
40 - 49
18
18,5
12
41,3
30
2
3,
8
50 - 59
16
16,5
6
20,6
22
1
7,
5
60 - 64
6
6,2
3
10,3
9
7,
2
Total
97
100
29
100
126
1
0
0
The injured were divided into two groups depending on the tactics of surgical treatment. The
main group consisted of 64 patients, the clinical and radiological parallels of which made it
possible to improve the tactics of surgical treatment. The comparison group included 62
victims, in the treatment of whom only traditional modern surgical principles were applied.
A clinical, radiological, and CT assessment of the presence and severity of signs of
degenerative-dystrophic damage to the ankle joint was conducted, and the patient's quality
of life in terms of joint function was studied. For this purpose, the following questionnaires
were used: AOFAS - American Orthopaedic Foot and Ankle Society Ankle - Hindfoot Scale,
FAAM - Foot and Ankle Ability Measure, FAOS - Foot and Ankle Outcome Score, SF-36 -
The SF-Health Survey.
Vo
lu
m
e
5,
Ju
ly
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
The developed surgical tactics were tested in the treatment of 64 patients who came for
treatment in the period from 2016 to 2018. The comparison group consisted of 62 patients
with similar fractures treated using traditional surgical tactics in the period from 2015 to
2016. This group was selected for the possibility of a comparative analysis of the clinical
effectiveness of the improved surgical tactics for the treatment of the studied category of
victims.
In general, the distribution of injuries in the studied area by the type of fracture under
consideration is characterized by the predominance of fractures B2 and C2 - 23.8% and
23.1%, respectively. In both the general group (8.7%) and the comparison groups (7.8% and
9.7%), the most frequent type of injury was a type V1 fracture.
The American Orthopaedic Foot and Ankle Society Ankle - Hindfoot Scale (AOFAS)
questionnaire, which was also used in this study, included 9 questions distributed among the
indicators: pain (40 points), the patient's range of motion and physical capabilities (50
points), stickiness of the foot (10 points) - a general scale from 0 to 100 points (100 points
correspond to the best score). This scale combines both subjective questions about the
intensity of pain, the limitation of maximum range of motion activity during walking, and
the results of clinical examination of the patient (walking, range of motion, sticking of the
leg to the surface during walking, joint stability). Evaluation of the results of filling this
scale was carried out by calculating the sum of the total points of answers to the questions of
each section (from 0 to 100).
One of the most informative methods used in this study is the "The Foot and Ankle Outcome
Score" (FAOS) scale (Institute of Sport Science and Clinical Biomechanics, University of
Southern Denmark), which consists of 42 questions scored from 0 to 4 points (0 - no
problem, 4 - extreme level of problem). This visual-analog scale includes a number of
separately assessed sections: pain (9 questions), other symptoms - edema, joint block,
immobility - (7 questions), the level of daily activity (17 questions), sports and active rest (5
questions), as well as the quality of life associated with the function of the foot and ankle
joint (4 questions). Each of the presented questions can be assessed by the patient from 0 to
100 points (100 points - no problem, 0 points - extreme level of problem). The score (%) for
each sub-scale is calculated by adding all scored answers to the questions that make up this
sub-scale and subsequently dividing by the maximum score for this sub-scale. The
maximum score on the "pain" subscale is 36, on the "symptoms" subscale - 28, "daily
activity" - 68, "sports and active recreation" - 20, "quality of life" - 16.
Vo
lu
m
e
5,
Ju
ly
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
A.
B.
в.
C.
D.
Figure 1-2. X-ray images before and after surgery.
Most intra-articular distal fractures of the tibia are complicated by fractures of the fibula. In
the first stage, in cases of simple closed fractures of the fibula, when it was impossible to
place and hold the bone fragments closed, open repositioning and fixation of the third part -
tubular or with a LCP plate - were used. Fragmented closed fractures of the fibula were
fixed after reconstruction of the tibia. A minimally invasive access with subcutaneous
insertion of a plate was used in the projection of the distal part of the fibula.
Table 2 Surgical sections in fractures of the lower third of the tibia
TYPE FRACTURE
Operational sections
Total
(n=62)
Anterior -medial
Anterior-lateral
Number
%
Number
%
Number
%
Vo
lu
m
e
5,
Ju
ly
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
TY
PE
В
В1
5
8,1
–
–
5
8,1
В2
6
9,7
–
–
6
9,7
В3
8
12,9
2
3,2
10
16,1
TY
PE
С
С1
12
19,4
1
1,6
13
21,0
С2
14
22,6
1
1,6
15
24,2
С3
11
17,7
2
3,2
13
20,9
Total
56
90,4
6
9,6
62
100
Results of a comparative study of methods of bone fragment repositioning and methods of
periosteal osteosynthesis
In the treatment of patients in the second group, open repositioning of bone fragments was
mainly used. This rule applied to the repositioning of intra-articular and extra-articular parts
of the tibial fracture. The size of the surgical accesses used in all clinical cases allowed
visualization of the fragments to achieve anatomical comparison, but this increased the
trauma of the surgical intervention and undoubtedly worsened the blood supply to the
fracture site.
After open repositioning of the intra-articular part of the fracture and closed indirect
repositioning of the extra-articular part, osteosynthesis of TBMDE with a limited contact
tibial distal medial plate: a) time of operation - the plate was inserted through an anterior-
medial minimally invasive access; b) intraoperative EOP - placement of the plate and
control of the quality of achieved reposition (Fig. 4).
а)
б)
Figure 4. Osteosynthesis of the tibia: a) stage of insertion of the plate through an
anterior-medial minimally invasive access; b) intraoperative EOP - control of the
position of the plate and the quality of achieved repositioning.
Vo
lu
m
e
5,
Ju
ly
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
Control X-ray examination was performed in 100% of the victims (126 patients) of both
compared groups. The tasks of radiological structural imaging of the TMJ and ankle joint
were considered to be the search for post-traumatic deformities and degenerative changes
that are the causes of pain and impaired ankle joint function.
The obtained data showed the best results among the victims in the main group. Thus, the
average score in patients receiving improved treatment approaches was 80.8±10.8. Similar
results for victims treated according to standard principles were 75.7±11.6 points. However,
no statistically significant differences were found between the compared groups according to
this criterion (p=0.38).
The number of unsatisfactory functional results, assessed on the basis of questionnaires, was
43.5% (27 victims) in the control group and 28.1% (18 patients) in the main group. The
proportion of satisfactory functional results in the control group was 37.4% (23 victims),
while in the main group the number of similar results was 42.1% (27 patients). Good results
were the lowest in the control and main groups - 19.1% (12 victims) and 29.8% (19 patients)
respectively. Excellent anatomical and functional results were not achieved in the compared
groups.
At the same time, the worst functional results of surgical treatment in the first and second
compared groups were observed in the victims who received complete impression-
fragmented intra-articular fractures, which were prognostically unfavorable. Regardless of
the approaches used in the surgical treatment of such patients, the results assessed by a set of
parameters were statistically significantly worse than in patients with incomplete intra-
articular fractures.
CONCLUSION
1. The main reasons for the unsatisfactory results of surgical treatment are the
underestimation of anatomical and topographical features with the incorrect choice of
fixation method, as well as the unjustified use of a standard anterior medial access without
taking into account the type of fracture and the degree of impression of the articular surface.
2. The created computer program allows creating a database and, based on the developed
algorithm, obtaining recommendations for optimal treatment tactics and prognosis. The use
of the program made it possible to correct the treatment tactics in 17.7% of cases and
achieved good results.
3. Within the framework of the developed algorithm for choosing treatment tactics, for the
effective functioning of the computer program, it is advisable to introduce data from clinical
and radiological examinations according to 23 parameters, including 13 radiological, 4 CT,
and 6 physical examinations.
References:
1.
Artemev A.A. Xirurgicheskoye lecheniye oskolchatelnix vnutri sustavnix perelomov
distalnogo otdela bolshoy bolshoy kosti / A.A.Artemev, N.I.Nelin, V.V.Naxayev i dr. //
Chelovek i yego zdorove: tez. dokl. 14 Rossiya milliy kongressi. - SPb., 2009. - B. 9.
Vo
lu
m
e
5,
Ju
ly
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
2.
Abebe E, Farrell DJ, Zelle B, Gruen G. Primary posterior blade plate tibiotalar
arthrodesis: a salvage procedure for complex nonreconstructable pilon fractures.// J Orthop
Trauma. 2017; 31(3): S30–33.
3.
Barei D. Revision of provisional stabilization in pilon fractures referred from outside
institutions / D.Barei, M.Gardner, S.Nork, S.Benirschke // J Bone Joint Surg. Brit. – 2011. –
Vol. 93–B, suppl. 3. – P. 264–265.
4.
Baymagambetov Sh.A. Oshiq-boldir bo‘g‘imi ochiq sinishlarini davolash /
Sh.A.Baymagambetov, S.S.Balgazarov, Ye.I.Junusov // Qo‘shma jarohatlar va oyoq-qo‘l
kasalliklarini davolash. - M., 2003. - B. 34.
5.
Crist B.D. Pilon fractures: Advances in surgical management / B.D.Crist,
M.Khazzam, Y.M.Murtha, G.J.Della Rocca / J. Amer. Acad. Orthop. Surg. – 2011. – Vol.
19, N 10. – P. 612–622.
6.
Helfet D.L. Minimally invasive percutaneous plate osteosynthesis of fractures of the
distal tibia / D.L.Helfet, M.Suk // Instr. Course Lect. – 2004. – Vol.53. – P. 471–475.
7.
Kline A.J. Early complications following the operative treatment of pilon fractures
with and without diabetes / A.J.Kline, G.S.Gruen, H.C.Pape // Foot Ankle Int. – 2009. – Vol.
30. – P. 1042–1047.
8.
Kutepov S.M., Volokitina Ye.A., Pomogayeva Ye.V., Antoniadi Yu.V., Gilev M.V.
Dvux etapniy metod lecheniya vnutri sustavnix perelomov distalnogo otdela kostey boleniya
// Geniy ortopedii. - 2016. - No3. - S. 21-26.
9.
Meng Y.C., Zhou X.H. External fixation versus open reduction and internal fixation
for tibial pilon fractures: A meta-analysis based on observational studies // Chinese Journal
of Traumatology. 2016 Oct; 19(5): 278–282.
10.
Tang X. Pilon fractures: a new classification and therapeutic strategies / X.Tang,
P.F.Tang, M.Y.Wang // Chin. Med. J. (Engl). - 2012. - Vol. 125, N 14. - P. 2487-2492.
11.
Zelle B.A. Primary Arthrodesis of the Tibiotalar Joint in Severely Comminuted
High-Energy Pilon Fractures / B.A.Zelle, G.S.Gruen, R.L.McMillen //J. Bone Joint Surg.
Am. – 2014. – Vol. 96. – P.:1-6.
