Pilon fractures present a unique challenge to the patient and orthopaedic surgeon. Care for the soft tissue envelope is as important as management of this articular fracture. Assessment of the degree of energy causing the fracture and careful planning of the joint reconstruction will lead to acceptable results in most cases.

Forty-five patients (AO-ASIF classification) treated between 2003 and 2008 were examined clinically and radiologically at an average of 24 months after injury. The patients were treated in three different ways: primary internal fixation with a plate following, which was reserved for patients with closed fractures without severe soft tissue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least eight weeks and hybrid external fixation. Objective evaluation criteria were infection rate, pseudarthrosis, amount of posttraumatic arthritis, range of ankle movement.

In 65% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication.

The complication rate depends mainly on the type of fracture, the soft tissue damage and the type of treatment. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the hybrid external fixation. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires

Tourniquet induced ischemia-reperfusion syndrome (IRS) may trigger systemic inflammatory response following a total knee arthroplasty. The IRS will be studied in a prospective randomized controlled study in humans undergoing total knee arthroplasty, by measuring blood inflammatory mediators and blood gases.

Materials and Methods: Forty four (n=44) patients (female/male: 35/9 male) with a mean age of 72 years, undergoing primary total knee arthroplasty for osteoarthritis, were prospectively randomized in two groups. 22 patients operated with tourniquet [tourniquet group (TG)] and 22 patients operated without a tourniquet [non-tourniquet group (NTG)]. The mean overall ischemia time was 90 minutes. Arterial and venous blood samples were collected preoperatively, and at 1, 2, 3, 6, 24, 48 hours postoperatively. The pro-inflammatory (IL-1b, IL-6) and anti-inflammatory cytokines (IL-10) as well as the adhesion molecules (ICAM, VCAM), the CRP and blood counts were measured and correlated with the blood gases.

Results: Patients in TG had higher cytokine and inflammatory mediators values, compared to the NTG group especially during the sixth postoperative hour and the first postoperative day. The most abrupt changes were evident in the patients with the highest preoperative levels of cytokines and inflammatory mediators especially when the ischemia time was more than 90 minutes. Male patients demonstrated the most significant changes.

Discussion: The use of the tourniquet triggers the systemic inflammatory response. The most remarkable changes in inflammatory mediators are evident during the sixth postoperative hour and the first posoperative day. Tourniquet may be used for Total knee Replacement but care should be taken to decrease the ischemia time to the absolutely necessary specifically in males.