Chapter 58: Pilon Fractures

David P. Barei

Chapter Outline

Introduction to Tibial Pilon Fractures

Distal tibial fractures remain one of the most substantial therapeutic challenges that confront the orthopedic traumatologist. Numerous features are responsible for this, but perhaps none are as difficult as the accompanying soft tissue injury that is frequently present. First described by the French radiologist Destot in 1911, ankle fractures that involve the weight-bearing distal tibial articular surface are known as pilon fractures.57 The term “pilon” is from the French language and refers to a pestle, specifically a club-shaped tool for mashing or grinding substances in a mortar, or a large bar moved vertically to stamp or pound. Later, Bonin would refer to a similar fracture as a “plafond” fracture.23 Plafond, meaning “ceiling” in French, likens the distal tibial articular weight-bearing surface to the ceiling of the ankle joint. Though commonly used interchangeably with the term “plafond,” a pilon fracture is a descriptive term suggesting that the talus acts as a hammer, or pestle, that impacts and injures the tibial plafond. Several key aspects of these poorly understood injuries were elucidated in 1968, when Ruedi published an influential paper on this topic, describing the fracture, its treatment principles, and a classification system.160 The surgical management of distal tibial fractures has evolved over the past 35 years in a large part due to an improved understanding of the importance of the soft tissue envelope. Specifically, the restoration of the osseous anatomy while ignoring the often-traumatized soft tissue envelope frequently led to poor postoperative outcomes and high complication rates. Although multiple treatment approaches and protocols have been described, there is no consensus regarding the optimal treatment of these challenging injuries. Similarly, long-term outcome data from randomized comparative treatment methods remains lacking. What does appear to be clear, however, is that the surgeon must balance the extent of osseous reduction and stability, particularly that of the articular surface, within the tolerances of the soft tissue envelope. Although the severity of these injuries, complexities of a variety of treatment methods, and the limitations of management having been well documented in the literature, excellent long-term results of treatment continue to elude the patients sustaining these fractures. 
Ruedi’s experience with immediate fixation of tibial plafond injuries, initially described in 1968, demonstrated satisfactory and durable results with few complications.160 A subsequent paper in 1973 evaluating 54 of the initial 82 patients an average of 9-years postinjury demonstrated the durability of the initial results with an overall improvement of function and only exceptional deterioration.159 These findings were in stark contrast to earlier published results that shaped the existing fatalistic attitude of these injuries.24,53,71,77 Ruedi’s results were supported over the following decade, initially by the results Heim86 and later by those of Ovadia and Beals.143 The authors of these manuscripts noted that their best results were obtained by open reduction and internal fixation (ORIF) according to the Arbeitsgemeinschaft fur Osteosynthese (AO) technique utilized by Ruedi. In part as a result of these publications, ORIF of tibial pilon fractures became the North American standard of care in the late 1980s and early 1990s. However, the enthusiasm for open treatment of these injuries soon became tempered by reports of substantial rates of wound complications particularly deep sepsis, osteomyelitis, and ultimately, poor outcomes.34,35,60,121,182,207 
Unlike the torsional, relatively lower-energy mechanisms of injury in Ruedi’s initial patient population, a greater proportion of North American injuries were noted to be the result of higher-energy axial-loading motor vehicle collisions. In addition, the experience with soft tissue handling techniques was potentially not as advanced as those for treating the osseous injury. Wrysch noted, in contrast to the skiing accident population reported by Ruedi, that a large percentage of urban trauma center patients incurred their injuries from axial compressive forces, resulting in severe articular comminution and an increased soft tissue injury severity.207 Because of the severity of the soft tissue injury and the disastrous results of deep wound complications felt to be attributed to extensive surgical exposures and bulky internal fixation devices, external fixation emerged as a successful technique for decreasing significant septic complications that had been previously attributed to open surgical management.21 In a series of high-energy tibial plafond fractures, Bone and colleagues reported their results using combined internal and external fixation techniques.22 This consisted of open reduction and stabilization of the articular surface with screws with subsequent ankle spanning external fixation used to primarily neutralize the distal metaphyseal fracture until union. There were three fractures with delayed unions that required bone grafting, but there were no significant infections in either the open or closed fracture groups. The authors attributed the decrease in complications to improved soft tissue management afforded by external fixation. Other authors similarly noted a comparable decrease in deep wound complications with the use of external fixation when compared with open plating techniques.20,84,165 Tornetta described combined open stabilization of the articular injury and neutralization of the metaphyseal fracture with the use of hybrid external fixation without spanning across the ankle joint.189 The theorized benefits of this treatment were similar to those of Bone,22 with the added potential benefit of allowing cartilage nutrition through the use of early ankle range of motion. Tornetta’s favorable results demonstrated a substantial decrease in soft tissue complications, with only one deep infection noted in 26 managed fractures, and 71% of patients demonstrating good and excellent results. These results were supported by other authors using hybrid or fully circular wire and ring external fixation devices.13,76,120,135,151,165,199,207 However, the use of external fixation gave rise to an additional set of problems, such as increased rates of malunion, nonunion, lower clinical scores, and a slower return to function.6,151 Subsequent investigations would demonstrate significant rates of pin tract infections, tendon injury, and impalement of neurovascular structures with the use of tensioned wire fixators.94,196 
The lack of consistent results with the use of external fixation techniques and an improved understanding of the associated soft tissue injury gave way to the reconsideration of open treatment with internal fixation but only after a period of soft tissue recovery. In their 1996 textbook, Schatzker and Tile made a distinction between the soft tissue envelope that is adequate for an immediate major surgical procedure and the soft tissue envelope that is not suitable for surgery because of the presence of marked swelling or fracture blisters.184 In this latter group, a delay of 7 to 10 days before definitive fixation was suggested, allowing for the skin and soft tissues to return to a “reasonable” state. Until resolution of the soft tissue injury, it was recommended that the limb undergo a closed reduction and plaster splint immobilization, or some form of skeletal traction or external fixation.184 Prior to this, Mast had recommended that if definitive surgery cannot be performed within 8 to 12 hours, that temporary treatment should be rendered and the definitive procedure delayed for 7 to 10 days to allow time for resolution of swelling.119 The author recommended that length stable injuries could be temporized with casting, but for those fractures with shortening, a period of calcaneal traction was allowed that restored fracture fragment length or even slight distraction.119 Hontzsch had also noted the advantages of two-stage treatment in treating 50 tibial pilon fractures, using external fixation as a temporizing device.91 
The last decade has noted resurgence in the treatment of tibial plafond fractures with ORIF techniques, but with strict attention to the critical appreciation and handling of the traumatized soft tissue envelope. This has led to the popularization of the staged management of tibial pilon fractures, championed in 1999 by two separate reports by Sirkin and colleagues, and Patterson and Cole.149,172 
These studies concluded that the historically high rates of infection associated with ORIF of pilon fractures may have been due to attempts at immediate fixation through swollen and compromised soft tissues. Although staged treatment remains the current foundation for the management of these injuries, the application of minimally invasive plating techniques,12,47,49,88 use of alternate exposures,7,85,89 the development of low profile and anatomically contoured plates,170 and a greater understanding of the osseous fracture anatomy187 has, in part, also been a response to the difficult soft tissue injury that accompanies these fractures. 
Despite the advances in the identification, understanding, and treatment of the concomitant soft tissue injury, the liberal use of computed tomographic (CT) scanning, advances in implant design including locking plate technology, and minimally invasive application techniques, satisfactory outcomes for the management of these challenging fractures remains elusive. 

Assessment of Tibial Pilon Fractures

Mechanisms of Injury for Tibial Pilon Fractures

Most articular fractures of the distal tibial weight-bearing surface are the result of high-energy mechanisms that occur during motor vehicle accidents, falls from heights, motorcycle accidents, and industrial mishaps.136 Malleolar ankle fractures are typically the result of lower-energy indirect rotational forces, whereas the majority of intra-articular fractures of the distal tibial weight-bearing surface are primarily the result of axial loading forces where the talus is forced proximally into the distal tibia producing the “explosion” fracture of the articular surface.97,163 These two main mechanisms of injury result in significantly different fracture patterns, soft tissue damage, associated injuries, and prognosis. Compared to rotational forces, axial loads are typically applied in a more rapid fashion. Because bone is viscoelastic, more energy is absorbed prior to failure; at failure, the energy is released and imparted to the soft tissue envelope. Even in the absence of direct trauma to the soft tissue envelope, it is this release of energy that results in the substantial swelling and blistering seen in these injuries (Table 58-1). Clearly a spectrum of injury results, with predominantly axial forces or rotational forces evident in combined mechanisms. 
Table 58-1
Characteristics of Rotational Compared with Axially Loading Fractures
Rotation Axial Load
Slow rate of load application Rapid rate of load application
Little energy released at failure (yield point) Large amount of energy released
Predominant translational displacement of the talus A component of proximal displacement of talus
Little comminution Comminuted articular surface and metaphysis
Minimal soft tissue injury Severe soft tissue injury
 

From Marsh JL, Saltzman CL. Ankle fractures. In: Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood and Green Fractures in Adults. 6th ed. Philadelphia, PA. Lippincott Williams & Wilkins; 2006.

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As initially hypothesized by Bohler19 and detailed by Ruedi,160 the ultimate fracture pattern depends on the direction and rate of application of the injurious force, and the position of the foot at the time of loading. Because of this, wide variations in fracture patterns occur. A vertical impact while the foot is in dorsiflexion results in cephalad and anterior force, resulting in significant anterior plafond comminution, although impact with the foot in the neutral position results in significant central comminution. These injury patterns are much more common than those of the posterior plafond, which are thought to occur during plantarflexion. The precise direction and position of the foot at the time of impact however, leads to wide variations in fracture patterns (Fig. 58-1). 
Figure 58-1
 
The position of the foot at the time of axial load determines which portion of the tibial plafond sustains the major impact of the talus.
The position of the foot at the time of axial load determines which portion of the tibial plafond sustains the major impact of the talus.
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Figure 58-1
The position of the foot at the time of axial load determines which portion of the tibial plafond sustains the major impact of the talus.
The position of the foot at the time of axial load determines which portion of the tibial plafond sustains the major impact of the talus.
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The advent of high-speed motor vehicle travel, improved automotive restraint systems, and improved life-saving trauma care systems have resulted in an increasing incidence of axial load-type intra-articular distal tibia fractures that confront the orthopedist. The same forces that may have previously been exerted to the head, chest and/or abdominal region and resulted in the death of the occupant are now neutralized by vehicle restraint systems; however, these same forces are still applied to the lower extremities, resulting in the increasingly frequent presentation of substantially severe extremity injuries including those involving the distal tibia. Tibial plafond fractures may present in isolation but are also frequently seen in the polytraumatized patient. Marked articular and metaphyseal comminution, wide displacement, chondral impaction, associated fibular fractures, and articular debris are commonly seen. Open wounds, deep abrasions, fracture blisters, and accompanying osseous and soft tissue devitalization are common and corroborate the high-energy mechanism. 
Intra-articular distal tibia fractures resulting from rotational forces have a spiral orientation, frequently without significant fracture comminution. The articular injury is composed of mildly or moderately displaced large articular fragments with minimal chondral impaction or disruption. The soft tissue envelope is injured to a lesser degree, although significant swelling may still be a component. Open wounds with significant devitalization are not common and the prognosis is more favorable. 

Associated Injuries with Tibial Pilon Fractures

High-energy forces, such as those encountered during motor vehicle collisions or falls from a height create a variety of associated injuries. In several large series of tibial plafond fractures, other fractures and other major system injuries were present between 27% and 51% of patients.11,22,47,85,87,150,189 The incidence of open fracture varies according to whether higher-energy or lower-energy mechanisms are reviewed. Ruedi noted the open fracture rate to be between 3% and 6%,159,162 where a high percentage of injuries occurred in skiers. Higher incidences of open fractures ranging between 12% and 56% have been reported in series where most of the fractures resulted from higher energy mechanisms such as motor vehicle collisions and falls from heights.22,85,150,199 
Compared to injuries of the proximal tibia, complete vascular injury and compartmental syndrome is relatively rare, with the incidence ranging from 0% to 5%.35,110,189 LeBus and Collinge, however, evaluated 25 consecutive patients sustaining high-energy tibial plafond fractures with CT angiography noting vascular abnormalities in 52%.104 Of the 14 arterial lesions identified, 9 involved the anterior tibial artery, 3 the posterior tibial artery, and 2 involved the peroneal artery. Fifty percent of these arterial lesions demonstrated complete occlusion, and a significant association was found between the presence of an open fracture and an arterial abnormality. Interestingly, all of these limbs demonstrated dorsalis pedis artery pulses or documented biphasic Doppler tones and none were described as pulseless or clinically ischemic. Although no sequelae regarding wound healing or fracture union related to the arterial abnormality was identified, patients with CTA-diagnosed vascular abnormalities tended to be treated with more minimally invasive surgery than those without vascular abnormalities. 
Ipsilateral injuries of the talus66 and/or the calcaneus128 are extremely unusual; however, chondral injuries of the talus, particularly gouges, scuffing, and frank chondral fractures are quite common but are likely under-reported.167 Although the definitive impact that these chondral injuries have remains unknown, it is intuitive that they likely negatively affect long-term outcome. 

Signs and Symptoms of Tibial Pilon Fractures

The patient history allows determination of the magnitude of energy involved, which in turn, allows the surgeon to assess the likelihood of associated skeletal or other system injuries, and the propensity for the development of significant soft tissue swelling and blistering of the distal tibial soft tissues. Medical comorbidities and nicotine usage are particularly important and history of such are detailed as they may modify the surgical tactic. Additional information that is obtained from the history include the type of employment, family support systems, level of education, and whether the injury occurred as the result of a work-related accident, as these have been identified as variables that appear to affect the functional outcome.150,204 The physical location of where the injury took place should be identified as this information may have an impact on the type and degree of contamination in open fractures and direct subsequent antibiotic treatment. 
Examination of the soft tissue envelope is of critical importance in the complete assessment of fractures of the tibial plafond and should be performed in a logical, consistent, and circumferential manner. The degree of swelling, the severity of contusions, and the presence of abrasions, blisters, open wounds, and compartmental syndrome are evaluated and noted. Not infrequently, widely displaced fracture fragments may create excessive skin tension and jeopardize local skin circulation. In these situations, manual correction of these gross deformities must be performed expeditiously, prior to radiographic examination, to minimize further vascular compromise to the local skin and soft tissues. The circulatory status is evaluated by palpation and/or Doppler ultrasound examination of the pedal pulses, and by noting the color and temperature of the foot. The dorsal and plantar aspects of the foot are examined for alterations in sensation. Open wounds are treated with initiation of intravenous antibiotics, removal of obvious foreign material and debris, sterile saline irrigation, and coverage with a sterile bandage. Occasionally, a fragment of bone remains extruded through the skin, resulting in crushing of the underlying skin and soft tissue envelope. Often this scenario occurs when the distal portion of the tibial shaft is extruded through the anteromedial skin of the distal tibia, putting the skin at the distal portion of the wound in jeopardy. In this situation, reduction of the extruded fragment should be attempted with the goal being to relieve further injury to the anteromedial soft tissues. Once the limb has been evaluated, it is re-aligned and placed it into a provisional splint that does not obscure radiographic detail. 
In addition to marked swelling, fractures of the distal tibia are frequently accompanied by the presence of fracture blisters (Fig. 58-2). Development of fractures blisters typically occurs rapidly after injury, often within hours, but may take up to 2 to 3 days.194 In a clinical and histologic study performed by Giordano and colleagues, the authors identified two clinical types of fracture blisters, clear filled and blood filled.80 Histologic evaluation demonstrated that both fracture-blister subtypes represented cleavage injuries at the dermal–epidermal junction. The main difference between clear-filled and blood-filled blister types was the retention of some degree of epidermal cells in the clear-filled blisters, which the authors believed contributed to a more rapid re-epithelialization and was indicative of a more superficial injury. Conversely, the dermis of the blood-filled subtype was completely free of epidermal cells, indicative of a deeper injury involving the papillary vasculature, and which may have led to increased re-epithelialization time. Disruption of the dermal–epidermal junction and the subsequent formation of fracture blisters appears to result from high strain exposure in the skin as it is deformed by bony displacement at the time the fracture occurs.81 Though reports in the orthopedic literature concerning fracture blisters and their management are limited, hemorrhagic blisters appear to be associated with increased complication rates, scarring, and delayed surgical intervention.79,175,194 There are several methods used to treat fracture blisters including: (1) sterile unroofing with the application of Silvadene and/or nonadherent dressings, (2) sterile aspiration with maintenance of the overlying roof, and (3) leaving the blister intact. There is no compelling evidence to support any method over another.79,175 What does appear reasonable, however, is to avoid the placement of incisions through a nonepithelialized blister bed, particularly a hemorrhagic blister, if possible.79,175,194 
Figure 58-2
 
Clinical photographs of the right lower extremity from the medial (A), and lateral (B) perspectives 5 days after sustaining a highly comminuted tibial pilon fracture. Initial treatment (spanning external fixation) was delayed secondary to associated life-threatening injuries. The severity of soft tissue injury laterally precluded fibular fixation for approximately 3 weeks.
Clinical photographs of the right lower extremity from the medial (A), and lateral (B) perspectives 5 days after sustaining a highly comminuted tibial pilon fracture. Initial treatment (spanning external fixation) was delayed secondary to associated life-threatening injuries. The severity of soft tissue injury laterally precluded fibular fixation for approximately 3 weeks.
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Figure 58-2
Clinical photographs of the right lower extremity from the medial (A), and lateral (B) perspectives 5 days after sustaining a highly comminuted tibial pilon fracture. Initial treatment (spanning external fixation) was delayed secondary to associated life-threatening injuries. The severity of soft tissue injury laterally precluded fibular fixation for approximately 3 weeks.
Clinical photographs of the right lower extremity from the medial (A), and lateral (B) perspectives 5 days after sustaining a highly comminuted tibial pilon fracture. Initial treatment (spanning external fixation) was delayed secondary to associated life-threatening injuries. The severity of soft tissue injury laterally precluded fibular fixation for approximately 3 weeks.
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Imaging and Other Diagnostic Studies for Tibial Pilon Fractures

The initial radiographic evaluation consists of standard ankle anteroposterior (AP), mortise, and lateral radiographs. The diagnosis of a displaced fracture of the tibial plafond is invariably made on these initial radiographs. Full-length images of the tibia and fibula complete the radiologic examination of the injured leg, and are used to rule out other potentially coexisting proximal fractures of the tibia and/or fibula. Although CT scanning has become a routine part of the radiographic assessment of tibial plafond fractures, a careful review of the plain radiographs will demonstrate a substantial amount of information. Key features to identify include the direction and magnitude of talar displacement or talar subluxation, the presence or absence of a fibular fracture, the degree of articular comminution, areas of articular impaction, and disruptions of the distal tibiofibular syndesmosis. Distally, associated injuries of the hindfoot and proximally, diaphyseal extension can be assessed. 
CT has been demonstrated to improve the ability to assess the injury and to formulate a preoperative plan prior to definitive fixation.45,187,188 Thin cut axial images combined with coronal and sagittal reformatting allow evaluation of major fracture planes, articular impaction, and the degree of comminution. The ability to accurately assess the location, size, and displacement of the articular surface greatly helps to determine the location and orientation of articular fixation, particularly when using percutaneous techniques. The information obtained from CT scans enables an accurate surgical plan, allowing the surgeon to apply strategic fixation with minimization of soft tissue dissection. For these reasons, axial CT scans with sagittal and coronal plane reformations should be obtained routinely to assist with definitive preoperative planning. In the author’s opinion, three-dimensional reconstructions add little to the information obtained using the axial images with sagittal and coronal reformations. 
To optimize comprehension of fracture relationships, however, CT scanning should be performed after a provisional reduction is obtained, preferably with a spanning external fixator. CT scans obtained with substantial shortening, angulation, and significant displacements of the talus and fracture fragments make the identification of fracture details more difficult and formulation of a preoperative surgical plan suboptimal. Occasionally, however, acute CT scanning of the distal tibia is appropriate. This situation occurs when the plain radiographic investigations demonstrate: (1) a “simple” and modestly displaced articular injury with a soft tissue envelope that does not preclude early ORIF or, (2) the plafond injury is part of a seemingly extra-articular distal tibia fracture with plain radiographic clues that suggest an intra-articular extension. In this latter situation, the CT scan is used predominantly as a diagnostic tool, rather than as a method for further delineating the fracture anatomy already identified on the plain radiographs. The distinguishing features of both of these scenarios are that: (1) the interpretation of the CT scan is clear and understandable and, (2) the operative strategy may consist of a single stage surgical procedure provided that the injury demonstrates is a satisfactory soft tissue envelope. 
Currently, there is no described role for routine magnetic resonance imaging of these injuries, and although angiography has been described as a diagnostic tool for clinically silent vascular abnormalities associated with fractures of the distal tibia,104 its routine use has not been supported. 

Classification of Tibial Pilon Fractures

Tibial Pilon Fracture Classification Systems

The two main classification systems used for fractures of the tibial plafond are the Ruedi and Allgower system160 and the OTA/AO Fracture Classification System.72 Both are descriptive systems, with the severity of injury only being inferred. The Ruedi and Allgower system160 is moderately useful and divides fractures of the tibial plafond into three types based on the displacement and degree of comminution of the articular surface (Fig. 58-3). Type I fractures are intra-articular fractures without displacement. Type II fractures demonstrate displaced articular fragments without comminution. Type III fractures demonstrate displacement and comminution of articular fragments. Interobserver and intraobserver agreement has been shown to be poor with the Ruedi–Allgower system.118 
Figure 58-3
Ruedi and Allgower classification of tibial plafond fractures.
 
Type I: Cleavage fracture of the distal tibia without significant displacement of the articular surface. Type II: significant fracture displacement of the articular surface without comminution. Type III: Impaction and comminution of the distal tibial articular surface.
Type I: Cleavage fracture of the distal tibia without significant displacement of the articular surface. Type II: significant fracture displacement of the articular surface without comminution. Type III: Impaction and comminution of the distal tibial articular surface.
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Figure 58-3
Ruedi and Allgower classification of tibial plafond fractures.
Type I: Cleavage fracture of the distal tibia without significant displacement of the articular surface. Type II: significant fracture displacement of the articular surface without comminution. Type III: Impaction and comminution of the distal tibial articular surface.
Type I: Cleavage fracture of the distal tibia without significant displacement of the articular surface. Type II: significant fracture displacement of the articular surface without comminution. Type III: Impaction and comminution of the distal tibial articular surface.
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The OTA/AO system is a more comprehensive classification scheme72 incorporating all fractures of the distal tibia including extra-articular fractures of the distal tibial metaphysis. Each bone is assigned a unique numerical designation and fractures are classified according to a consistent framework. The tibia is assigned the numeric code of 43. Injuries of the tibial plafond are then categorized as extra-articular (43 type A), partial articular (43 type B), or total articular (43 type C) (Fig. 58-4). Each type is then further divided into one of three groups depending on the amount of fracture comminution. Each of these, in turn, can be further divided into subgroups by other characteristics of the fracture, such as the direction, description, or location of a fracture line; the presence or absence of asymmetric metaphyseal impaction; and the location and amount of comminution. As expected, the resultant 27 subgroups form a fairly large and cumbersome classification system. Swiontkowski demonstrated moderate observer agreement using the OTA/AO system, particularly in the determination of the fracture type (type A, B, or C), with poorer observer agreement noted with fracture grouping (e.g., C1, C2, or C3).181 Martin demonstrated improved interobserver reliability when classifying fractures into major types with the OTA/AO system (k = 0.60) than with that of the Ruedi and Allgower system (k = 0.46).118 However, for describing these injuries, and for the purposes of developing a surgical tactic, the authors find that grouping the fractures according to the OTA/AO system (e.g., C1, C2, or C3) can be useful. 
Figure 58-4
The three major types of distal tibia fractures according to the AO/OTA classification system.
 
Type A fractures are extra-articular. Type B fractures are partial articular. Type C fractures are complete articular. Subdivisions within Types A and C are based on increasing amounts of comminution. Subdivisions within Type B (partial articular) involve determining the presence or absence of split and depressed articular components.
Type A fractures are extra-articular. Type B fractures are partial articular. Type C fractures are complete articular. Subdivisions within Types A and C are based on increasing amounts of comminution. Subdivisions within Type B (partial articular) involve determining the presence or absence of split and depressed articular components.
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Figure 58-4
The three major types of distal tibia fractures according to the AO/OTA classification system.
Type A fractures are extra-articular. Type B fractures are partial articular. Type C fractures are complete articular. Subdivisions within Types A and C are based on increasing amounts of comminution. Subdivisions within Type B (partial articular) involve determining the presence or absence of split and depressed articular components.
Type A fractures are extra-articular. Type B fractures are partial articular. Type C fractures are complete articular. Subdivisions within Types A and C are based on increasing amounts of comminution. Subdivisions within Type B (partial articular) involve determining the presence or absence of split and depressed articular components.
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Soft Tissue Injury Classification

The recognition of the soft tissue injury that is associated with tibial plafond fractures has resulted in the evolution of their surgical treatment. Despite this being a critical therapeutic consideration, a clinically useful classification system that guides treatment still remains lacking. What has become apparent is that classifying soft tissue injuries is even more difficult than classifying the fracture.38,92 Therefore, a thorough evaluation of the soft tissue envelope, and individual surgeon experience and judgment remain the mainstay. 
The soft tissue injury classification system of Tscherne and Goetzen is subjective and grades soft tissue injuries of closed fractures into one of four categories, organized from 0 to 3.192 Closed fractures with no appreciable soft tissue injury are Grade 0 and demonstrate an indirect fracture with a simple pattern. Grade 1 soft tissue injuries have superficial abrasion or contusion of skin; simple or medium-energy fracture patterns are evident with displaced fracture fragments exerting pressure on the skin. Grade 2 injuries have deep abrasions and local contused skin; medium to severe fracture patterns are identified. The Grade 2 injury may also demonstrate an imminent compartmental syndrome. Finally, Grade 3 injuries have extensive contusions or crushing, and significant muscle destruction and subcutaneous tissue degloving. Compartmental syndrome, vascular injuries, and severe fracture comminution and a high-energy mechanism are often identified as part of Grade 3 injuries. 
Although the Tscherne and Goetzen method of classifying the soft tissue injury is widely discussed in the literature, the observer reliability and reproducibility have not been evaluated. The extent of soft tissue injury does not necessarily vary directly with the OTA/AO fracture classification, and whereas higher energy injuries often demonstrate increased fracture comminution and worse soft tissue injuries, the reverse does not necessarily hold true. Therefore, while the underlying fracture type may provide a clue to the amount of soft tissue injury, it is important to evaluate and classify the soft tissue injury separately from the fracture configuration. 
The Tscherne soft tissue injury classification was expanded by the AO group to create a more objective system that evaluates and grades each component of the soft tissue envelope, including the skin, musculotendinous components, and neurovascular tissue.134 This comprehensive system is very complicated and not clinically practical, but does provide the framework for the surgeon to systematically and critically evaluate the associated soft tissue injury. 

Outcome Measures for Tibial Pilon Fractures

The last decade has seen an improvement in outcomes data with the use of validated, patient-specific outcome tools. Specific to tibial pilon fractures, studies using various prospective validated outcome scores are limited, but outcomes have been reported using the Short Form (36) Health Survey, SF-36, Iowa Ankle Score, Musculoskeletal Function Assessment (MFA), Sickness Impact Profile (SIP), Foot Function Index (FFI), and visual analog pain scale. Because the reported literature uses a number of the available functional outcome scores, comparison amongst studies remains problematic. 
The SF-36 is a multipurpose, short-form health survey composed of 36 questions. It yields an eight-scale profile of functional health and well-being scores as well as psychometrically based physical and mental health summary. It is a generic measure, as opposed to one that targets a specific age, disease, anatomical area, or treatment group. It has proven useful in surveys of general and specific populations, comparing the relative burden of diseases, and in differentiating the health benefits produced by a wide range of different treatments.75 
The Iowa Ankle Score is a clinician-based outcome measure and was developed from a model of pre-existing ankle scores and used to measure morbidity around the ankle following tibial diaphyseal fractures. Introduced in 1989 to evaluate long-term ankle function after tibial shaft fractures,127 it has been validated against the SF-3661 but its methodologic development has not been rigorously evaluated. Despite this, it is utilized in a number of publications related to the treatment of tibial plafond fractures. 
The MFA is a generic patient-reported musculoskeletal quality-of-life outcome index, consisting of 10 categories, from which a total score can be calculated.116 MFA values range from 0 to 100, and lower scores indicate a higher level of overall function. The MFA has been determined to be valid, reliable, and consistent.116,118,178 It has been validated in trauma patients and includes evaluation of the entire musculoskeletal system. Because the MFA is not a limb-, or injury-specific outcome assessment tool, the presence of multisystem and/or multiple orthopedic injuries of varying severity may produce a confounding effect. A short version of the MFA (SMFA) has been validated and is simpler to administer.178 
The SIP is a generic patient-reported quality-of-life outcome scale developed in the United States as a measure of health status or dysfunction generated by a disease.16 It is a behaviorally based questionnaire for patients and addresses activities such as sleep and rest, mobility, recreation, home management, emotional behavior, social interaction, and other similar items. It measures the patient’s perceived health status and is sensitive enough to detect changes or differences in health status occurring over time or between groups. The higher the score, the greater the disability. 
In 1991, the FFI was developed as a self-reporting measure that assesses multiple dimensions of foot function on the basis of patient-centered values.39 The FFI consists of 23 items divided into 3 subscales that quantify the impact of foot pathology on pain, disability, and activity limitation. It has been found to have good reliability and validity and has had wide appeal to clinicians and research scientists alike. In the past 20 years, the FFI has been widely used by clinicians and investigators to measure pain and disability in various foot and ankle disorders and its use has expanded to involve children, adults, and older individuals. Furthermore, the FFI has been widely used in the study of various pathologies and treatments pertaining to foot and ankle problems such as congenital, acute and chronic diseases, injuries, and surgical corrections. 

Pathoanatomy and Applied Anatomy Relating to Tibial Pilon Fractures

Tibial Pilon Fracture Surgical Anatomy

Because of the complexity of these injuries, multiple surgical approaches are frequently required. Therefore, a thorough understanding of each approach and the associated anatomical structures is necessary to properly care for these injuries. The choice of surgical approach(es) is arrived at by an understanding of the fracture anatomy, and balancing the need for accessing and manipulating displaced articular segments, while minimizing further injury to the soft tissue envelope. The most frequent approaches used include the anterolateral, anterior, anteromedial, posteromedial, and posterolateral. Because of the subcutaneous nature of the distal tibia, direct medial approaches are associated with an unacceptably high rate of soft tissue complications and should be avoided. 

Tibial Pilon Osseous and Ligamentous Anatomy

The relevant osseous anatomy of the tibial pilon includes the distal tibia, the distal fibula, and the talus (Fig. 58-5). The distal ends of the tibia and fibula together form a deep socket or box-like mortise into which the superior dome of the talus fits.129 The articular surface of the distal tibia is rectangular in shape and forms the roof of the mortise. Its surface is wider anteriorly than posteriorly and slightly concaves from anterior to posterior.129 The centrally concave distal tibial articular surface demonstrates anterior and posterior extensions. The posterior tibial articular surface extends more distally, making a posterior arthrotomy for joint inspection impractical. Although the anterior tibia extends over the dome of the talus, the entire articular surface of the tibia can be viewed from any of the anteriorly based approaches. The medial malleolus is a distal and slightly anterior projection from the medial aspect of the weight-bearing surface. It presents a chondral surface that is oriented approximately 90 degrees to the horizontal tibial plafond and articulates with the medial aspect of the talar body. The lateral malleolus is the terminal distal portion of the fibula that articulates with the lateral aspect of the talus. In addition, it demonstrates an important articulation with the posterolateral aspect of the distal tibia, the distal tibiofibular syndesmosis. Maximum compressive strength of the tibial plafond occurs within approximately 3 cm from the articular surface, with virtually no resistance to compression in the trabecular bone at a distance of more than 3 cm proximal to the subchondral region.3 The strongest cancellous bone in the region of the distal tibia is located near the subchondral bone plate3 and may provide an optimal area for fixation devices. The relevant anatomy of the talus includes those nonarticular portions of the talar neck that are useful in the placement of Schanz pins to facilitate talar manipulation and application of distraction across the ankle joint. Laterally, there is substantially more area available at the talar neck than that available medially. Relative to the anatomic axis of the tibia, the orientation of the tibial plafond in the frontal plane is slight valgus, with the lateral distal tibial angle approximating 88 degrees,146 and the mid-diaphyseal line (or anatomic axis) of the tibia passes just medial to the midline of the talus.146 In the sagittal plane, the plafond is slightly extended, approximating 80 to 85 degrees,146 and the mid-diaphyseal line of the tibia passes through the lateral process of the talus (center of rotation of the ankle joint) when the foot is at 90 degrees to the tibia.146 Understanding these relationships is particularly important during the application of external fixation devices and the use of indirect fracture reduction techniques. In the author’s experience, radiographs of the contralateral ankle form the best reference for restoring each patient’s unique osseous anatomy. 
Figure 58-5
Osseous anatomy of the right ankle joint.
 
A: Anterior view. B: Posterior view. C: Superior view of the right talus. D: Undersurface view of the right tibial plafond.
A: Anterior view. B: Posterior view. C: Superior view of the right talus. D: Undersurface view of the right tibial plafond.
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Figure 58-5
Osseous anatomy of the right ankle joint.
A: Anterior view. B: Posterior view. C: Superior view of the right talus. D: Undersurface view of the right tibial plafond.
A: Anterior view. B: Posterior view. C: Superior view of the right talus. D: Undersurface view of the right tibial plafond.
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An understanding of the ligamentous attachments at the ankle joint is useful for appreciating fracture displacement patterns, and when considering planes of safe surgical dissection. The distal tibiofibular syndesmosis is formed by the irregular convex surface of the medial aspect of the distal fibular and the irregular concave surface on the lateral aspect of the tibia. In its distal portion, the fibula is effectively secured to the distal tibia by the anterior tibiofibular ligament, the posterior tibiofibular ligament, and the strong interosseous tibiofibular ligament. The flat and triangular-shaped anterior tibiofibular ligament travels from the anterolateral aspect of the distal tibia, usually referred to as the tubercle of Chaput, laterally and distally to insert on the anterior aspect of the distal fibula.147 The smaller and more horizontally oriented posterior tibiofibular ligament is comprised of a superficial and deep component. The latter is also known as the transverse tibiofibular ligament and projects below the margin of the distal tibia to form a labral articulation for the posterolateral talus.138 The deltoid ligament is a strong, flat, broad triangular band composed of a superficial and deep set of fibers. The superficial fibers pass distally from the anterior colliculus of the medial malleolus to the navicular, sustentaculum tali of the calcaneus, and to the anterior portion of the medial tubercle of the talus.148 The clinically important deep portion of the deltoid consists of a posterior band, the deep posterior talotibial ligament, that originates from the posterior colliculus and intercollicular groove and travels posterolaterally and distally to insert into the entire nonarticular medial surface of the talus.147,148 This deep portion of the deltoid ligament is the principal stabilizer of the talus in the ankle mortise (Fig. 58-6). Using MRI ankle arthrography, Lee and colleagues have delineated the proximal capsular extension of the ankle joint.105 The mean capsular extension anterior to the distal tibia was 9.6 mm proximal to the anteroinferior tibial margin and 3.8 mm proximal to the dome of the tibial plafond. In the tibiofibular recess, the mean capsular extension was 19.2 mm proximal to the anteroinferior tibial margin and 13.4 mm proximal to the dome of the tibial plafond. These and other authors have noted that these areas, therefore, are at risk for being traversed with the use of fine wire external fixation techniques for distal tibial plafond fractures.105,196 
Figure 58-6
A: Anterior view. B: Posterior view.
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Figure 58-6
Important ligamentous structures around the ankle are illustrated.
A: Anterior view. B: Posterior view.
A: Anterior view. B: Posterior view.
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Knowledge of the basic muscular and tendinous anatomy of the distal tibia and ankle joint is necessary to allow for uncomplicated approaches and dissections in safe planes (Fig. 58-7). The anterior tibial compartment contains, from medial to lateral, the tibialis anterior, the extensor hallucis longus (EHL), the extensor digitorum longus (EDL), and the peroneus tertius muscles. Because these muscles are all innervated by branches from the deep peroneal nerve proximally in the leg, distal approaches that are medial, lateral, and between these muscles can be utilized. Distally, the continuation of the deep peroneal nerve and the anterior tibial vessels are located between the EHL and the EDL, requiring direct identification and protection in the direct anterior approach. The lateral compartment of the leg contains the peroneus longus and peroneus brevis muscles, both of which are innervated in their proximal portions by the superficial peroneal nerve. The peroneus brevis has a more distal muscle belly and is located posterior to the peroneus longus. Both are firmly attached along the distal fibula by the peroneal sheath. In the distal third of the leg, the superficial peroneal nerve is purely sensory, pierces the lateral compartment fascia, and travels in the subcutaneous tissue from posterior to anterior, typically being encountered during the anterolateral surgical exposure. 
Figure 58-7
 
Axial view of the distal tibia just proximal to the distal tibiofibular syndesmosis demonstrating the relevant local surgical anatomy and surgical approaches for management of distal tibial plafond fractures. A: Anteromedial. B: Anterolateral. C: Posterolateral (fibula). D: Posterolateral (tibia) D′: Posterolateral (fibula). E: Posteromedial. F: Medial.
Axial view of the distal tibia just proximal to the distal tibiofibular syndesmosis demonstrating the relevant local surgical anatomy and surgical approaches for management of distal tibial plafond fractures. A: Anteromedial. B: Anterolateral. C: Posterolateral (fibula). D: Posterolateral (tibia) D′: Posterolateral (fibula). E: Posteromedial. F: Medial.
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Figure 58-7
Axial view of the distal tibia just proximal to the distal tibiofibular syndesmosis demonstrating the relevant local surgical anatomy and surgical approaches for management of distal tibial plafond fractures. A: Anteromedial. B: Anterolateral. C: Posterolateral (fibula). D: Posterolateral (tibia) D′: Posterolateral (fibula). E: Posteromedial. F: Medial.
Axial view of the distal tibia just proximal to the distal tibiofibular syndesmosis demonstrating the relevant local surgical anatomy and surgical approaches for management of distal tibial plafond fractures. A: Anteromedial. B: Anterolateral. C: Posterolateral (fibula). D: Posterolateral (tibia) D′: Posterolateral (fibula). E: Posteromedial. F: Medial.
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The superficial posterior compartment contains the gastrocnemius, soleus, and plantaris muscles, all of which are innervated by the tibial nerve. In the distal quarter of the leg, the tendo Achilles is formed by the confluence of the soleus and gastrocnemius tendons and their tendon sheath requires protection in any posterior approaches. At the level of the ankle joint, the deep posterior compartment muscles are largely tendinous and include the posterior tibial, the flexor digitorum longus, and the flexor hallucis longus (FHL) muscles. The FHL, however, has a very distal and large muscle belly, and its identification is especially useful in the posterolateral approach to the distal tibia. These muscles are innervated by the tibial nerve, which passes with the posterior tibial vessels deep to the tendinous arch of the soleus muscle in the proximal quarter of the leg. The tibial nerve then descends deep to the soleus muscle and runs distally on the tibialis posterior muscle along with the posterior tibial vessels. The tibialis posterior, flexor digitorum longus, posterior tibial artery, tibial nerve, and FHL travel along the posteromedial aspect of the distal tibia within the tarsal tunnel. These structures require protection and identification during posteromedial surgical exposures. 
Borrelli et al. has described the extraosseous blood supply of the tibia using cadaveric injection techniques.29 The distal metaphyseal areas of the tibia have a rich extraosseous blood supply that is primarily rendered by branches of the anterior tibial and posterior tibial arteries. Distally, the anterior tibial artery gives off several medial and lateral arterial branches that pass onto the surface of the anterior distal tibial metaphysis. The posterior tibial artery provides the majority of the extraosseous vasculature to the medial and posterior aspects of the distal tibial metaphysis. On the medial aspect of the distal tibia, these branches anastomose with branches from the anterior tibial artery and form a complex vascular network. In addition, the posterior tibial artery provides numerous extraosseous branches to the medial malleolar area and to the posterior aspect of the distal metaphysis just proximal to the tibial plafond. This extraosseous blood supply is at risk for disruption during the injurious process, but is also at risk during plate applications to the distal tibia.29 

Tibial Pilon Fracture Anatomy

Although the array of fracture patterns involving the tibial plafond are near limitless, general fracture characteristics have been observed. Frequently, the important ligaments of the ankle often remain largely intact after a tibial plafond fracture and are associated with the three commonly observed major fracture segments. These three fracture fragments, which have recently been mapped out using CT scans,45 are the medial malleolar fragment, the anterolateral (Chaput) fragment, and the posterolateral Volkmann 15 fragment (Fig. 58-8A–C). In complete articular injuries (OTA/AO C-type fractures) these fracture segments typically retain connections with portions of the deltoid (medial malleolar segment), posterior tibiofibular ligament (posterior malleolar segment), and the anterior tibiofibular ligament (anterolateral tibial segment). As the complexity increases, the number of fragments and the associated comminution increase. Often within the intersection of these major fracture segments areas of comminution and impaction can be identified, frequently involving the central and anterolateral portions of the tibial plafond corroborating the axial load and cephalad displacement of the talus within the distal tibial metaphysis at the time of injury. Partial articular injuries may affect any aspect of the tibial plafond, but most commonly involve the anterior plafond, the medial malleolar segment, or combinations thereof. It is critical in these partial articular injuries to closely examine that portion of the intact tibial plafond immediately adjacent to the fracture to identify subtle areas of impaction. Clinically, the fractured edge of the intact segment frequently demonstrates substantial chondral injury and small zones of comminution that may frustrate an exact reduction. Using CT scanning, Topliss has performed an extensive anatomic description of the major fracture lines at the level of the tibial plafond, further delineating the fracture morphology of the anterolateral, posterolateral, and medial malleolar fracture fragments.187 The status of the fibula is an important surgical consideration when managing fractures of the distal tibia. Unlike rotational injuries of the ankle, axial loading fractures of the tibial plafond frequently demonstrate comminuted fibular fractures with transverse and oblique fracture plane orientation. Fibular fractures appear to be more commonly associated with OTA/AO C-type distal tibial plafond fractures than with partial articular (B-type) patterns.14 Using a rank order technique, this same study also determined that tibial plafond injuries with fibular fractures appeared to be more radiographically severe than those without fibula fractures.14 Compressive fibular failure is commonly seen with tibial plafond fractures that present with valgus angulation, whereas tension fibular failure is commonly identified with tibial plafond fractures that present with varus angulation (Fig. 58-8 A–C). The mechanism and inherent lack of stability associated with comminuted fibular fractures that occur in the setting of tibial plafond injuries, simple fibular fixation devices, such as tubular plates, may be inadequate at achieving the desired stability. Because a purely ligamentous failure of the anterior and posterior distal tibiofibular ligaments is very unusual187 restoration of fibular length, alignment, and rotation has a substantial impact on the indirect realignment of the anterolateral and posterolateral tibial plafond from their attachments to the anterior and posterior tibiofibular syndesmotic ligaments. Any change in either the length or the rotation of the distal fibula will be reflected in the anterolateral and posterolateral segments of the distal tibia. Similarly, because of the intimate articulation between the tibia and the fibula at the distal tibiofibular joint, angular deformity of the distal fibula in any plane will have implications on distal tibial reduction. In addition, anatomic realignment of the fibula also indirectly reduces the talus beneath the anatomic axes of the tibia. Equally as important to appreciate then, that fibular malalignment or residual shortening can therefore have a substantial negative impact on: (i) the ability to reduce the articular surface of the distal tibia, (ii) restore distal tibial alignment and, (iii) the final position of the talus beneath the tibia (Fig. 58-9). Any surgical approach chosen should respect any remaining ligamentous attachments to these structures. 
Figure 58-8
Anteroposterior (A) and lateral (B) injury radiographs of a 42-year-old man after falling from a ladder.
 
Initial displacement demonstrates varus angulation with anterior translation of the talus relative to the tibia. The associated transverse fibular fracture at the level of the tibial plafond indicates a tensile failure mechanism of the fibula. (C) demonstrates the three commonly identified major fragments: a medial malleolar fragment, an anterolateral (Chaput) fragment, and a posterior malleolar (Volkmann) fragment. Articular comminution is noted between all fracture fragments, most notably at the central intersection of all three fragments. Posterolateral, anterolateral, and medial malleolar fracture fragments remain discernible.
Initial displacement demonstrates varus angulation with anterior translation of the talus relative to the tibia. The associated transverse fibular fracture at the level of the tibial plafond indicates a tensile failure mechanism of the fibula. (C) demonstrates the three commonly identified major fragments: a medial malleolar fragment, an anterolateral (Chaput) fragment, and a posterior malleolar (Volkmann) fragment. Articular comminution is noted between all fracture fragments, most notably at the central intersection of all three fragments. Posterolateral, anterolateral, and medial malleolar fracture fragments remain discernible.
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Initial displacement demonstrates varus angulation with anterior translation of the talus relative to the tibia. The associated transverse fibular fracture at the level of the tibial plafond indicates a tensile failure mechanism of the fibula. (C) demonstrates the three commonly identified major fragments: a medial malleolar fragment, an anterolateral (Chaput) fragment, and a posterior malleolar (Volkmann) fragment. Articular comminution is noted between all fracture fragments, most notably at the central intersection of all three fragments. Posterolateral, anterolateral, and medial malleolar fracture fragments remain discernible.
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Figure 58-8
Anteroposterior (A) and lateral (B) injury radiographs of a 42-year-old man after falling from a ladder.
Initial displacement demonstrates varus angulation with anterior translation of the talus relative to the tibia. The associated transverse fibular fracture at the level of the tibial plafond indicates a tensile failure mechanism of the fibula. (C) demonstrates the three commonly identified major fragments: a medial malleolar fragment, an anterolateral (Chaput) fragment, and a posterior malleolar (Volkmann) fragment. Articular comminution is noted between all fracture fragments, most notably at the central intersection of all three fragments. Posterolateral, anterolateral, and medial malleolar fracture fragments remain discernible.
Initial displacement demonstrates varus angulation with anterior translation of the talus relative to the tibia. The associated transverse fibular fracture at the level of the tibial plafond indicates a tensile failure mechanism of the fibula. (C) demonstrates the three commonly identified major fragments: a medial malleolar fragment, an anterolateral (Chaput) fragment, and a posterior malleolar (Volkmann) fragment. Articular comminution is noted between all fracture fragments, most notably at the central intersection of all three fragments. Posterolateral, anterolateral, and medial malleolar fracture fragments remain discernible.
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Initial displacement demonstrates varus angulation with anterior translation of the talus relative to the tibia. The associated transverse fibular fracture at the level of the tibial plafond indicates a tensile failure mechanism of the fibula. (C) demonstrates the three commonly identified major fragments: a medial malleolar fragment, an anterolateral (Chaput) fragment, and a posterior malleolar (Volkmann) fragment. Articular comminution is noted between all fracture fragments, most notably at the central intersection of all three fragments. Posterolateral, anterolateral, and medial malleolar fracture fragments remain discernible.
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Figure 58-9
 
Anteroposterior (A) and lateral (B) radiographs of a patient with a tibial pilon fracture referred after fibular ORIF and spanning external fixation. In image B, the posterior aspect of the proximal and distal fibular fragments is marked in yellow. The mid-diaphyseal tibial axis is represented in red. The extension deformity of the fibula fracture has resulted in significant anterior translation of the talus relative to the tibia.
Anteroposterior (A) and lateral (B) radiographs of a patient with a tibial pilon fracture referred after fibular ORIF and spanning external fixation. In image B, the posterior aspect of the proximal and distal fibular fragments is marked in yellow. The mid-diaphyseal tibial axis is represented in red. The extension deformity of the fibula fracture has resulted in significant anterior translation of the talus relative to the tibia.
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Figure 58-9
Anteroposterior (A) and lateral (B) radiographs of a patient with a tibial pilon fracture referred after fibular ORIF and spanning external fixation. In image B, the posterior aspect of the proximal and distal fibular fragments is marked in yellow. The mid-diaphyseal tibial axis is represented in red. The extension deformity of the fibula fracture has resulted in significant anterior translation of the talus relative to the tibia.
Anteroposterior (A) and lateral (B) radiographs of a patient with a tibial pilon fracture referred after fibular ORIF and spanning external fixation. In image B, the posterior aspect of the proximal and distal fibular fragments is marked in yellow. The mid-diaphyseal tibial axis is represented in red. The extension deformity of the fibula fracture has resulted in significant anterior translation of the talus relative to the tibia.
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The combination of fracture pattern, associated soft tissue condition, open wounds, patient comorbidities, and surgeon expertise determines the surgical approach(es) to be used. Open wounds may or may not be extended as a component of the surgical approach. Frequently, the soft tissues are the most traumatized over the distal tibia and avoidance of incisions in this region may prove prudent. One of the most important factors in choosing the appropriate surgical approach for a given injury is the location of the fracture lines and the associated comminution. The most frequently used approaches for articular injuries are the anterolateral and the anteromedial. 

Tibial Pilon Fracture Treatment Options

Nonoperative Treatment of Tibial Pilon Fractures

Indications/Contraindications for Nonoperative Treatment of Tibial Pilon Fractures

Several decades ago, purely conservative treatment of pilon fractures using closed reduction and plaster cast immobilization had largely been demonstrated to have relatively poor functional results, resulting in its abandonment in favor of operative therapy. Several authors have noted the same consistent difficulties with cast treatment: (1) The inability to maintain the talus from its common anteriorly and superiorly displaced position, (2) the inability to accurately realign or reduce displaced osteochondral fracture fragments, and (3) trophic impairments secondary to prolonged joint immobilization.163 Although it does represent the minimum risk for soft tissue injury, skin necrosis complications may still occur secondary to local skin ischemia from displaced fracture fragments. Accordingly, nonoperative management should be reserved for those fractures that are truly nondisplaced or for those patients who have a significant or absolute contraindication to surgical management, such as nonambulatory patients, those with a very poor soft tissue envelope, and/or patients with tenuous vascular supply to the limb. Indications for nonoperative management of displaced intra-articular fractures of the tibial plafond, therefore, are extremely limited. 

Nonoperative Techniques for Tibial Pilon Fractures

Depending on the magnitude of articular injury and the degree of fracture instability, patients treated using nonoperative methods can be managed with closed manipulative reduction and cast immobilization. Progressive weight bearing with ankle and subtalar range of motion is initiated based on radiographic healing, typically within 6 to 12 weeks after their injury. Severely injured or ill patients with marked fracture instability, displacement, and substantial soft tissue injury can be treated with calcaneal pin traction184 and transitioned into a cast when the overall condition of the patient and limb allow. 

Outcomes of Nonoperative Treatment of Tibial Pilon Fractures

Rouff noted that closed reduction and cast immobilization often did not prevent the talus from its natural tendency to displace anteriorly and superiorly, recognizing that maintaining the normal tibiotalar relationship was an important component of restoring ankle function.163 Ayeni found that while closed treatment and casting gave good results in minimally displaced fractures (Ruedi type I), a substantial number of poor results occurred in displaced fractures, and felt that casting was not even applicable in those with significant comminution.8 In a small comparative series, Kellam noted that, in both rotational and compression types of tibial plafond injuries, the results of operative treatment were superior to the results of nonoperative treatment.97 The best results of nonoperative treatment in that study occurred in those rotational injuries that did not displace over the duration of closed management. Bourne evaluated the results of 42 tibial pilon fractures classified according to the Ruedi and Allgower system.34,35 In all fracture types, the authors noted worse results with closed treatment compared with open treatment, with universally poor results noted with increasing comminution and displacement (types II and III).34,35 Collectively, the conclusions of these studies, and others, is that casting is ineffective in maintaining limb length and in reducing impacted articular segments, particularly in axial loading injuries with significant displacement and comminution. In those intra-articular distal tibial fractures with an intact fibula, the persistent varus tendency makes maintenance of limb alignment with nonoperative techniques difficult. Similarly, displaced partial articular injuries frequently demonstrate talar subluxation within the mortise that cannot be effectively managed with closed techniques. Despite the shortcomings of closed treatment, this management method is still preferred in a small number of patients, such as those who are bedridden or who have minimal ambulatory capacity or functional demands. In addition, patients with significant associated medical comorbidities, particularly those that substantially affect bone and soft tissue healing may be candidates for closed treatment. 

Operative Treatment of Tibial Pilon Fractures

Indications/Contraindications for Operative Treatment of Tibial Pilon Fractures

The majority of displaced distal tibial fractures are managed operatively; particularly those with displaced intra-articular fracture fragments. However, the ideal operative treatment modality has yet to be determined.210 Unstable, displaced extra-articular distal tibial fractures can be treated with numerous techniques including external fixation,2,55 open or percutaneous reduction and plate fixation,26,47,74,88,95,108,193 medullary nailing,99,133,137,156 and combinations thereof. The fracture pattern and conditions of the local soft tissue envelope are the major determinants for the surgical technique chosen. These same principles apply when managing intra-articular fractures of the distal tibia. 
The data obtained from the closed management of displaced intra-articular distal tibial plafond fractures strongly suggests that the tibiotalar joint poorly tolerates articular incongruity and talar subluxation.8,35,97,142,163 More recently, Anderson and colleagues studied a small group of operatively treated tibial pilon fractures using finite element modeling.5 Their findings supported the existence of a contact stress exposure threshold above which incongruously reduced tibial plafond fractures are highly likely to develop posttraumatic osteoarthrosis. The degree to which residual articular incongruity affects long-term functional outcomes, posttraumatic arthrosis, and the need for further surgical intervention, however, remains controversial,111,115 but continues to be delineated. Thomas et al., utilized novel CT-based image analysis to quantify acute pilon injury characteristics.183 Then applying a combined severity score made up of articular disruption and fracture energy, the authors were able to predict posttraumatic arthrosis severity. Although there are no strict guidelines for determining how much articular step-off or gap can be tolerated, a visible incongruity at the tibial plafond that is demonstrated on plain radiographs should be considered an indication for operative reduction and fixation in properly selected patients. Associated angular malalignment and/or talar subluxation further jeopardize tibiotalar joint function, especially with associated articular incongruity, and are strong indications for operative management. 

Definitive External Fixation of Tibial Pilon Fractures

External fixation has evolved as an integral component in the management of tibial pilon fractures, and can be used as a definitive treatment method or in combination with staged ORIF. In this latter scenario, the external fixation device always crosses and immobilizes the ankle joint (incorporating the foot into the construct) and is used to temporarily maintain gross fracture alignment and stability while awaiting soft tissue recovery enabling definitive ORIF. In the former scenario, the most common rationale for the use of external fixation is to obtain and maintain reduction of the distal tibial metaphyseal fracture, obviating the need for plate stabilization of this area, thereby decreasing the risk of significant wound complications previously associated with open plate fixation. Although Bone reported successful results with ankle spanning external fixation in severe tibial pilon fractures,22 concerns regarding prolonged bridging of the ankle joint gave rise to two solutions: the use of external fixation constructs that span the ankle joint and those that do not. Typically, ankle-spanning systems are comprised of a unilateral fixation frame anchored at the medial border of the shaft of the tibia, the calcaneus, and the talus, creating a bridge across the ankle joint. The ankle sparing systems are typically a hybrid of the unilateral frame and the circular, tensioned thin-wire systems, or a completely tensioned thin-wire system with circular rings popularized by Ilizarov. The former system consists of a fixation ring applied distally with tensioned wires used to connect the epiphysis to the circular portions of the frame, and half pins placed into the tibial diaphysis proximally. A version of the ankle spanning system has the potential to be articulated, allowing the theoretical benefits of ankle motion while still maintaining stability of the distal epiphyseal fracture segments during the osseous healing phase. When using external fixation devices, the surgeon has the option of managing the articular reduction with true open reduction techniques via standard incisions and approaches or using limited incisions combined with percutaneous screw insertions. 
Tibiotalar Sparing External Fixation.
Several external fixator and fixation constructs are available that stabilize distal tibia fractures externally purely on the tibial side of the tibiotalar articulation. Clinical utilization has been reported using Ilizarov fine wire ring fixators,4,37,120,135,195,208,209 hybrid fixators that typically combine fine wire fixation of the distal tibial segment with half pin fixation proximally,2,6,13,73,76,84,107,139,189 and pin-only fixators.50 All of these fixators have successfully decreased wound complication rates compared with older plating techniques. Although some infections over the distal tibia are still reported, ranging from 4% to 13% in several series,6,84,94,189 the union rate has been generally high, with 75% to 81% good and excellent results being reported. Disadvantages of tibiotalar sparing external fixation include the narrow safe corridors available for wire placement may result in tendon impalement or neurovascular injury.139,196 Because stability of the distal tibial metaphysis is dependent upon stable fixation into the epiphyseal segment, certain comminuted distal tibia fractures are not amenable to same-side external fixation, with some authors suggesting that the presence of 2 cm of intact bone is necessary to achieve adequate stability.84 Although less common than seen in the tibial plateau,94 septic arthritis of the ankle secondary to juxta-articular wires at the level of the tibial plafond have been reported.6,94 This indicates that there remains a risk of significant deep wound complications when placing external fixator pins or wires in the zone of injury to stabilize high-energy distal tibia fractures. Very distal injuries, therefore, represent a therapeutic conundrum since pins placed within 2 cm of the joint line, particularly when traversing the distal tibiofibular articulation, may be intracapsular and a subsequent superficial infection of these pins can develop into septic arthritis.105,197 
Katsenis and colleagues recently however illustrated the utility of hybrid external fixation for the treatment of tibial pilon fractures with substantial metaphyseal comminution.96 Using open reduction of the articular surface combined with hybrid external fixation, the authors were able to obtain satisfactory results in patients with moderate metaphyseal comminution (1 to 3 cm) using acute shortening and distraction osteogenesis, or distraction osteogenesis without acute shortening in patients with more substantial comminution (>3 cm). 
Transarticular Spanning External Fixation.
A transarticular spanning pin fixator is an excellent method to temporarily stabilize the ankle, particularly in the setting of a high-energy tibial plafond fracture and is typically applied soon after the injury in an initial surgical procedure followed by a planned second operation after a delay of days or even weeks.18,59,91,149,172 It is less commonly used, however, as the definitive method to neutralize forces during fracture repair. One of the most significant advantages of transarticular spanning external fixation is that it is technically the easiest to apply. In addition, because the zone of injury is not typically violated during its application, it is also the safest to apply since the fractured distal tibia and the surrounding injured soft tissue envelope remain unviolated by the skeletal fixation elements. Until a definitive treatment plan has been decided upon, temporary transarticular spanning external fixation indirectly maintains limb length, alignment, and rotation, which facilitates soft tissue recovery and does not preclude other definitive treatment methods, such as the later application of plates, screws, conversion to hybrid fixation, or combinations of these. Alternatively, a spanning fixator may be used as the definitive method to stabilize the distal tibia.18,22,59 The spanning fixator functions to neutralize the fracture, and the articular surface is reduced and internally fixed, either percutaneously or through limited open approaches or through more extensive open reduction. Cited disadvantages of definitive tibiotalar spanning external fixation for tibial plafond fractures include ankle and hindfoot stiffness, loss of reduction, malunion, and poor overall outcome compared with open techniques.9,18,59,151 
Articulated fixators, popularized by Marsh and others20,21,52,110,111,112,115,165,204 utilize a hinge that is approximated to the center of rotation of the ankle enabling limited ankle movements during the treatment period. Initially, the fixator can be used to distract the tibiotalar joint to facilitate articular visualization and reduction. The device is subsequently used to maintain reduction of the distal metaphysis. According to Marsh, one of the hind-foot pins is incorporated into the talus, allowing precise control of the talar position beneath the tibia and also facilitates partial reduction of the distal fibula, often eliminating the need to fix the fibula internally.114 However, because the neurovascular bundle and the subtalar joint are in the immediate proximity, precise positioning of pins inserted into the hind foot is required. Inaccurate centering of the hinge relative to the approximate axis of ankle rotations will limit the amount of postoperative ankle motion. In addition, because pins are placed into both the talus and the calcaneus, the subtalar joint is immobilized while the fixator is in place. Marsh prospectively examined 31 fractures at an average of 30 months after the injury treated with medial articulated external fixation and minimal incision articular reduction and stabilization.110 There were no deep infections, and while one-third of patients reported a satisfactory or excellent result, almost half were scored as unsatisfactory.110 Additional clinical experience with the articulated external fixator for tibial plafond fractures has also demonstrated a low incidence of significant complications, high union rates, and reasonable patient outcomes.20,21,52,110,111,112,115,165,204 
Although a number of authors have demonstrated successful results with the use of articulated external fixation, particularly related to minimization of wound complications,58,110,165,190 the benefits of early ankle motion with this device remain inconclusive.112 In addition, while cadaveric mechanical evidence has demonstrated that during ankle movement through a well-aligned articulated hinge results in minimal distal tibial segment motion,33,70 Marsh, in a randomized trial, identified three patients treated with articulating external fixation that demonstrated delayed fracture healing when compared with patients treated with similar but static ankle spanning external fixation devices.112 The inference is that the delay to union in those patients may have potentially been due to motion occurring at the metaphyseal fracture site rather than at the intended tibiotalar articulation. 
Articular Reduction and External Fixation.
In part, the treatment goal of using external fixation for the management of distal tibial fractures is to maintain tibial length, alignment, and rotation until union has occurred with minimal additional soft tissue injury from the surgical treatment. Reduction is obtained indirectly using ligamentotaxis. The surgeon, however, has options regarding the management of the articular injury. One technique is to perform a true open reduction using standard surgical approaches. The articular surface is visualized, secured with a series of screws, and the external device is used to neutralize the metaphyseal injury. Another technique is to perform limited or small incision reductions, with fixation using cannulated screws or percutaneous wires. The technique for limited incision reduction requires that the surgeon have a clear understanding of the articular fracture morphology from the CT scan and be able to subsequently plan the location and direction of lag screws or tensioned small-diameter olive wires to achieve articular reduction and interfragmentary compression. Having a thorough understanding of the fracture morphology from the CT scan facilitates interpretation of intraoperative fluoroscopic views of the quality of reduction. Last, in certain situations, open reductions of the articular surface of any sort are contraindicated due to soft tissue constraints or associated injuries that prevent patients from undergoing a prolonged operative procedure. In these situations, restoration of distal tibial alignment and maintenance of the talus centered beneath the mechanical axis of the tibia are the main objectives. Provided that union is achieved with satisfactory alignment, subsequent reconstructive procedures in these patients may be facilitated by the lack of surgical incisions and implants. 
Management of Concomitant Fibula Fractures with Definitive External Fixation.
When ORIF is chosen as the definitive management for a displaced fracture of the tibial plafond, associated displaced fibula fractures are invariably managed with operative stabilization. As espoused by Ruedi, reconstruction of correct fibular length is the first of the four sequential principles in the successful open treatment of these fractures.159,160 The treatment of co-existing fibular fractures when using external fixation as the definitive treatment, however, remains more controversial. Although many authors suggest that this step is beneficial in aligning the limb,76,84,109,135,140 Williams, in a study of tibial plafond fractures treated with external fixation, noted significant complications associated with fibular plating including wound infections, nonunions, and malalignment.203 Late varus deformity, particularly with early frame removal, was noted by French and Tornetta, who concluded that plating of the fibula is not indicated when pilon fractures are treated with limited open reduction and external fixation.73 

Open Reduction and Internal Fixation of Tibial Pilon Fractures

Timing of Open Reduction and Internal Fixation of Tibial Pilon Fractures.
Ruedi and Allgower’s seminal English language manuscript in 1969 described a principled technique for ORIF of the tibial plafond that demonstrated a substantial improvement in functional outcome, complications from arthrosis, and a minimal treatment complication rate compared to nonoperative management.161 This landmark article would become the benchmark for the treatment of these injuries with only 3 of 84 consecutive patients who developed a deep wound infection. The original description of these four principles consisted of restoration of anatomic fibular length, anatomic restoration of the distal tibial articular surface, bone grafting of metaphyseal defects, and stable fixation of the fracture with medial buttress plating. Although some flexibility is required when managing these challenging injuries, these basic principles remain the foundation for formulating a surgical tactic. Subsequent to this publication, the history of open reduction and plate stabilization of tibial plafond fractures in North America demonstrated a marked increase in deep wound infection rates and complications with associated poor outcomes. Although formal open reduction with internal fixation can achieve optimal articular reduction and distal tibial reconstruction, wound complications and deep infection have plagued this form of treatment.34,35,60,121,182,207 When critically assessed, a consistent feature of the failures of ORIF appears to be the timing of the procedure relative to the injury. In their 5-year experience with internal fixation of pilon fractures, McFerran reported a 40% major complication rate, the majority due to soft tissue complications and infections.121 The mean time delay between injury and definitive surgery was approximately 4.5 days, with 46% of patients operated upon within 36 hours. Teeny and Wiss evaluated 60 tibial plafond fractures treated with open reduction and plate fixation noting that poor results occurred in 50% of cases, with a 37% deep infection rate in comminuted pilon fractures.182 This latter finding was strongly correlated with a surgical postoperative wound infection, squarely placing the complication on the shoulders of the treatment. In that study, closed fractures were operatively managed an average of 6 days after injury. Wyrsch and colleagues, in a prospective study, reported a near 40% soft tissue complication rate in patients treated with primary ORIF.207 All of the fractures in this study occurred from motor vehicle accidents or falls/jumps from a height. The average time from injury to operative fixation for closed fractures was 5 days; however, the goal was for fractures to be operatively stabilized within 48 hours unless “severe swelling or fracture blisters were present.” All of the preceding authors recognized that ORIF techniques in a previously underappreciated traumatized soft tissue envelope was a causative factor in the development of significant wound complications and poor outcomes. 
At least two major differences can be identified between Ruedi’s study and those with higher complication rates noted above: (1) the time delay from injury to definitive surgery, and (2) the mechanism of injury. Though not often noted, 75% of Ruedi’s patients were definitively managed surgically on the day of their injury. Fourteen patients were delayed for over 7 days secondary to “severe swelling or doubtful skin conditions,” and the remaining six patients had been treated initially with casting elsewhere but the exact time to their definitive procedure was not indicated. Importantly, of the 84 fractures in Ruedi’s manuscript, 60 fractures (71%) occurred from skiing injuries, 19 fractures (23%) occurred from a fall between 3 and 12 feet, and only 5 fractures (6%) occurred from higher-energy traffic accidents. Comparatively, the manuscripts indicated above describe a time delay between injury and definitive treatment between 3 and 6 days. Furthermore, they also describe a greater proportion of their patient population as having sustained their injuries from higher energy motor vehicle collisions, or other high energy mechanisms. Obviously, many other factors may also be responsible for the differences in outcomes and complications, including the experience of the surgeons, achievement of fracture stability, and other perioperative variables that were poorly controlled. The difference in timing and injury mechanisms however remain key differences and shaped the evolution of tibial pilon fracture care over the past 30 years. 
The past two decades have witnessed a substantial reassessment of the optimal treatment for pilon fractures. Though the concept of delayed definitive ORIF to allow soft tissue recovery had been previously described,91,119 Sirkin’s influential study popularized staged treatment of these injuries.172 The authors acutely managed displaced tibial plafond fractures with a closed manipulative reduction and the immediate application of temporary transarticular external fixation. When fractured, ORIF of the fibula was also performed acutely. Definitive ORIF of the tibia was then performed an average of approximately 13 days later in the closed fracture group, and 14 days later in the open fracture group.172 The time to definitive tibial fixation was predicated on resolution of edema, and was a clinical determination. Using this technique a dramatic decrease in early soft tissue complications, and later problems of osteomyelitis and deep sepsis was noted. In a total of 46 fractures, the authors identified 3 deep septic complications, 2 of which occurred in open fractures. Using a similar protocol, Patterson and Cole had no cases of superficial or deep wound complications in 21 patients followed an average of 22 months.149 Currently, definitive ORIF through formal operative distal tibial exposures requires a critical assessment of the soft tissue envelope. Although not all patients with tibial plafond fractures will demonstrate significant soft tissue injuries, many patients who present with high-energy tibial plafond fractures will have fracture blisters, deep contusions, and early onset of significant edema. This patient group may also sustain other injuries that require evaluation and treatment, often delaying operative orthopedic intervention to a point in time where soft tissue swelling obviously precludes definitive care. It is imperative therefore that the surgeon recognizes the magnitude of any associated soft tissue injury and that the development of a surgical tactic considers timing and soft tissue recovery. Although the optimal time to surgery remains controversial, surgery is often delayed for at least 10 days to allow wrinkles to return, blisters to re-epithelialize, and wounds to heal. At this approximate time delay, the soft tissues enter the reparative phase and are able to tolerate surgical intervention. Because of the typical shortening, displacement, and instability seen with tibial plafond fractures, particularly those considered to be associated with high-energy mechanisms, simple splintage or casting of these fractures for between 10 and 21 days prior to operative intervention makes definitive tibial reduction markedly more difficult and prolongs time to recovery of the soft tissue envelope. Because of this, most surgeons that utilize formal ORIF for these injuries, currently favor the two-stage treatment protocol described to promote recovery of the traumatized soft tissue envelope prior to definitive fixation.149,172 
It is unlikely, however, that the decrease in septic wound complications with ORIF has been entirely attributable to a delay in treatment, as improvements in soft tissue handling,7,29,90,93,164,174,175 the use of lower profile implants,103,170,206 the use of percutaneous and limited incision exposures, and a better understanding of fracture and fixation mechanics were introduced concurrently, and have all contributed to decreasing significant wound complication rates. Although the bulk of unfavorable data used to condemn ORIF has focused on wound and soft tissue complications, the results of many of these studies are also confounded by the inability to have achieved stable internal fixations and/or anatomic reductions. Of eleven patients reviewed by Dillin, only one had plate stabilization of the tibia, with the authors noting that poor results in their series may be secondary to their inexperience at the AO techniques described by Ruedi and colleagues.60 Similarly, of the 16 comminuted tibial pilon fractures treated with ORIF, Bourne noted that anatomic reduction and stable fixation were achieved in only two.35 Teeny and Wiss noted that 37% of their Ruedi type II and 30% of Ruedi type III tibial plafond fractures were unable to be anatomically reduced.182 They also noted that loss of fixation, fracture displacement, and implant failure were present in 30% of Ruedi type III fractures. Wrysch noted that an increasing number of nonanatomic reductions occurred in fractures with increasing comminution (Ruedi type III).207 What is apparent from these studies is that ORIF of comminuted tibial plafond fractures is difficult, and that if one does not attain an anatomic reduction and stable fixation, and is performed through an intolerant soft tissue envelope, the outcome will likely be poor. 
Immediate (Acute) Open Reduction and Internal Fixation.
Intuitively, ORIF is easiest to perform immediately after injury, and before the development of organizing hematoma, soft tissue contraction, callus formation, and osteopenia and bone resorption secondary to the early inflammatory response has occurred. Very recently, White and colleagues revisited the concept of acute ORIF of comminuted tibial pilon fractures.202 The authors reported on 95 patients injured from relatively high energy mechanisms treated using current ORIF techniques by trauma surgeons facile in the management of these injuries. Eighty-eight percent were definitively managed within 48 hours, and the median time to definitive fixation was 18 hours. The authors noted a 2.7% deep infection rate for closed fractures, a 19% deep infection rate for open fractures, and an overall deep wound sepsis rate of 6%. Ninety percent of the 68 with radiographs available (72% of the original cohort) were determined to have anatomical reductions. Similar to Ruedi and Allgower’s work, the authors noted that a minority of patients still could not be managed with immediate ORIF, including those with severe soft tissue injuries, polytrauma patients with multisystem injury, some complex associated proximal tibia fractures, or fractures that were not amenable to primary ORIF. Overall, a high quality of reduction was noted with a medium term outcome that compares favorably with other modalities of treatment. 
Although immediate (acute) ORIF of tibial pilon fractures remains a viable treatment option, this tactic should be approached with caution. Factors that are critical for success include the execution of definitive treatment within 48 hours of injury, a skilled surgeon with experience in the management of high energy tibial pilon fractures, and a facility with adequate resources. To avoid the complications seen two decades ago, repeated series of acute ORIF in higher energy mechanisms should be obtained to corroborate the findings of White before generalizing this technique. 
Staged Open Reduction and Internal Fixation of Tibial Pilon Fractures.
The goals of staged ORIF are anatomic articular reduction, and anatomic restoration of length, alignment, and rotation of the distal tibia. This is performed after a period of soft tissue recovery. The initial treatment provides limb length, alignment, and rotation, often by fibular reduction and internal fixation, and tibial external fixation. This treatment method requires close attention to the creation of a surgical tactic at each intervention. Failure to do so may compromise the final result and increase the risk of complications (Table 58-2). 
 
Table 58-2
ORIF of Tibial Pilon Fractures
View Large
Table 58-2
ORIF of Tibial Pilon Fractures
Preoperative Planning Checklist
Stage 1: Fibular ORIF and Tibiotalar Spanning External Fixation
OR table
  •  
    Caudally radiolucent table (i.e., Midmark)
Position/positioning aids
  •  
    Supine with supportive buttock/flank bump
  •  
    Foam ramp beneath the injured limb to allow lateral fluoroscopic imaging
  •  
    Radiolucent tibial nailing triangle
Fluoroscopy location
  •  
    Contralateral
Equipment
  •  
    Large external fixator set
  •  
    Periarticular fibular plates, mini-fragment plates, one-third and one-quarter tubular plates
  •  
    Small fragment screws (3.5, 2.7 mm), mini-fragment screws (2, 2.4 mm)
  •  
    Wire driver, small fragment pointed and serrated bone clamps
Tourniquet
X
Stage 1: Fibular Open Reduction and Internal Fixation and Spanning Tibiotalar Spanning External Fixation
The goal of the initial operative stage is on the reduction and stabilization of the osseous component of the fracture, particularly restoration of limb length, alignment, and rotation, but primarily as it relates to its effects on soft tissue stabilization. Specifically, this means the elimination of skin tenting, soft tissue distortion, areas of ischemia from displaced osseous fragments, and restoration of soft tissue length. This first stage is typically performed urgently as soon as the patient’s general condition permits. Critical elements of this stage include the accurate placement of skin incisions, external pin placement, anticipation of where definitive tibial surgical incisions and implants will be placed, and the execution of optimal reduction of the fibula and tibial fractures. It is the author’s opinion that, if possible, the surgeon performing the initial stage should also perform the definitive stage, or share a similar management philosophy. Decisions and treatments that occur during this initial stage can have significant impact on the final result. Furthermore, one should not be lulled into the assumption that this stage is “simple” or only “provisional” (Table 58-3). 
 
Table 58-3
ORIF of Tibial Pilon Fractures
View Large
Table 58-3
ORIF of Tibial Pilon Fractures
Surgical Steps
Stage 1: Fibular ORIF
  •  
    Expose fibula using a relative posterolateral exposure
  •  
    Confirm fracture reduction method (direct vs. indirect) and stabilization technique (absolute vs. relative) as dictated by the fracture comminution identified pre- and intraoperatively
  •  
    Reduce and provisionally stabilize fibula fracture using direct or indirect methods
  •  
    Confirm accurate fibular length, alignment, and rotation
  •  
    Apply posterolateral plate with sufficient proximal, distal, and if appropriate, interfragmentary screws
  •  
    Close fibular incision using Allgower–Donati technique with 3-0 nylon suture with suture knots posterior to the incision
X
Preoperative Planning for Fibular Open Reduction and Internal Fixation and Tibiotalar Spanning External Fixation
The key features of this stage include the anticipation of all skin incisions (for this and later stages), debridement of any open wounds, ORIF of an associated fibular fracture, and closed manipulative reduction and temporary spanning external fixation of the tibial plafond fracture. Close evaluation of the injury radiographs will help determine whether an associated fibula fracture failed predominantly in compression, tension, or rotation, and aid in selecting optimal fibular fixation. It is infrequent that anything beyond fibular fixation and tibiotalar spanning external fixation is performed in the first stage, but there are some exceptions. In a small subset of tibial plafond fracture patterns, extension of the fracture may propagate into the diaphysis. Occasionally acute reduction and stabilization of this fracture component during the initial stage may facilitate the subsequent stage of definitive articular and axial reductions and fixations62 (Fig. 58-10). Similarly, widely displaced or rotated posterolateral Volkmann fragments may also be addressed during the initial stage. Although this is an infrequent occurrence, a careful preoperative plan will allow the fibula fracture and posterolateral Volkmann fragment to be addressed via the same posterolateral skin incision.98 It is imperative, however, that the surgeon refrains from overzealous open tibial reductions during this initial stage. 
Figure 58-10
 
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
View Original | Slide (.ppt)
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
View Original | Slide (.ppt)
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
View Original | Slide (.ppt)
Figure 58-10
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
View Original | Slide (.ppt)
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
View Original | Slide (.ppt)
Injury radiographs of a left distal tibial pilon fracture (A, B) demonstrating a large posterior plafond fragment dissociated from the metadiaphysis by a simple, noncomminuted spiral fracture. The talus is anteriorly and proximally displaced relative to the unstable posterior plafond fragment. Acute and accurate reduction and stabilization of the posterior plafond to the metadiaphysis was performed to convert a OTA/AO C-type fracture with complete dissociation of the articular surface from the shaft to a B-type partial articular fracture. This allows a more accurate reduction of the talus beneath the tibial plafond, and potentially decreases surgical dissection at the time of definitive ORIF. Percutaneous, fluoroscopically assisted clamp and lag screw fixation was performed (C–F), followed by the application of a biplanar external fixator (G–J).
View Original | Slide (.ppt)
X
Positioning for Fibular Open Reduction and Internal Fixation and Tibiotalar Spanning External Fixation
The patient is placed supine on a radiolucent operating table. A soft supportive bump or roll is placed beneath the ipsilateral buttock, flank, and shoulder region to minimize the tendency for the entire limb to externally rotate. A sturdy foam ramp or pillow is placed beneath the injured extremity to slightly flex the ipsilateral hip and knee, and elevate the leg, thereby allowing easier access to the posterolateral aspect of the fibula and to allow unobstructed lateral fluoroscopic imaging of the foot, ankle, and tibia. The ipsilateral arm is placed across the chest to avoid a traction injury to the brachial plexus. All bony prominences should be padded, particularly the fibular head and lateral malleolar regions of the contralateral leg. A tourniquet is rarely used for this procedure. 
The leg is shaved, aseptically prepared, and free draped to the mid-thigh. A first generation cephalosporin antibiotic is administered within 60 minutes of the surgical incision. The image intensifier is brought in from the contralateral side of table. When performing operative fixation of the fibula, the monitor is best viewed when it is located at the foot of the bed. During the application of external fixation, particularly when applying traction to the foot, the monitor is best positioned closer to the head of the bed. 
fibular open reduction and internal fixation Surgical Approaches for Fibular Open Reduction and Internal Fixation
Although a straight lateral incision is typically performed for simple fractures of the fibula, the skin incision for fibular fixation in the setting of a tibial plafond fracture should be performed in a relative posterolateral location; specifically, slightly posterior to the palpable posterior border of the fibula (Fig. 58-11). This allows for the use of the same incision if a posterolateral tibial approach is later chosen, and increases the soft tissue bridge if an anterolateral exposure is required for tibial fixation. Though historically a 7 cm skin bridge was routinely recommended,119,134,173 Howard demonstrated minimal soft tissue complications with skin incision bridges between 5 cm and 6 cm when treating tibial plafond fractures.93 This posterolateral incision is also not directly located over the subcutaneous fibula, and therefore, may help to minimize wound complications in this area.136 
Figure 58-11
Anteroposterior (A) and lateral (B) radiographs of a comminuted tibial pilon fracture.
 
Note the valgus angulation of the distal tibia and the compression failure of the fibula. The fibular component of this patient’s pilon fracture has been stabilized using a posterolateral periarticular plate via a posterolateral fibular surgical exposure. C: The peroneal musculature is retracted posteriorly to demonstrate fibular plate fixation. Note that the incision is largely over the peroneal musculature rather than over the subcutaneous portion of the fibula. D: The incision is closed using the Allgower–Donati suture technique with nylon suture material to preserve skin vascularity and distribute the skin tension equitably. E: Final closure. Anteroposterior (F) and lateral (G) radiographs at the conclusion of fibular plating and application of a biplanar spanning external fixator. The “broken” dime sign evident on the anteroposterior radiograph is indicative of slight distraction of the talus rather than fibular shortening.
Note the valgus angulation of the distal tibia and the compression failure of the fibula. The fibular component of this patient’s pilon fracture has been stabilized using a posterolateral periarticular plate via a posterolateral fibular surgical exposure. C: The peroneal musculature is retracted posteriorly to demonstrate fibular plate fixation. Note that the incision is largely over the peroneal musculature rather than over the subcutaneous portion of the fibula. D: The incision is closed using the Allgower–Donati suture technique with nylon suture material to preserve skin vascularity and distribute the skin tension equitably. E: Final closure. Anteroposterior (F) and lateral (G) radiographs at the conclusion of fibular plating and application of a biplanar spanning external fixator. The “broken” dime sign evident on the anteroposterior radiograph is indicative of slight distraction of the talus rather than fibular shortening.
View Original | Slide (.ppt)
Note the valgus angulation of the distal tibia and the compression failure of the fibula. The fibular component of this patient’s pilon fracture has been stabilized using a posterolateral periarticular plate via a posterolateral fibular surgical exposure. C: The peroneal musculature is retracted posteriorly to demonstrate fibular plate fixation. Note that the incision is largely over the peroneal musculature rather than over the subcutaneous portion of the fibula. D: The incision is closed using the Allgower–Donati suture technique with nylon suture material to preserve skin vascularity and distribute the skin tension equitably. E: Final closure. Anteroposterior (F) and lateral (G) radiographs at the conclusion of fibular plating and application of a biplanar spanning external fixator. The “broken” dime sign evident on the anteroposterior radiograph is indicative of slight distraction of the talus rather than fibular shortening.
View Original | Slide (.ppt)
Figure 58-11
Anteroposterior (A) and lateral (B) radiographs of a comminuted tibial pilon fracture.
Note the valgus angulation of the distal tibia and the compression failure of the fibula. The fibular component of this patient’s pilon fracture has been stabilized using a posterolateral periarticular plate via a posterolateral fibular surgical exposure. C: The peroneal musculature is retracted posteriorly to demonstrate fibular plate fixation. Note that the incision is largely over the peroneal musculature rather than over the subcutaneous portion of the fibula. D: The incision is closed using the Allgower–Donati suture technique with nylon suture material to preserve skin vascularity and distribute the skin tension equitably. E: Final closure. Anteroposterior (F) and lateral (G) radiographs at the conclusion of fibular plating and application of a biplanar spanning external fixator. The “broken” dime sign evident on the anteroposterior radiograph is indicative of slight distraction of the talus rather than fibular shortening.
Note the valgus angulation of the distal tibia and the compression failure of the fibula. The fibular component of this patient’s pilon fracture has been stabilized using a posterolateral periarticular plate via a posterolateral fibular surgical exposure. C: The peroneal musculature is retracted posteriorly to demonstrate fibular plate fixation. Note that the incision is largely over the peroneal musculature rather than over the subcutaneous portion of the fibula. D: The incision is closed using the Allgower–Donati suture technique with nylon suture material to preserve skin vascularity and distribute the skin tension equitably. E: Final closure. Anteroposterior (F) and lateral (G) radiographs at the conclusion of fibular plating and application of a biplanar spanning external fixator. The “broken” dime sign evident on the anteroposterior radiograph is indicative of slight distraction of the talus rather than fibular shortening.
View Original | Slide (.ppt)
Note the valgus angulation of the distal tibia and the compression failure of the fibula. The fibular component of this patient’s pilon fracture has been stabilized using a posterolateral periarticular plate via a posterolateral fibular surgical exposure. C: The peroneal musculature is retracted posteriorly to demonstrate fibular plate fixation. Note that the incision is largely over the peroneal musculature rather than over the subcutaneous portion of the fibula. D: The incision is closed using the Allgower–Donati suture technique with nylon suture material to preserve skin vascularity and distribute the skin tension equitably. E: Final closure. Anteroposterior (F) and lateral (G) radiographs at the conclusion of fibular plating and application of a biplanar spanning external fixator. The “broken” dime sign evident on the anteroposterior radiograph is indicative of slight distraction of the talus rather than fibular shortening.
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The incision is longitudinal, centered over the fibula fracture, and is located just posterior to the palpable posterior border of the fibula. Dissection is carried directly through the subcutaneous tissue and the fascia of the lateral compartment is incised longitudinally along the entire length of the skin incision. The anterior edge of the incised fascia is then retracted anteriorly and the peroneal musculature is retracted posteriorly. To preserve vascularity to the skin, care is taken to minimize the creation of planes between the subcutaneous tissue and the fascia over the lateral compartment. Depending on the location of the fracture, the superficial peroneal nerve may be encountered within the lateral compartment before exiting the fascia and travelling within the subcutaneous layer. 
technique—fibula plate fixation
In the common scenario of a coexisting fibular fracture associated with the tibial pilon fracture, fibular reduction and stabilization positively influences the initial management of these injuries in the following ways: 
  1.  
    restoration of accurate fibular length, alignment and rotation indirectly reduces the majority of tibial deformity secondary to the ligamentous and other soft tissue attachments between the two bones;
  2.  
    after fibular reduction and fixation, residual tibial displacement can be managed with an ankle joint spanning external fixator using the reduced and stabilized fibula as a fulcrum;
  3.  
    (fibular reduction commonly neutralizes the tendency for valgus angulation and/or lateral translation of the talus and associated tibial pilon fracture fragments;
  4.  
    anatomic reduction of the fibula allows indirect reduction of the associated anterolateral (Chaput) and posterior (Volkmann) tibial articular fragments via the anterior and posterior distal tibiofibular syndesmotic ligaments, respectively.
Fibular malreduction, therefore, may result in the talus not being centered beneath the anatomic axis of the tibia, or may result in distal tibial metaphyseal malalignment (Fig. 58-9). Notably, extension malreduction of the fibula is not infrequent and results in anterior translation of the talus relative to the anatomic axis of the tibia and ultimately anterior talar extrusion from beneath the tibial plafond. Fibula fractures that occur predominantly from rotational or tension mechanisms are typically stabilized with one-third tubular plates. Unlike rotational ankle fractures, however, the associated fibular fractures seen with high-energy tibial plafond fractures fail in compression or tension. Compression failures frequently demonstrate comminution with transverse and oblique fracture plane orientations. Tension failures are usually simpler, in terms of comminution, and generally occur in a relatively distal location. Although one-third tubular plates may occasionally be satisfactory, stiffer constructs are often required. Stacked one-third tubular plates, precontoured distal fibular periarticular plates, and 3.7 mm or 3.5 mm dynamic compression plates may be required. Manufactured, stiff precontoured periarticular distal fibular plates are particularly advantageous, in that they provide satisfactory stability, while providing a reduction template by virtue of their design. 
The fibula is reduced using direct or indirect techniques, or a combination thereof, and stabilizing implants are typically applied to the posterolateral aspect of the bone.141,205 The placement of supportive bumps solely beneath the posterior aspect of the hindfoot or ankle, as is commonly done for rotational ankle fractures, should be avoided as this can result in an extension deformity of the fibula and tibia. If improved access to the fibula is required, the entire leg should be elevated and supported on several bumps to avoid creating this common but avoidable angulatory deformity. 
Although fibular reduction and fixation is typically performed prior to tibial reduction and external fixation, there are occasions where reversal of this sequence may be advantageous. If limb shortening or instability is significant, obtaining fibular reduction will be problematic. In these situations, external fixation of the tibial component is performed initially, to obtain provisional restoration of length, alignment, and rotation. Fibular reduction and fixation is then performed. Similarly, in the setting of a substantially comminuted fibula fracture where a comparatively minimally comminuted tibial fracture component exists, closed manipulative reduction and external fixation of the tibia initially, may more accurately restore length, alignment, and rotation of the limb and facilitate the subsequent fibular reduction. In situations with significant fibular comminution, indirect reduction using a periarticular fibular plate is very useful. Using an open approach, but with minimization of dissection in the zone of injury, the distal portion of the plate is applied to the lateral malleolus in an anatomic position and held with Kirschner wires (K-wires) and a small bone holding clamp. Gradual restoration of fibular length is achieved with traction applied to the foot and heel, either manually or with a fibular or tibial external fixator. Once length is achieved, the proximal portion of the plate is secured to the proximal fibular fragment using another bone holding clamp. The reduction is then adjusted until there is clinical and fluoroscopic confirmation of restored anatomic fibular length. 
technique—fibula medullary fixation
Occasionally, the associated fibula fracture is axially and rotationally stable, as demonstrated by a transverse or short oblique fracture pattern with minimal comminution. In these situations, medullary fixation is a reasonable option and can be achieved with less surgical dissection than plate fixation.65 Fractures within 5 to 7 cm from the tip of the lateral malleolus can be stabilized with a long medullary 3.5 mm screw. Segmental fractures or those above 7 cm from the tip of the lateral malleolus can be stabilized with commercially available titanium rods or guide rods from humeral, femoral, or tibial medullary nailing sets. Regardless of the device, the radiographs should be closely examined to determine the presence and diameter of the medullary canal of the fibula. Occasionally, the fibular medullary canal is stenotic or nonexistent and cannot accept a longitudinally oriented medullary implant. 
Fluoroscopically, the tip of the lateral malleolus is identified. A 2 cm longitudinal incision is made from the tip of the lateral malleolus and directed distally. The tip of the lateral malleolus is identified by blunt dissection. Using a 2.7 mm trochar-tipped drill bit with drill sleeve, an entry hole is created in the tip of the lateral malleolus in the direction of the fibular canal. A long 2.5 mm drill bit is then inserted into the entry hole and directed into the medullary canal of the fibula using biplanar fluoroscopy. Since the starting point is not collinear with the medullary canal, the drill bit is required to bend as it becomes centered within the endosteal surface. Placing the drill on oscillate and slowly advancing the drill bit will help facilitate this. Care should be taken to avoid breakage of the drill bit within the canal. In displaced fractures, limited exposure confined to the fibular fracture site is performed, typically utilizing a 2 to 4 cm incision. The peroneal musculature is retracted and the fracture is identified under direct visualization. Using two serrated clamps, the fracture is realigned and the drill bit advanced across it. The drill bit is removed and an appropriate length medullary 3.5 mm screw (or medullary wire) is inserted. Anatomical fibular length and rotation is assured and the wounds are closed (Fig. 58-12). 
Figure 58-12
 
Injury anteroposterior (A) and lateral (B) radiographs of an open comminuted and widely displaced tibial pilon fracture. Stage 1 management included urgent reduction and provisional stabilization of the posterior plafond (C). To minimize further soft tissue disruption, the transverse fibula fracture was managed with medullary stabilization using a small open exposure directly at the fracture site (D). An accurate entry hole and trajectory into the lateral malleolus was performed (E), followed by preparation of the distal fibula using a long 2.5 mm drill bit (F), and subsequent retrograde insertion of the medullary rod. At the conclusion of the stage 1, anteroposterior (G) and lateral (H) images demonstrate satisfactory restoration of distal tibial and fibular alignment.
Injury anteroposterior (A) and lateral (B) radiographs of an open comminuted and widely displaced tibial pilon fracture. Stage 1 management included urgent reduction and provisional stabilization of the posterior plafond (C). To minimize further soft tissue disruption, the transverse fibula fracture was managed with medullary stabilization using a small open exposure directly at the fracture site (D). An accurate entry hole and trajectory into the lateral malleolus was performed (E), followed by preparation of the distal fibula using a long 2.5 mm drill bit (F), and subsequent retrograde insertion of the medullary rod. At the conclusion of the stage 1, anteroposterior (G) and lateral (H) images demonstrate satisfactory restoration of distal tibial and fibular alignment.
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Injury anteroposterior (A) and lateral (B) radiographs of an open comminuted and widely displaced tibial pilon fracture. Stage 1 management included urgent reduction and provisional stabilization of the posterior plafond (C). To minimize further soft tissue disruption, the transverse fibula fracture was managed with medullary stabilization using a small open exposure directly at the fracture site (D). An accurate entry hole and trajectory into the lateral malleolus was performed (E), followed by preparation of the distal fibula using a long 2.5 mm drill bit (F), and subsequent retrograde insertion of the medullary rod. At the conclusion of the stage 1, anteroposterior (G) and lateral (H) images demonstrate satisfactory restoration of distal tibial and fibular alignment.
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Figure 58-12
Injury anteroposterior (A) and lateral (B) radiographs of an open comminuted and widely displaced tibial pilon fracture. Stage 1 management included urgent reduction and provisional stabilization of the posterior plafond (C). To minimize further soft tissue disruption, the transverse fibula fracture was managed with medullary stabilization using a small open exposure directly at the fracture site (D). An accurate entry hole and trajectory into the lateral malleolus was performed (E), followed by preparation of the distal fibula using a long 2.5 mm drill bit (F), and subsequent retrograde insertion of the medullary rod. At the conclusion of the stage 1, anteroposterior (G) and lateral (H) images demonstrate satisfactory restoration of distal tibial and fibular alignment.
Injury anteroposterior (A) and lateral (B) radiographs of an open comminuted and widely displaced tibial pilon fracture. Stage 1 management included urgent reduction and provisional stabilization of the posterior plafond (C). To minimize further soft tissue disruption, the transverse fibula fracture was managed with medullary stabilization using a small open exposure directly at the fracture site (D). An accurate entry hole and trajectory into the lateral malleolus was performed (E), followed by preparation of the distal fibula using a long 2.5 mm drill bit (F), and subsequent retrograde insertion of the medullary rod. At the conclusion of the stage 1, anteroposterior (G) and lateral (H) images demonstrate satisfactory restoration of distal tibial and fibular alignment.
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Injury anteroposterior (A) and lateral (B) radiographs of an open comminuted and widely displaced tibial pilon fracture. Stage 1 management included urgent reduction and provisional stabilization of the posterior plafond (C). To minimize further soft tissue disruption, the transverse fibula fracture was managed with medullary stabilization using a small open exposure directly at the fracture site (D). An accurate entry hole and trajectory into the lateral malleolus was performed (E), followed by preparation of the distal fibula using a long 2.5 mm drill bit (F), and subsequent retrograde insertion of the medullary rod. At the conclusion of the stage 1, anteroposterior (G) and lateral (H) images demonstrate satisfactory restoration of distal tibial and fibular alignment.
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Acute Tibia Open Reduction and Internal Fixation
Infrequently, a widely displaced or dislocated posterolateral Volkmann fracture fragment is identified on the injury radiographs. This fracture pattern can be particularly challenging since the anterior tibial plafond exposures used for definitive tibial fixation may not allow adequate visualization or opportunity for satisfactory stabilization of this fragment. In these situations, a posterolateral surgical approach to the tibia can be performed in conjunction with the initial stage and can substantially simplify the subsequent tibial reduction and fixation.98 Identification of this fracture pattern is essential to the preoperative plan because reduction and fixation requires the patient to be in the lateral decubitus or prone position, rather than supine. 
technique—volkmann open reduction and internal fixation
The patient is positioned in the lateral decubitus position with the uninjured limb down, and held there with a deflated beanbag or padded bolsters. The down limb is padded, particularly around the peroneal nerve at the knee and the lateral malleolus. A ramp pillow or folded blankets are used to support the injured extremity. Infrequently, the patient is positioned prone, which provides simpler access to, and manipulation of, the posterior aspect of the tibia and fibula, but complicates external fixation placement (Fig. 58-13). The skin incision is performed halfway between the posterior border of the fibula and the lateral aspect of the Achilles tendon. Care is taken to avoid injury to the sural nerve. The fascia overlying the peroneal musculature and tendons is incised and the peroneals are retracted anteriorly. The underlying fascia is identified and incised longitudinally, exposing the FHL muscle. This is elevated from the posteromedial aspect of the fibula and retracted posteromedially. During this dissection, the peroneal artery and accompanying veins may be encountered immediately posterior to the fibula, and require ligation. The posterior Volkmann fragment is then identified, cleansed of organizing hematoma, and the posterior tibiofibular ligament is left intact. The fibula can then be approached by now retracting the peroneals posteriorly. Fibular reduction often greatly aids in the reduction of the posterior Volkmann fragment and is the first reduction maneuver performed. In situations where a poor ligamentotaxis effect on the fragment with fibular reduction occurs, reduction of the fibula helps to bring the talus into a more centralized position beneath the tibia allowing easier manipulation of the Volkmann fragment. One-third tubular, one-quarter tubular, or 2 mm plates are typically satisfactory for achieving stability. If the lateral decubitus position has been used, the patient is allowed to roll backward to a “sloppy lateral” position once the fibula and Volkmann fractures are reduced and stabilized. This will allow the application of the external fixator. If the patient is in the prone position, repositioning to the supine position is typically required for external fixation application. 
Figure 58-13
The patient is positioned prone on padded bolsters (A).
 
Note that a small foam support is used to elevate the operative leg, facilitating lateral fluoroscopic imaging. A posterolateral exposure has been performed (B). The peroneal musculature (*) and the flexor hallucis longus musculature (FHL) (‡) can be identified. Posteromedial retraction of the peroneal musculature reveals the posterolateral aspect of the plated fibula (C). Medial retraction of the FHL and anterolateral retraction of the peroneal musculature now demonstrates the plated posterior aspect of the distal tibia (D).
Note that a small foam support is used to elevate the operative leg, facilitating lateral fluoroscopic imaging. A posterolateral exposure has been performed (B). The peroneal musculature (*) and the flexor hallucis longus musculature (FHL) (‡) can be identified. Posteromedial retraction of the peroneal musculature reveals the posterolateral aspect of the plated fibula (C). Medial retraction of the FHL and anterolateral retraction of the peroneal musculature now demonstrates the plated posterior aspect of the distal tibia (D).
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Figure 58-13
The patient is positioned prone on padded bolsters (A).
Note that a small foam support is used to elevate the operative leg, facilitating lateral fluoroscopic imaging. A posterolateral exposure has been performed (B). The peroneal musculature (*) and the flexor hallucis longus musculature (FHL) (‡) can be identified. Posteromedial retraction of the peroneal musculature reveals the posterolateral aspect of the plated fibula (C). Medial retraction of the FHL and anterolateral retraction of the peroneal musculature now demonstrates the plated posterior aspect of the distal tibia (D).
Note that a small foam support is used to elevate the operative leg, facilitating lateral fluoroscopic imaging. A posterolateral exposure has been performed (B). The peroneal musculature (*) and the flexor hallucis longus musculature (FHL) (‡) can be identified. Posteromedial retraction of the peroneal musculature reveals the posterolateral aspect of the plated fibula (C). Medial retraction of the FHL and anterolateral retraction of the peroneal musculature now demonstrates the plated posterior aspect of the distal tibia (D).
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At the conclusion of the procedure, and prior to the application of the external fixator, the fibular skin incision is closed using a modified Allgower–Donati suture with the knots tied posteriorly.164 Deep suture is rarely required. 
Tibiotalar Spanning External Fixation
External fixation effectively stabilizes the tibial component of the injury, maintains neutral talar tilt, and resists the tendency of the talus to displace anteriorly out of the ankle mortise. It is usually performed after fibular stabilization and achieves these goals indirectly using ligamento-taxis. One of the most influential indirect reduction methods for obtaining an accurate restoration of tibial length and alignment is the achievement of an accurate and stable fibular reduction. Because this type of external fixation is only temporary, elaborate constructs are not needed; however, the reduction must be rendered effectively stable as this provides a key component to soft tissue recovery. The author routinely uses a biplanar external fixation construct for the temporization of significantly displaced tibial pilon fractures except those with associated calcaneal fractures that will require a lateral extensile exposure, or those patients with severe soft tissue injuries around the lateral hindfoot (Fig. 58-14). In these situations, a uniplanar medially based frame is constructed (Fig. 58-15). A well-applied biplanar external fixator can also be utilized for intra-articular distraction and visualization at the time of definitive tibial ORIF (Table 58-4). 
Figure 58-14
 
Injury anteroposterior (A) and lateral (B) radiographs of a 42-year-old man who fell from a ladder sustaining a closed tibial plafond fracture with an intact fibula. Note the marked tibial shortening. C: Intraoperative lateral fluoroscopic view demonstrating transcalcaneal Schanz pin placement (white arrow). Final anteroposterior (D) and lateral (E) radiographs after closed manipulative reduction and application of a biplanar spanning external fixator. Satisfactory length and centering of the tibia is evident.
Injury anteroposterior (A) and lateral (B) radiographs of a 42-year-old man who fell from a ladder sustaining a closed tibial plafond fracture with an intact fibula. Note the marked tibial shortening. C: Intraoperative lateral fluoroscopic view demonstrating transcalcaneal Schanz pin placement (white arrow). Final anteroposterior (D) and lateral (E) radiographs after closed manipulative reduction and application of a biplanar spanning external fixator. Satisfactory length and centering of the tibia is evident.
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Figure 58-14
Injury anteroposterior (A) and lateral (B) radiographs of a 42-year-old man who fell from a ladder sustaining a closed tibial plafond fracture with an intact fibula. Note the marked tibial shortening. C: Intraoperative lateral fluoroscopic view demonstrating transcalcaneal Schanz pin placement (white arrow). Final anteroposterior (D) and lateral (E) radiographs after closed manipulative reduction and application of a biplanar spanning external fixator. Satisfactory length and centering of the tibia is evident.
Injury anteroposterior (A) and lateral (B) radiographs of a 42-year-old man who fell from a ladder sustaining a closed tibial plafond fracture with an intact fibula. Note the marked tibial shortening. C: Intraoperative lateral fluoroscopic view demonstrating transcalcaneal Schanz pin placement (white arrow). Final anteroposterior (D) and lateral (E) radiographs after closed manipulative reduction and application of a biplanar spanning external fixator. Satisfactory length and centering of the tibia is evident.
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Figure 58-15
Anteroposterior (A) and lateral (B) radiographs of a 52-year-old man after a fall down a flight of stairs.
 
Note the significant shortening of the fracture relative to the intact fibula. Treatment consisted of uniplanar medial external fixation with a satisfactory reduction, but could have been easily treated with a biplanar external fixator as well. The anteroposterior (C) image demonstrates satisfactory restoration of limb length with normalization of the talus relative to the tibia. A focused view of the lateral malleolus (D) illustrates restoration of the “dime sign.” The lateral (E) radiograph demonstrates satisfactory restoration of centering of the talus beneath the mid-diaphyseal line of the tibia. Note the orientation of the tibiocalcaneal bar is marked with the black arrow. Sawbones models demonstrating the external fixation construct from the anterior (F) and lateral (G) vantage points. H: Clinical photo of a medial uniplanar ankle spanning external fixator.
Note the significant shortening of the fracture relative to the intact fibula. Treatment consisted of uniplanar medial external fixation with a satisfactory reduction, but could have been easily treated with a biplanar external fixator as well. The anteroposterior (C) image demonstrates satisfactory restoration of limb length with normalization of the talus relative to the tibia. A focused view of the lateral malleolus (D) illustrates restoration of the “dime sign.” The lateral (E) radiograph demonstrates satisfactory restoration of centering of the talus beneath the mid-diaphyseal line of the tibia. Note the orientation of the tibiocalcaneal bar is marked with the black arrow. Sawbones models demonstrating the external fixation construct from the anterior (F) and lateral (G) vantage points. H: Clinical photo of a medial uniplanar ankle spanning external fixator.
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Note the significant shortening of the fracture relative to the intact fibula. Treatment consisted of uniplanar medial external fixation with a satisfactory reduction, but could have been easily treated with a biplanar external fixator as well. The anteroposterior (C) image demonstrates satisfactory restoration of limb length with normalization of the talus relative to the tibia. A focused view of the lateral malleolus (D) illustrates restoration of the “dime sign.” The lateral (E) radiograph demonstrates satisfactory restoration of centering of the talus beneath the mid-diaphyseal line of the tibia. Note the orientation of the tibiocalcaneal bar is marked with the black arrow. Sawbones models demonstrating the external fixation construct from the anterior (F) and lateral (G) vantage points. H: Clinical photo of a medial uniplanar ankle spanning external fixator.
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Figure 58-15
Anteroposterior (A) and lateral (B) radiographs of a 52-year-old man after a fall down a flight of stairs.
Note the significant shortening of the fracture relative to the intact fibula. Treatment consisted of uniplanar medial external fixation with a satisfactory reduction, but could have been easily treated with a biplanar external fixator as well. The anteroposterior (C) image demonstrates satisfactory restoration of limb length with normalization of the talus relative to the tibia. A focused view of the lateral malleolus (D) illustrates restoration of the “dime sign.” The lateral (E) radiograph demonstrates satisfactory restoration of centering of the talus beneath the mid-diaphyseal line of the tibia. Note the orientation of the tibiocalcaneal bar is marked with the black arrow. Sawbones models demonstrating the external fixation construct from the anterior (F) and lateral (G) vantage points. H: Clinical photo of a medial uniplanar ankle spanning external fixator.
Note the significant shortening of the fracture relative to the intact fibula. Treatment consisted of uniplanar medial external fixation with a satisfactory reduction, but could have been easily treated with a biplanar external fixator as well. The anteroposterior (C) image demonstrates satisfactory restoration of limb length with normalization of the talus relative to the tibia. A focused view of the lateral malleolus (D) illustrates restoration of the “dime sign.” The lateral (E) radiograph demonstrates satisfactory restoration of centering of the talus beneath the mid-diaphyseal line of the tibia. Note the orientation of the tibiocalcaneal bar is marked with the black arrow. Sawbones models demonstrating the external fixation construct from the anterior (F) and lateral (G) vantage points. H: Clinical photo of a medial uniplanar ankle spanning external fixator.
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Note the significant shortening of the fracture relative to the intact fibula. Treatment consisted of uniplanar medial external fixation with a satisfactory reduction, but could have been easily treated with a biplanar external fixator as well. The anteroposterior (C) image demonstrates satisfactory restoration of limb length with normalization of the talus relative to the tibia. A focused view of the lateral malleolus (D) illustrates restoration of the “dime sign.” The lateral (E) radiograph demonstrates satisfactory restoration of centering of the talus beneath the mid-diaphyseal line of the tibia. Note the orientation of the tibiocalcaneal bar is marked with the black arrow. Sawbones models demonstrating the external fixation construct from the anterior (F) and lateral (G) vantage points. H: Clinical photo of a medial uniplanar ankle spanning external fixator.
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Table 58-4
ORIF of Tibial Pilon Fractures
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Table 58-4
ORIF of Tibial Pilon Fractures
Surgical Steps
Stage 1: Tibiotalar External Fixation
  •  
    Pin insertions:
    •  
      With fluoroscopy, identify the proximal tibial fracture extent and mark the location with a surgical marking pen
    •  
      Insert a 5 mm anteroposterior proximal tibial Schanz pin out of the anticipated area that will be used for definitive tibial fixation
    •  
      Using the lateral fluoroscopic image of the ankle and hindfoot, insert a 5 mm centrally threaded transcalcaneal Schanz pin
    •  
      Place the limb on a radiolucent tibial nailing triangle and obtain an anteroposterior image of the foot. Insert a 4 mm Schanz pin from medial to lateral into the medial, middle, and lateral cuneiforms
  •  
    Manipulate the medial and lateral aspects of the transcalcaneal Schanz pin to restore tibial length, alignment, and rotation. This should perform the vast majority of the required reduction
    •  
      Utilize the “dime-sign” to assure adequate distraction
  •  
    Secure the proximal tibial pin to the medial and lateral aspects of the transcalcaneal Schanz pin using two longitudinally oriented radiolucent bars. This will maintain the vast majority of tibial reduction
  •  
    Secure the proximal tibial pin to the cuneiform pin to maintain a plantigrade foot (avoid ankle equinus and midfoot supination)
  •  
    Secure cuneiform pin to the medial aspect of transcalcaneal Schanz pin
  •  
    Correct residual displacement of the distal end of the proximal segment (commonly the metadiaphysis is in a minor amount of apex anteromedial deformity)
  •  
    Insert second 5 mm tibial Schanz pin (typically just distal to the initial proximally placed tibial pin) and secure this to one or both of the medial longitudinally oriented radiolucent bars to maintain final reduction
  •  
    Confirm adequacy of reduction fluoroscopically
  •  
    Apply posterior below knee splint
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technique—temporary tibiotalar spanning external fixation
Fluoroscopy is used to localize a point in the proximal tibia well out of any anticipated surgical approaches or implants that may be used for definitive tibial fixation. After drilling with an appropriate drill and protection sleeve, a 5 mm Schanz pin is placed bicortically anterior to posterior through the proximal tibial diaphysis. The C-arm is brought into the lateral position and a true lateral of the talus is obtained. A centrally threaded 5 mm Schanz pin is then placed from medial to lateral into the posterior aspect of the calcaneal tuberosity and should avoid the numerous calcaneal sensory branches from the tibial nerve.41 This pin should be placed parallel to the midcoronal plane of the patient and collinear with the superior surface of the talus (or plantar surface of the foot). The threaded portion of the pin should be located within the calcaneus and the length of the pin that is externally located on the medial and lateral aspects of the foot should be roughly symmetrical, with slightly more pin available laterally preferred. The knee is then flexed and supported with a radiolucent triangular support commonly used for tibial nailing. This position allows placement and fluoroscopic imaging of a midfoot Schanz pin. This is a 4 mm Schanz pin placed from medial to lateral across the three cuneiforms of the ipsilateral midfoot. To minimize the risk of septic complications after definitive surgery, it is imperative that these pins are inserted out of the anticipated location of plates, screws, and incisions. Talar neck pins are specifically avoided, as these will compromise many anterior and anteromedial exposures of the distal tibia. Manipulation of the calcaneal Shanz pin performs the vast majority of the reduction and is comprised of: (1) traction (restores tibial length); (2) varus or valgus correction (to achieve a horizontal talus in the frontal plane); and (3) posterior translation (to reduce the commonly seen anterior talar displacement). Because the calcaneal Schanz pin can be manipulated from both the lateral and medial aspects, excellent control of the hindfoot, and the talus and distal tibia via ligamentotaxis occurs. After these reduction goals are achieved, two radiolucent bars are applied that connect the tibial pin to the medial and lateral aspects of the transcalcaneal pin. Placement of this initial bar stabilizes the vast majority of the reduction. At this time, the talus should be centered beneath the tibia on both the AP and lateral fluoroscopic images, and the talar dome should be perpendicular to the longitudinal axis of the tibial shaft on the AP view. Restoration of tibial length is estimated by re-establishing the normal relationship of the lateral process of the talus with the distal tip of the fibula (i.e., the so-called “dime sign”).200 It is imperative that the tibia is distracted to its normal length, with slight over distraction being preferred. Because the force vector between the tibial pin and the calcaneal pin (represented by the radiolucent bar) is located posterior to the anatomic axis of the tibia, the talus is held posteriorly beneath the tibial plafond which minimizes anterior displacement. A second radiolucent bar connects the cuneiform pin to the tibial pin, and maintains the tibiotalar articulation in a neutral dorsi- and plantarflexion position. A third bar connects the medial aspect of the transcalcaneal pin to the cuneiform pin increasing the rigidity of the external fixation construct. A second 5 mm anteromedial to posterolateral Schanz pin is then inserted into the tibial diaphysis just distal to the initial tibial Schanz pin and is typically connected to both of the longitudinally oriented bars, completing the construct. Insertion of this last pin allows reduction and stabilization of small amounts of angulation and translation of the proximal fragment. 
There are several situations where a biplanar external fixator is particularly useful. This includes: (1) an unstabilized fibula fracture; (2) tibial pilon fractures with a delayed presentation (greater than 5 to 7 days postinjury); (3) plafond fractures with substantial valgus angulation despite an intact or operatively reduced and stabilized fibula; (4) marked displacement, particularly tibial shortening, with an intact fibula. This latter situation presumes that there is talofibular capsulo-ligamentous disruption and the fibula is no longer helpful in directing the reduction of the talus, and hence, the fracture fragments of the tibial plafond. In these situations, a biplanar calcaneal Schanz pin greatly assists in the restoration of tibial length and coronal plane talar alignment. 
The limb is placed into a well-padded splint and a CT scan of the distal tibia and fibula is then obtained to allow for the preoperative planning of the definitive tibial fixation. Final tibial reduction and fixation is usually performed 7 to 21 days after this initial stage and only after soft tissue recovery has occurred149,172 (Table 58-5). 
Table 58-5
Stage 1: Fibular ORIF and Tibiotalar Spanning External Fixation
Potential Pitfalls and Preventions
Pitfall Prevention
Fibular malreduction Anatomically contoured fibular plates.
To minimize extension deformity at the fracture, avoid bumps or supports located solely beneath the heel.
Apply external fixation first, thereby generally restoring limb length, alignment, and rotation.
External fixation pins within the anticipated definitive surgical field Localize the fracture extent and potential pin sites with C-arm prior to insertion.
Inability to close fibular ORIF incision Recognize that some pilon fractures may only tolerate external fixation initially, followed by ORIF several days later.
Utilized vacuum-assisted closure devices followed by delayed primary closure when swelling has subsided.
Acutely infected external fixator pin site Prevention: Predrilling with a sharp drill and irrigation to minimize thermal necrosis.
Treatment: Oral antibiotic, and removal +/- reinsertion at a clean site if required for external fixator frame stability.
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Postoperative Care for Fibular Open Reduction and Internal Fixation and Tibiotalar Spanning External Fixation
Postoperatively, patients receive antibiotic prophylaxis for 24 hours, parenteral and oral analgesia, and the limb is splinted with a removable posterior prefabricated support. Limb elevation, pin site care, and active motion of the toes are encouraged. If there are no other significant injuries, the patient receives deep venous thrombosis prophylaxis until they are mobilized and discharged home. As noted above, a thin cut axial CT scan is obtained with sagittal and coronal reformations is obtained prior to discharge. The patient returns to the outpatient clinic for an assessment of soft tissue swelling and to review the definitive operative plan at one week. 
Stage 2: Definitive Tibial Pilon Fracture Open Reduction and Internal Fixation
Definitive management of the high-energy tibial pilon fracture is challenging. Although restoration of the articular surface along with stable internal fixation that allows early motion is felt to be the most important predictor of a satisfactory outcome,35,64,97,143,162 this remains controversial.111,204 Open management requires meticulous attention to preoperative planning, soft tissue handling, and the appropriate timing of intervention. Avoidance of serious soft tissue complications and an anatomic stable articular and metaphyseal reduction provides the ideal environment for obtaining a satisfactory outcome. 
Preoperative Planning for Definitive Tibial Pilon Fracture Open Reduction and Internal Fixation
The vast majority of the surgical tactic is obtained from: (1) a complete review and assessment of the postspanned CT scan, to assess the degree of articular surface involvement particularly noting the magnitude and location of articular surface displacement, (2) the initial injury radiographs to determine the optimum location for implants to stabilize the metadiaphysis and, (3) a clinical assessment of the soft tissue envelope to determine areas that are optimal or suboptimal for surgical incisions and implants. Because the ligamentous structures of the ankle remain largely intact after a tibial pilon fracture, OTA C-type injury patterns commonly demonstrate three main fracture segments: the anterolateral (Chaput) fragment, the posterior (Volkmann) fragment, and the medial malleolar fragment.45,187 Each of these fragments typically remains attached to the anterior tibiofibular ligament, the posterior tibiofibular ligament, and the deltoid ligament, respectively. Infrequently, subtle areas of comminution around the anterolateral and posterolateral fragments, may represent detachment of the anterior tibiofibular and posterior tibiofibular ligaments. The importance of this is that the ligamentotaxis effects on these fragments from fibular reduction may be much less than anticipated, and may also result in syndesmotic incompetence despite fixation of the posterolateral and anterolateral fracture fragments. Articular comminution and impaction are noted along the intersection of the major fracture lines that separate the three major articular components described. These areas of comminution and impaction are readily identified on the CT scan. The preoperative plan must include an assessment of the major fracture components and how their manipulation will allow access to the areas of comminution while respecting their soft tissue and ligamentous attachments. Ideally, stabilizing implants will secure reduced articular fragments as well as neutralizing the major anticipated displacing forces that occur in the metadiaphyseal region. A simple way to determine the likely direction of displacement is to review the injury radiographs and assess the direction and displacement of the talus. A review of the fibula fracture and plafond fracture will help determine the specific osseous areas that failed under tension, compression, rotation, or combined mechanisms. This subsequently leads to an estimation of zones of articular impaction and areas that are appropriate for implant placement to provide buttress, anti-glide, or tension-band effects. All of this must be done within the limitations of the soft tissue injury and within the limits that the available surgical approaches offer. 
Precontoured periarticular distal tibial plates are extremely useful in the definitive management of these fractures. Anterolateral, medial, and posterior distal tibial periarticular plates are now commonly available and provide the surgeon with the ability to place multiple screws into the epiphyseal portion of the distal tibia, while allowing the plate to facilitate indirect reduction of the metaphyseal component. Similarly, the stiffness of these plates is particularly useful for unstable AO/OTA C-type injuries. More malleable implants, such as distal radius T-plates, quarter tubular, third tubular, and mini-fragment plates are occasionally useful, particularly in partial articular injuries, where neutralization of the metadiaphysis is unnecessary, or in conjunction with stiffer implants when metadiaphyseal neutralization is required and the larger implant is insufficient for complete fracture stability or is less than ideal for articular fracture fragment neutralization. Additional equipment often includes a universal distractor, Schanz pins, a large external fixation set, allograft or bone graft substitute, headlamp illumination, K-wires, mini-fragment screws, osteotomes, dental picks, and a variety of Freer elevators and bone clamps (Table 58-6). 
 
Table 58-6
ORIF of Tibial Pilon Fractures
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Table 58-6
ORIF of Tibial Pilon Fractures
Preoperative Planning Checklist
Stage 2: Definitive Tibial ORIF
OR table
  •  
    Caudally radiolucent table (i.e., Midmark)
Position/positioning aids
  •  
    Supine with supportive buttock/flank bump
  •  
    Foam ramp beneath the injured limb to allow lateral fluoroscopic imaging
Fluoroscopy location
  •  
    Contralateral
Equipment
  •  
    Large external fixator
  •  
    Large universal distractor
  •  
    Large and small pointed and serrated bone reduction clamps
  •  
    Small and large bone reduction picks/hooks
  •  
    Small caliber Kirschner wires and wire driver
  •  
    Distal tibial periarticular plating system (locking/nonlocking dependent upon the anticipated bone quality, degree of metaphyseal comminution, anticipated time to union, etc.)
  •  
    Small fragment set (2.7, 3.5 mm)
  •  
    Tubular plates (1/3, 1/4)
  •  
    Mini-fragment plates/screws (2, 2.4 mm)
  •  
    Bone graft (typically allograft) and/or bone graft substitute
Tourniquet
  •  
    Proximal thigh sterile or unsterile appropriately draped in or out of the field, respectively.
X
Positioning for Definitive Tibial Pilon Fracture Open Reduction and Internal Fixation
The great majority of tibial plafond fractures are managed with anterior-based exposures and therefore, the patient is typically positioned supine and is similar to that used for the initial stage. Specifically, a soft buttock and flank support is used to allow the patella of the injured extremity to be pointing anteriorly. Because the surgical procedure may take several hours, a foley catheter is inserted, and care is taken to pad all bony prominences. A nonsterile thigh tourniquet is commonly used to improve visualization of the articular surface. After the induction of anesthesia and positioning of the patient, the limb is given a provisional scrub to remove loose skin and debris. Provided the pin sites have been well maintained, the entirety of the pre-existing external fixator is prepared and draped into the surgical field. The surgeon is typically located at the distal end of the radiolucent table and the image intensifier is placed contralateral to the injured extremity. A first generation cephalosporin or other appropriate antibiotic is administered within 60 minutes of the surgical procedure. 
In those unusual situations where a posterolateral approach is indicated, the patient is placed in the lateral or prone position, which facilitates a posterolateral exposure of the distal tibia. If the patient is in the lateral decubitus position, externally rotating the limb and tilting the operating table slightly can subsequently allow supplemental anterior or medial exposures. The positioning for the posterolateral approach is given above. 
Very uncommonly, a posteromedial exposure is required to adequately address the main components of the injury. Radiographic clues that may suggest the need for a posteromedial approach include posteromedial articular comminution and impaction, with posterior translation of the talus (unlike the typical anterior displacement), and an intact or relatively intact anterior plafond. Rarely, tendinous and/or neurovascular entrapment between posterior aspect of the medial malleolus and the posterior plafond, or tibial nerve dysfunction with osseous debris or fragment displacement identified within the tarsal tunnel, may mandate a posteromedial approach. The exposure can be performed with the patient in the supine or prone position. If the patient is in the supine position, a small soft support is placed under the contralateral buttock and flank region thereby facilitating external rotation of the injured leg. Both legs are slightly elevated on ramp pillows or bumps with the injured limb placed slightly higher than the uninjured limb. Occasionally the prone position is used and allows an easier trajectory for the insertion of screws and provisional stabilizing wires. In this situation, the patient is positioned prone on padded bolsters. The injured limb is elevated on bumps or pillows to allow attainment of lateral fluoroscopic images. Access to the anterior aspect of the plafond is limited in this position. 
Surgical Approaches for Definitive Tibial Pilon Fracture Open Reduction and Internal Fixation
The choice of surgical approach depends on the location and displacement of the major fragments and the local soft tissue conditions. Numerous surgical exposures for the operative treatment of tibial plafond fractures have been described and include an anterolateral Bohler approach,89,126 a straight anterior approach,167 a classic and a modified anteromedial approach,7,119,134,173 a straight lateral approach,85 a posterolateral approach,17,100 and a posteromedial approach.62 Because of a greater understanding of the tibial plafond fracture anatomy and the importance of soft tissue preservation, percutaneous adjuncts, limited arthrotomies, and indirect articular reductions have also been described and clearly have a role in the treatment of these injuries.12,25,26,42,48,88,108,144,145 The author utilizes the modified anteromedial or anterolateral exposures to manage the vast majority of tibial plafond fractures. Posterolateral and posteromedial exposures are uncommonly required (Table 58-7). 
 
Table 58-7
ORIF of Tibial Pilon Fractures
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Table 58-7
ORIF of Tibial Pilon Fractures
Surgical Steps
Stage 2: Definitive Tibial ORIF
  •  
    Careful preoperative assessment of the injury and stage 1 radiographs, and axial CT scan with sagittal and coronal reformations
  •  
    Identify:
    •  
      Main articular fragments and zones of comminution/impaction
    •  
      Determine best approach to visualize and manipulate articular segments to achieve anatomic articular reduction
    •  
      Determine fixation strategy appropriate for the articular segment (i.e., anterior to posterior fixation, medial to lateral fixation, combined)
    •  
      Determine the best area to buttress the distal epimetaphyseal region (i.e., medial buttress, anterolateral buttress, combined)
    •  
      Determine if ideal articular fragment fixation and metaphyseal buttressing can be achieved with single implant or multiple implants
    •  
      Choose exposure based on the answers to the above bulletted points, and local soft tissue injury/constraints
  •  
    Expose distal tibia and perform capsulotomy longitudinally between the main fracture fragments
  •  
    Apply joint distraction using either external fixator or universal distractor
  •  
    Reduce articular segment (typical sequence):
    •  
      Inflate tourniquet if desired
    •  
      Reduce posterolateral Volkmann fragment relative to the fibula and to the anatomic axis of the tibial shaft (in particular, assess and reduce an impaction of the articular surface on the Volkmann fragment)
    •  
      Reduce the posterolateral Volkmann fragment to the posteromedial articular fragment along the commonly present posteromedial fracture line
    •  
      Reduce/disimpact central plafond comminution
    •  
      Reduce medial malleolar/anterior plafond fragment(s)
    •  
      Reduce anterolateral (Chaput) fragment
  •  
    Each reduced fragment is provisionally stabilized with Kirschner wires placed out of the way of the anticipated definitive fixation implants
  •  
    Bone graft supra-articular metaphyseal bone defects
  •  
    Confirm articular reduction fluoroscopically
  •  
    Reduce metaphyseal as to epiphysis/diaphysis to restore anatomic axial alignment in the coronal, sagittal, and transverse planes. In comminuted fractures, this is often done indirectly. Not infrequently, cortical interdigitations within the exposure used for articular reduction can be used to provide direct reduction in this area
  •  
    Apply definitive stabilizing implant (anterolateral and/or medial buttress plate) with interfragmentary compression of the articular fracture fragments, if possible
  •  
    Confirm accuracy of reduction
  •  
    Remove provisional K-wires, clamps, and distractive devices
  •  
    Careful layered wound closure and splint application with the foot in a neutral plantigrade position
X
anteromedial approach
The anteromedial approach to the distal tibia is a classic extensile exposure that allows adequate visualization of a large percentage of the tibial plafond. It is particularly useful in medial-sided articular injury patterns as it allows optimal visualization and management of the central and medial aspects of the tibial plafond, the medial malleolus, and the subcutaneous portion of the distal tibial metadiaphysis. The approach can be extended proximally to manage associated contiguous or noncontiguous fractures of the tibial diaphysis. The most significant drawback from this exposure has been the creation of a large anteromedial skin flap that may already be at risk from the injury. 
Beginning in the distal diaphyseal region, the traditional anteromedial exposure begins approximately 1 cm lateral to the tibial crest and follows the course of the tibialis anterior tendon.27,119,134,173 At the level of the ankle joint, the skin incision continues distally and medially, ending at the distal tip of the medial malleolus. The skin and subcutaneous tissue is elevated from the underlying deep fascia only to a point where the medial aspect of the tibialis anterior tendon is identified. Immediately medial to the tibialis anterior tendon, a full thickness incision directly to the osseous surface of the anteromedial distal tibia is made. Ideally, the deep dissection should not enter the tibialis anterior paratenon. The anteromedial skin, subcutaneous tissue, and periosteum are subsequently elevated as a full thickness flap, similar to that performed during the extensile lateral exposure for calcaneal fracture management. Retraction of the anterior compartment laterally allows for limited visualization of the lateral aspect of the distal tibia. As in all tibial plafond fracture exposures, the joint is entered by longitudinally incising the capsule in the location of the major anterior fracture line. 
modified anteromedial approach
A subtle modification of the traditional anteromedial approach has been recently described by Assal, and is the author’s preferred anteromedial exposure7 (Fig. 58-16). This exposure allows visualization of the anterior and medial aspects of the distal tibia, while improving visualization of the lateral distal tibial metaphysis and lateral articular surface. The main drawback to this approach is similar to the standard anteromedial approach, specifically, the creation of an anteromedial skin flap. In addition, and unlike the traditional anteromedial exposure, a relatively acute angle is created at the level of the ankle joint and the skin of the tip of the anteromedial flap may be more prone to superficial necrosis. 
Figure 58-16
Modified anteromedial exposure (A) illustration of the modified anteromedial skin incision.
 
B: Note the approximate 105 to 110 degree angle between the vertical and horizontal limbs of the incision. Illustration (C) demonstrating the identification of the medial aspect of the tibialis anterior tendon. Care is taken to not undermine the medial skin flap significantly beyond this region. D: Illustrated example demonstrating elevation of the medial skin, subcutaneous, and periosteal flap medially and retraction of the anterior compartment laterally allowing exposure of the anteromedial aspect of the distal tibia. E: Illustration demonstrating retraction of the anterior compartment laterally, enabling access to the anterolateral aspect of the distal tibia. F: Illustration demonstrating the initiation of deep closure over the implants. A secure deep closure minimizes the tension that is required to reapproximate the skin incision. Clinical example demonstrating the placement of multiple deep figure-of-eight monofilament sutures (G) and subsequent closure of the deep layer (H). I: Illustration demonstrating skin closure using Allgower–Donati technique with the knots tied at the periphery of the incision.
B: Note the approximate 105 to 110 degree angle between the vertical and horizontal limbs of the incision. Illustration (C) demonstrating the identification of the medial aspect of the tibialis anterior tendon. Care is taken to not undermine the medial skin flap significantly beyond this region. D: Illustrated example demonstrating elevation of the medial skin, subcutaneous, and periosteal flap medially and retraction of the anterior compartment laterally allowing exposure of the anteromedial aspect of the distal tibia. E: Illustration demonstrating retraction of the anterior compartment laterally, enabling access to the anterolateral aspect of the distal tibia. F: Illustration demonstrating the initiation of deep closure over the implants. A secure deep closure minimizes the tension that is required to reapproximate the skin incision. Clinical example demonstrating the placement of multiple deep figure-of-eight monofilament sutures (G) and subsequent closure of the deep layer (H). I: Illustration demonstrating skin closure using Allgower–Donati technique with the knots tied at the periphery of the incision.
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B: Note the approximate 105 to 110 degree angle between the vertical and horizontal limbs of the incision. Illustration (C) demonstrating the identification of the medial aspect of the tibialis anterior tendon. Care is taken to not undermine the medial skin flap significantly beyond this region. D: Illustrated example demonstrating elevation of the medial skin, subcutaneous, and periosteal flap medially and retraction of the anterior compartment laterally allowing exposure of the anteromedial aspect of the distal tibia. E: Illustration demonstrating retraction of the anterior compartment laterally, enabling access to the anterolateral aspect of the distal tibia. F: Illustration demonstrating the initiation of deep closure over the implants. A secure deep closure minimizes the tension that is required to reapproximate the skin incision. Clinical example demonstrating the placement of multiple deep figure-of-eight monofilament sutures (G) and subsequent closure of the deep layer (H). I: Illustration demonstrating skin closure using Allgower–Donati technique with the knots tied at the periphery of the incision.
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Figure 58-16
Modified anteromedial exposure (A) illustration of the modified anteromedial skin incision.
B: Note the approximate 105 to 110 degree angle between the vertical and horizontal limbs of the incision. Illustration (C) demonstrating the identification of the medial aspect of the tibialis anterior tendon. Care is taken to not undermine the medial skin flap significantly beyond this region. D: Illustrated example demonstrating elevation of the medial skin, subcutaneous, and periosteal flap medially and retraction of the anterior compartment laterally allowing exposure of the anteromedial aspect of the distal tibia. E: Illustration demonstrating retraction of the anterior compartment laterally, enabling access to the anterolateral aspect of the distal tibia. F: Illustration demonstrating the initiation of deep closure over the implants. A secure deep closure minimizes the tension that is required to reapproximate the skin incision. Clinical example demonstrating the placement of multiple deep figure-of-eight monofilament sutures (G) and subsequent closure of the deep layer (H). I: Illustration demonstrating skin closure using Allgower–Donati technique with the knots tied at the periphery of the incision.
B: Note the approximate 105 to 110 degree angle between the vertical and horizontal limbs of the incision. Illustration (C) demonstrating the identification of the medial aspect of the tibialis anterior tendon. Care is taken to not undermine the medial skin flap significantly beyond this region. D: Illustrated example demonstrating elevation of the medial skin, subcutaneous, and periosteal flap medially and retraction of the anterior compartment laterally allowing exposure of the anteromedial aspect of the distal tibia. E: Illustration demonstrating retraction of the anterior compartment laterally, enabling access to the anterolateral aspect of the distal tibia. F: Illustration demonstrating the initiation of deep closure over the implants. A secure deep closure minimizes the tension that is required to reapproximate the skin incision. Clinical example demonstrating the placement of multiple deep figure-of-eight monofilament sutures (G) and subsequent closure of the deep layer (H). I: Illustration demonstrating skin closure using Allgower–Donati technique with the knots tied at the periphery of the incision.
View Original | Slide (.ppt)
B: Note the approximate 105 to 110 degree angle between the vertical and horizontal limbs of the incision. Illustration (C) demonstrating the identification of the medial aspect of the tibialis anterior tendon. Care is taken to not undermine the medial skin flap significantly beyond this region. D: Illustrated example demonstrating elevation of the medial skin, subcutaneous, and periosteal flap medially and retraction of the anterior compartment laterally allowing exposure of the anteromedial aspect of the distal tibia. E: Illustration demonstrating retraction of the anterior compartment laterally, enabling access to the anterolateral aspect of the distal tibia. F: Illustration demonstrating the initiation of deep closure over the implants. A secure deep closure minimizes the tension that is required to reapproximate the skin incision. Clinical example demonstrating the placement of multiple deep figure-of-eight monofilament sutures (G) and subsequent closure of the deep layer (H). I: Illustration demonstrating skin closure using Allgower–Donati technique with the knots tied at the periphery of the incision.
View Original | Slide (.ppt)
X
Similar to the previously described anteromedial exposure, the skin incision for the modified anteromedial approach begins proximally approximately 1 to 2 cm lateral to the anterior crest of the tibia and over the anterior compartment. This longitudinal component is continued distally to the level of the tibiotalar articulation and then the incision curves medially, creating an angle between the vertical and the horizontal limbs of approximately 105 to 110 degrees. The horizontal portion of the incision then extends to a point approximately 1 cm distal to the tip of the medial malleolus and frequently terminates once the saphenous vein is identified. The medial edge of the tibialis anterior tendon is identified and protected as the extensor retinaculum and periosteum immediately medial to the tibialis tendon sheath is incised sharply. Similar to the traditional anteromedial exposure, a full thickness skin, subcutaneous, and periosteal tissue flap is then elevated from the distal tibial metaphyseal region. The capsular incision is performed longitudinally between the major anterior fracture fragments. 
anterolateral approach
The main advantage of the anterolateral approach is the avoidance of dissection over the tenuous anteromedial soft tissue envelope of the distal tibia (Fig. 58-17). It is an excellent alternative to the anteromedial exposures. Unlike the anteromedial exposures, the anterolateral approach is mainly limited in the surgeon’s ability to visualize and manipulate medial plafond comminution. The anterolateral approach otherwise allows excellent access to a substantial amount of the tibial plafond, particularly the lateral, posterior, and central aspects.126 The exposure relies on mobilizing and externally rotating the anterolateral (Chaput) fragment on the anterior tibiofibular ligament. This maneuver allows access to the posterior and central aspects of the plafond. Anterolateral plate application is simplified with this exposure because the anterior compartment is retracted medially. This exposure, however, is nonextensile and proximal screw fixations are typically made percutaneously. If needed, medial implants can be placed percutaneously or through a separate medial malleolar approach. The skin incision is oriented longitudinally and placed in line with the fourth ray. The incision travels over the anterolateral aspect of the distal tibia and is usually centered over the anterolateral fracture fragment. Because of the origin of the anterior compartment musculature, the maximum proximal extent of the incision is limited to approximately 7 cm above the plafond. The variably located superficial peroneal nerve and/or its arborizations are almost universally identified immediately within the subcutaneous fat. The nerve and its branches are mobilized to allow retraction either medially or laterally. The distal extent of the fascia overlying the anterior compartment and its confluence with the superior extensor retinaculum are identified. The superior and inferior extensor retinaculae are incised longitudinally, immediately lateral to the course of the long toe extensor tendons and peroneus tertius tendon. The longitudinal incision in the retinaculum is carried proximally through the fascia of the anterior compartment. The entirety of the anterior compartment is retracted medially exposing the underlying anterolateral aspect of the distal tibia (Chaput fragment) and the capsule of the ankle joint. A longitudinal capsulotomy is performed at the medial extent of the Chaput fragment thereby exposing the tibiotalar articulation. Transversely oriented capsular vessels are often encountered and require cauterization. Mobilization of the anterolateral Chaput fragment on its anterior distal tibiofibular ligament allows visualization of the central and posterior tibial plafond. A summary of the relative placement of skin incisions for anterior exposures of the distal tibia is demonstrated in Figure 58-18
Figure 58-17
Illustration (A) and clinical example (B) of the anterolateral exposure for a fracture of the tibial plafond.
 
The incision is longitudinally oriented, in line with the fourth ray. Immediately deep to the skin incision, the arborizing superficial peroneal nerve is identified and protected (C). Illustrated example of the anterior compartment mobilized medially (D). A laterally based universal distractor is applied to facilitate visualization of the articular surface (E, F). Clinical example of visualization and reduction of the articular surface (G, H). Anterolateral plating is performed (I, J), and the joint capsule is closed. The skin incision is closed with an Allgower–Donati suture technique.
The incision is longitudinally oriented, in line with the fourth ray. Immediately deep to the skin incision, the arborizing superficial peroneal nerve is identified and protected (C). Illustrated example of the anterior compartment mobilized medially (D). A laterally based universal distractor is applied to facilitate visualization of the articular surface (E, F). Clinical example of visualization and reduction of the articular surface (G, H). Anterolateral plating is performed (I, J), and the joint capsule is closed. The skin incision is closed with an Allgower–Donati suture technique.
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The incision is longitudinally oriented, in line with the fourth ray. Immediately deep to the skin incision, the arborizing superficial peroneal nerve is identified and protected (C). Illustrated example of the anterior compartment mobilized medially (D). A laterally based universal distractor is applied to facilitate visualization of the articular surface (E, F). Clinical example of visualization and reduction of the articular surface (G, H). Anterolateral plating is performed (I, J), and the joint capsule is closed. The skin incision is closed with an Allgower–Donati suture technique.
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Figure 58-17
Illustration (A) and clinical example (B) of the anterolateral exposure for a fracture of the tibial plafond.
The incision is longitudinally oriented, in line with the fourth ray. Immediately deep to the skin incision, the arborizing superficial peroneal nerve is identified and protected (C). Illustrated example of the anterior compartment mobilized medially (D). A laterally based universal distractor is applied to facilitate visualization of the articular surface (E, F). Clinical example of visualization and reduction of the articular surface (G, H). Anterolateral plating is performed (I, J), and the joint capsule is closed. The skin incision is closed with an Allgower–Donati suture technique.
The incision is longitudinally oriented, in line with the fourth ray. Immediately deep to the skin incision, the arborizing superficial peroneal nerve is identified and protected (C). Illustrated example of the anterior compartment mobilized medially (D). A laterally based universal distractor is applied to facilitate visualization of the articular surface (E, F). Clinical example of visualization and reduction of the articular surface (G, H). Anterolateral plating is performed (I, J), and the joint capsule is closed. The skin incision is closed with an Allgower–Donati suture technique.
View Original | Slide (.ppt)
The incision is longitudinally oriented, in line with the fourth ray. Immediately deep to the skin incision, the arborizing superficial peroneal nerve is identified and protected (C). Illustrated example of the anterior compartment mobilized medially (D). A laterally based universal distractor is applied to facilitate visualization of the articular surface (E, F). Clinical example of visualization and reduction of the articular surface (G, H). Anterolateral plating is performed (I, J), and the joint capsule is closed. The skin incision is closed with an Allgower–Donati suture technique.
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X
Figure 58-18
 
The relative placement of skin incisions for (A) the classic anteromedial, (B) modified anteromedial, and (C) anterolateral surgical exposures for the management of tibial plafond fractures is demonstrated.
The relative placement of skin incisions for (A) the classic anteromedial, (B) modified anteromedial, and (C) anterolateral surgical exposures for the management of tibial plafond fractures is demonstrated.
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Figure 58-18
The relative placement of skin incisions for (A) the classic anteromedial, (B) modified anteromedial, and (C) anterolateral surgical exposures for the management of tibial plafond fractures is demonstrated.
The relative placement of skin incisions for (A) the classic anteromedial, (B) modified anteromedial, and (C) anterolateral surgical exposures for the management of tibial plafond fractures is demonstrated.
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X
posterolateral approach
The posterolateral approach is a relatively uncommon but extremely useful exposure for the management of select tibial plafond fractures. It is most useful for partial articular tibial plafond fractures where the unstable articular segment is located posteriorly and there is no significant articular comminution. As noted earlier, it can be used in conjunction with other anterior exposures to adequately reduce and stabilize the entire articular surface.98 Complete articular fracture patterns that are most amenable to this adjunctive approach include: (1) those with complete dissociation of the posterolateral (Volkmann) fragment from the fibula, especially those that remain substantially displaced despite anatomic reduction of any associated fibula fracture and, (2) articular injury patterns that demonstrate a large but minimally comminuted posterior plafond fragment that can be anatomically reduced to the posterior metadiaphysis. Because of the orientation of the tibial plafond, once the posterior or posterolateral portion of the tibial plafond is reduced, direct visualization of the articular surface is extremely difficult if not impossible with this exposure. The articular reduction is achieved indirectly using any available posterior cortical interdigitations, and is confirmed radiographically. The posterolateral exposure is described above and can be performed with the patient in either the lateral or prone position. 
posteromedial approach
The indications for the posteromedial approach to the tibial plafond are limited. The longitudinal incision is placed just medial to the medial border of the Achilles tendon. Avoid disruption of the paratenon overlying the Achilles tendon. Incise the fascia overlying the FHL musculature. Depending on the location of the fracture fragments, the posteromedial aspect of the distal tibia is best approached in one of two ways. Retraction of the FHL and the contents of the tarsal tunnel medially allow the most central and lateral exposure of the posterior plafond. Because of the fibular origin of FHL, significant proximal dissection of the distal tibial metaphysis is limited, however. Mobilization of the FHL from the neurovascular bundle allows more medial visualization at the joint level and also allows much more proximal medial visualization of the metadiaphyseal area. In situations where a large posteromedial fragment spike can be reduced to the metadiaphyseal region without the need for posteromedial articular visualization, a small longitudinal incision can be made immediately posterior to the posteromedial distal tibial border and the digitorum musculature elevated posterolaterally, immediately revealing the posteromedial surface of the tibia without directly disturbing the neurovascular bundle. The posteromedial exposure described can be performed with the patient in either the supine or prone position (Fig. 58-19). 
Figure 58-19
Injury anteroposterior (A) and lateral (B) radiographs of a tibial pilon fracture in a 45-year-old male.
 
Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
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Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
View Original | Slide (.ppt)
Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
View Original | Slide (.ppt)
Figure 58-19
Injury anteroposterior (A) and lateral (B) radiographs of a tibial pilon fracture in a 45-year-old male.
Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
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Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
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Substantial displacement, particularly of the posterolateral articular fragment is noted. Staged treatment consisted of fibular ORIF and biplanar spanning external fixation. Despite an accurate fibular reduction, substantial displacement of the anterolateral (Chaput) fragment (C) and posterolateral (Volkmann) fragment (D) remained. Working through the fibular incision, the anterolateral and posterolateral articular fragments were grossly realigned radiographically and secured with percutaneously inserted K-wires (E, F). The axial CT scan demonstrated a large medial malleolar fragment with posteromedial metadiaphyseal apex (G). The definitive surgical tactic consisted of a posteromedial metadiaphyseal exposure initially to restore metadiaphyseal alignment and begin articular reduction (H, I), followed by an anterolateral exposure to complete the posterolateral and anterolateral articular reductions (J, K).
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lateral approach
As described by Grose, the direct lateral approach has been advocated as a soft tissue friendly technique by which both the fibula and tibia can be exposed, reduced, and stabilized through the creation of a single robust thick soft tissue flap.85 Relative contraindications to this approach are: (1) fractures lines that cannot be easily accessed, particularly medial-sided impaction and, (2) those injuries that demonstrate wounds or soft-tissue compromise that prevent extensile incisions from safely being made along the anterior border of the fibula. The reduction sequence is similar to that performed during the anterolateral approach. 
The incision is made at the anterior fibular border from the most proximal fracture line (either fibular or tibial) and extending 3 to 4 cm distal to the joint. The anterior border of the fibula is identified, and the dissection is then carried posteriorly to expose and allow posterior retraction of the peroneal musculature to facilitate subsequent fibular reduction and fixation. Tibial exposure is performed by careful blunt dissection over the anterior edge of the fibula to the interosseous membrane. The plane between the interosseous membrane and the overlying contents of the anterior compartment is developed with a periosteal elevator. The anteroinferior tibiofibular ligament is then identified and followed medially to the anterolateral (Chaput) fragment.85 Depending on the fracture configuration, this fragment can be displaced to allow visualization and manipulation of central and posterior plafond fragments. 
Surgical Technique for Definitive Tibial Pilon Fracture Open Reduction and Internal Fixation
The reduction and fixation sequence of any tibial pilon fracture varies according to the specific fracture pattern. The author regards the articular reduction as the most critical aspect of surgical care and, therefore, this remains the priority of the surgical tactic. The reduction sequence, selected exposure(s), and location and type of stabilizing implants are all directed toward achieving and maintaining an accurate articular reduction. 
Treatment of complete articular tibial plafond fractures (AO/OTA C-type) are among the most challenging fracture patterns to operatively manage. Although there are numerous possible fracture patterns, articular reduction of the tibial plafond often begins with an assessment, reduction, and stabilization of the posterolateral (Volkmann) fragment. Via the posterior tibiofibular ligament, an accurate fibular reduction begins the tibial reduction by indirectly reducing the posterolateral Volkmann fragment relative to the proximal tibia, and of course, to the reduced fibula. In some circumstances, however, despite an accurate fibular reduction, there remains residual displacement, angulation, or articular impaction of the posterolateral Volkmann fragment. Whether further reduction of the posterolateral fragment is performed via an anterior exposure, or directly using a posterolateral exposure, depends on the degree of persistent displacement after the initial stage (Fig. 58-20). For example, occasionally the posterolateral plafond exhibits a dorsiflexion impaction displacement that can be identified on the plain lateral radiograph and more easily identified on the sagittal CT reformations. Subsequent reductions to the impacted posterior plafond will result in an extension deformity of the articular surface and a tendency to anterior talar extrusion. Management of this residual deformity can usually be performed through the anterior exposure (Fig. 58-21). Once satisfactorily reduced, the reduction sequence commonly involves reducing the posterior aspect of the medial malleolar fragment to the posterolateral fragment. Impacted central comminution is then reduced and secured to the posterior plafond. The medial malleolar fragment is secured using the medial shoulder chondral interdigitations, followed by reduction of the anterolateral (Chaput) fragment. This sequence, however, must be flexible and all strategies that achieve satisfactory articular and extra-articular reductions used. For example, a useful technique for reduction of the articular segment as well as that of the metadiaphysis is to identify a fracture fragment that contains some amount of articular surface distally while demonstrating a minimally comminuted metaphyseal or metadiaphyseal proximal extension. An anatomic reduction of the proximal metadiaphyseal component essentially converts the C-type tibial pilon fracture into a partial articular (B-type) injury, greatly facilitating the reduction of the remaining articular surface, and providing a basis for reduction of axial alignment. Large medial malleolar fragments, posterior osteochondral fragments, or large posterolateral fragments are ideal for this reduction strategy. At each step of the reduction process, provisional fixation is accomplished with the use of strategically applied clamps and small (0.045 inch) K-wires. Subchondral bone defects are managed with morselized allograft cancellous chips or bone substitutes that provide stability, such as some calcium phosphate materials (Fig. 58-22). 
Figure 58-20
A, B: Injury radiographs of a 49-year-old man after falling from a height of 10 feet.
 
Note the displaced posterolateral plafond fragment (white arrow). After application of a spanning external fixator, axial (C), and sagittal (D) CT scans demonstrate significant articular injury, with dislocation of the posterolateral plafond relative to the talus and the fibula. With the patient in the lateral position, the operative tactic included a posterolateral approach with direct reduction and stabilization of this fragment initially (E). The leg was then externally rotated and a small anterolateral exposure was performed to reduce and secure the large coronal plane fracture separating the plafond into two halves (F). The metadiaphyseal fracture was then stabilized with a percutaneous medial plate (G, H).
Note the displaced posterolateral plafond fragment (white arrow). After application of a spanning external fixator, axial (C), and sagittal (D) CT scans demonstrate significant articular injury, with dislocation of the posterolateral plafond relative to the talus and the fibula. With the patient in the lateral position, the operative tactic included a posterolateral approach with direct reduction and stabilization of this fragment initially (E). The leg was then externally rotated and a small anterolateral exposure was performed to reduce and secure the large coronal plane fracture separating the plafond into two halves (F). The metadiaphyseal fracture was then stabilized with a percutaneous medial plate (G, H).
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Note the displaced posterolateral plafond fragment (white arrow). After application of a spanning external fixator, axial (C), and sagittal (D) CT scans demonstrate significant articular injury, with dislocation of the posterolateral plafond relative to the talus and the fibula. With the patient in the lateral position, the operative tactic included a posterolateral approach with direct reduction and stabilization of this fragment initially (E). The leg was then externally rotated and a small anterolateral exposure was performed to reduce and secure the large coronal plane fracture separating the plafond into two halves (F). The metadiaphyseal fracture was then stabilized with a percutaneous medial plate (G, H).
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Figure 58-20
A, B: Injury radiographs of a 49-year-old man after falling from a height of 10 feet.
Note the displaced posterolateral plafond fragment (white arrow). After application of a spanning external fixator, axial (C), and sagittal (D) CT scans demonstrate significant articular injury, with dislocation of the posterolateral plafond relative to the talus and the fibula. With the patient in the lateral position, the operative tactic included a posterolateral approach with direct reduction and stabilization of this fragment initially (E). The leg was then externally rotated and a small anterolateral exposure was performed to reduce and secure the large coronal plane fracture separating the plafond into two halves (F). The metadiaphyseal fracture was then stabilized with a percutaneous medial plate (G, H).
Note the displaced posterolateral plafond fragment (white arrow). After application of a spanning external fixator, axial (C), and sagittal (D) CT scans demonstrate significant articular injury, with dislocation of the posterolateral plafond relative to the talus and the fibula. With the patient in the lateral position, the operative tactic included a posterolateral approach with direct reduction and stabilization of this fragment initially (E). The leg was then externally rotated and a small anterolateral exposure was performed to reduce and secure the large coronal plane fracture separating the plafond into two halves (F). The metadiaphyseal fracture was then stabilized with a percutaneous medial plate (G, H).
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Note the displaced posterolateral plafond fragment (white arrow). After application of a spanning external fixator, axial (C), and sagittal (D) CT scans demonstrate significant articular injury, with dislocation of the posterolateral plafond relative to the talus and the fibula. With the patient in the lateral position, the operative tactic included a posterolateral approach with direct reduction and stabilization of this fragment initially (E). The leg was then externally rotated and a small anterolateral exposure was performed to reduce and secure the large coronal plane fracture separating the plafond into two halves (F). The metadiaphyseal fracture was then stabilized with a percutaneous medial plate (G, H).
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Figure 58-21
Injury anteroposterior (A) and lateral (B) radiographs of a 28-year-old male involved in a motocross accident.
 
Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
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Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
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Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
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Figure 58-21
Injury anteroposterior (A) and lateral (B) radiographs of a 28-year-old male involved in a motocross accident.
Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
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Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
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Note that his fibula is intact. After spanning external fixation, the lateral fluoroscopic view (C) demonstrates a dorsiflexion deformity of the articular surface of the posterior plafond. The axial CT scan demonstrates a large posterior plafond fragment with central and posteromedial comminution (D). The sagittal reformation corroborates the dorsiflexion deformity (E). Using a modified anteromedial exposure, the reduction sequence consisted of first, clamping the metadiaphyseal fracture (F). An osteotome is introduced proximal into the posterior fragment proximal to physeal scar (G). Downward pressure applied to the osteotome, correcting the impaction injury (H). The reduced posterior fragment is secured to the fibula with percutaneous Kirschner wires, and the remainder of the plafond is reduced and provisionally secured (I). An undercontoured low-profile T-plate is secured to the anterior aspect of the distal tibia, effectively stabilizing the articular reduction (J). A stiff medial plate is applied to neutralize the varus tendency of this fracture pattern. Final anteroposterior (K) and lateral (L) images.
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Figure 58-22
Calcium phosphate: Injury anteroposterior (A) and lateral (B) radiographs of a tibial pilon fracture in a 32-year-old male.
 
Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
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Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
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Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
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Figure 58-22
Calcium phosphate: Injury anteroposterior (A) and lateral (B) radiographs of a tibial pilon fracture in a 32-year-old male.
Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
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Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
View Original | Slide (.ppt)
Important initial fracture characteristics include the very distal nature of the injury, the tension failure of the posterior cortex of the Volkmann fragment, anterior talar extrusion, and the impacted anterior plafond. Spanning external fixation using a biplanar construct (C, D) demonstrates improved position of the talus beneath the mid-diaphysis of the tibia, but the articular impaction remains unchanged. After resolution of soft tissue swelling, an anteromedial surgical approach was performed. The external fixator was left in place and used to provide articular distraction and maintain the talus posteriorly translated. The operative sequence began with reduction of the Volkmann fragment to the metaphysis (E). The anterior plafond was disimpacted and reduced to the Volkmann fragment (F). K-wires were placed for provisional fixation. Note the significant corticocancellous defect immediately proximal to the anterior articular fragment on both the AP (G) and lateral (F) views. A commercially available calcium phosphate product (H, I) followed by internal fixation using anterolateral and medial malleolar plating was used to provide maximum stability of the anterior plafond. Anteroposterior (J) and lateral (K) radiographs demonstrate the final reduction and construct.
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Articular visualization is greatly aided by the use of a transarticular external fixator or universal distractor with placement of a Schanz pin directly into the talar neck. When an anteromedial exposure is performed, a medial-to-lateral talar neck pin is inserted; conversely, when utilizing an anterolateral exposure, a lateral-to-medial talar neck pin is inserted. By connecting the newly inserted talus pin to a pre-existing tibial pin that was part of the initial spanning external fixator or an additional tibial Schanz pin proximal to the fracture, distraction can be applied across the ankle joint to aid in visualization. Although visualization is improved with this type of distraction, occasionally the talus translates anteriorly and creates a paradoxical block to visualization and manipulation of articular fragments. One method to minimize this is to utilize biplanar distraction via the tibial pins proximally, the transcalcaneal pin distally, and the radiolucent bars from an external fixator set. Several advantages are associated with this technique: (1) The talus remains posteriorly translated and distracted in the plafond allowing easier manipulation of the articular fragments; (2) the distraction often achieves excellent overall metaphyseal alignment, rather than inducing an angulatory malalignment as can be seen with a uniplanar distractor; (3) the external fixation bars are posterior to the surgical exposure at the articular surface level and are not obstructive. 
Provisional stabilizing implants are critical for the success of the procedure. Liberal use of small diameter K-wires, clamps, and mini-fragment plates and screws are very useful in maintaining a provisional reduction. These devices should be placed out of the zone of definitive implants and therefore a pre-existing knowledge of the definitive implants, reduction sequence, and choices of surgical approaches is required. 
Historically, implants used for tibial plafond fractures were placed on the anteromedial surface of the tibia. Their size, poor design, and limited areas for strategic screw placement limited their usefulness and may have contributed to wound problems. Current implants exhibit a more anatomical-based lower profile design, and simplify percutaneous and indirect plate reduction techniques. The goals of definitive internal fixation should include absolute stability and inter-fragmentary compression of reduced articular segments, stable fixation of the articular segment to the tibial diaphysis, and restoration of coronal, transverse, and sagittal plane alignments. The location, rigidity, and number of these implants are based on each individual fracture. Important factors to consider when choosing internal fixation for tibial plafond fractures include the degree of comminution, the ability to achieve cortical contact and intrinsic fracture stability, the bone quality, the direction of the initial failure of the bone (varus, valgus, flexion, extension), the status of the soft tissue envelope, any associated bone loss, among others. 
Ideally, the thickness of the plate should balance the need for an implant that has adequate stiffness to counter the anticipated loads, while minimizing plate prominence and soft tissue injury particularly along the anteromedial surface of the tibia. Complete articular injuries (AO/OTA C-type) typically require at least one stiff implant (e.g., 3.5 mm compression plate) to maintain metadiaphyseal alignment. Partial articular injuries (B-type) can usually be managed with lower profile implants that simply provide buttressing of the partial articular injury. The use of locked plating remains poorly defined for intra-articular fractures of the distal tibia, and current evidence-based recommendations are lacking. However, poor bone quality, inability to load the fracture, and anticipated prolonged time to union are all reasonable indications for the use of locking plate fixation (Fig. 58-23). Despite this the majority of tibial pilon fractures at the author’s institution continue to be successfully managed with nonlocking screw-plate devices. 
Figure 58-23
This 51-year-old female was involved in a high-speed motor vehicle collision, sustaining multiple injuries.
 
Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
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Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
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Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
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Figure 58-23
This 51-year-old female was involved in a high-speed motor vehicle collision, sustaining multiple injuries.
Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
View Original | Slide (.ppt)
Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
View Original | Slide (.ppt)
Her past medical history is significant for rheumatoid arthritis, managed with chronic nonsteroidal anti-inflammatory medications, and brief periods of prednisone for significant exacerbations of pain. Physical examination and anteroposterior (A) and lateral (B) injury radiographs demonstrate a substantially comminuted open distal tibial pilon fracture, with radiographic evidence of significant osteopenia. The patient was initially managed with surgical wound debridement, fibular ORIF, and biplanar external fixation (C, D). Fibular fixation consisted of medullary wires because of the diminutive stature of the patient and poor soft tissue quality. Axial (E), coronal (F), and sagittal (G) CT scanning corroborate the articular comminution and poor bone quality. After resolution of soft tissue swelling, definitive treatment consisted of ORIF using an anterolateral approach and a fixed-angle anterolateral implant (H–J). Supplemental transarticular external fixation was utilized to augment stability of the grossly unstable metadiaphyseal region. Multiple juxta-articular K-wires and trans-syndesmotic screws were used to maintain articular fracture fragment congruity. The external fixator was removed after 8 weeks. Weight-bearing anteroposterior (K), and lateral (L) radiographs demonstrate fracture union and acceptable maintenance of alignment and articular congruity.
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X
Attention to wound closure is another critical component to successfully decrease soft tissue complications. At the conclusion of the surgical procedure, the joint capsule is closed with interrupted figure-of-eight absorbable suture. Closure of the extensor retinaculum (anterolateral approach) and deep fascial layer (anteromedial approach) are similarly closed with interrupted figure-of-eight absorbable suture. The suture ends are not tied until the sutures for the entire layer have been placed. Gentle traction is then applied to the suture ends, evenly distributing the forces required for the deep closure. The sutures are then sequentially hand tied and cut. The skin is closed with nylon suture in an Allgower–Donati fashion. Steri-strips are routinely applied over the skin incision to help maintain re-approximation and minimize skin tension at the incision (Table 58-8). 
 
Table 58-8
Stage 2: Definitive Tibial ORIF
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Table 58-8
Stage 2: Definitive Tibial ORIF
Potential Pitfalls and Preventions
Pitfall Prevention
Articular malreduction Careful assessment of the preoperative CT scan to identify areas of comminution and articular impaction
Adequate joint visualization with external fixator or universal distractor
Identify a larger articular fragment that can be accurately reduced to the metaphysis to build to
Axial malalignment Utilized precontoured periarticular plates
Intraoperative plain radiographs to confirm frontal and sagittal plane alignments
More common when utilizing indirect reduction of comminuted metaphysis
Obstructing provisional fixation Understand and plan for location of definitive implants and keep provisional wires and clamps out of these areas
Inability to close surgical wound Close deep layers as much as safely possible, apply wound suction device and return to the operating room in 48 hours for repeat closure attempt.
Plastic surgery consultation for assistance with wound closure
Poor fixation Consider locking screw/plate device
Definitive K-wire support of comminuted articular segment
Supplemental tibiotalar joint spanning external fixation for enhanced external support
Bone graft or bone graft substitute
X
Postoperative Care for Tibial Pilon Fracture Open Reduction and Internal Fixation
At the conclusion of the procedure, the injured limb is placed into a well-padded plaster splint with the foot in neutral position. Pain is controlled with patient-controlled anesthesia devices. Peripheral nerve blocks, including peripheral nerve catheters, are commonly used during the first 24 to 48 hours, and are inserted at the conclusion of the procedure while the patient is still under general anesthesia. Patients are discharged from the hospital on a long-acting and a short-acting narcotic medication. The authors typically withhold nonsteroidal anti-inflammatory medications until approximately 3 months, to minimize the theoretical risk of delayed or nonunion.40,54,78,82,153 The wound is typically examined in the outpatient clinic area approximately 4 to 5 days postoperatively, and the limb is subsequently splinted in a neutral position until the sutures are removed at 2 to 3 weeks. A supervised physical therapy program consisting of active, active-assisted, and passive range of motion of the ankle, subtalar, and metatarsophalangeal joints is then initiated. To avoid equinus contracture, a removable nighttime and resting splint is recommended. Partial progressive weight bearing in a removable boot is initiated approximately 12 weeks after definitive surgery. The physical therapy focus at this point consists of maximization of motion, strengthening, gait training, and the weaning of ambulatory devices such as crutches, canes, and external supports. Postoperatively, edema may be substantial and persist for several months following injury. In addition to patient education regarding this normal phenomenon, an elastic stocking is provided to help decrease dependency-related swelling. 
Outcomes of Tibial Pilon Fracture Open Reduction and Internal Fixation.
Despite optimal treatment of AO/OTA C-type tibial plafond fractures with anatomical articular reconstruction, restoration of distal tibial alignment, and avoidance of surgical complications, the outcome is not always favorable. The irreversible injury that occurs to the chondral surface and other supporting structures continues to be delineated and likely represents important variables in patients outcomes.30,31,32,123,124,125,185 Although the factors that most predictably affect patient outcome after high-energy fractures of the tibial plafond have yet to be entirely determined, validated outcome instruments for ascertaining disability after musculoskeletal injury have demonstrated the significant impact that fractures of the tibial plafond have on patient health. 
Specifically, traditional tibial plafond fracture management indicates that the surgical goals are anatomic articular reduction and restoration of distal tibial alignment. Many clinicians have considered that the severity of articular injury is the most critical determinant of outcome.51,64,110 However others have contended that if an anatomic reduction of the articular surface is achieved, then a good outcome can be expected.149,159 As in other periarticular areas, proving that this has any substantial impact on the final patient outcome has been exceedingly difficult.111 Interestingly, DeCoster demonstrated that neither injury severity nor quality of reduction consistently correlated with clinic ankle scores, but that the quality of reduction did correlate with arthrosis.52 Discerning the effect that each of these preceding variables has on the final outcome becomes even more problematic because of the inherently close association between more severe injuries and the inability to obtain an accurate articular reduction.204 The obvious inference is that poor results in patients with severe injuries may be attributed to inadequate reduction when in fact the patients with poor reductions usually have the most severe articular injuries.204 Williams performed a review of 32 tibial plafond fractures at a minimum of 2 years after injury treated with ankle spanning external fixation and limited internal fixation.204 Similar to the findings of DeCoster,52 the authors noted that the severity of injury and accuracy of articular reduction as assessed on preoperative and postoperative radiographs, strongly correlated with the radiographic presence of arthrosis, but that the presence of arthrosis had no correlation with the clinical ankle score. These authors also found that neither the injury, the quality of reduction, nor measurements of soft tissue injury correlated with any of their patient-derived outcome scores. It should be noted, however, that several reports have suggested that the accuracy and reproducibility of plain radiographic measurements of articular congruity may be suboptimal.28,46,102,117 Regardless, a preponderance of socioeconomic factors did correlate with the clinical ankle score, with females, college graduates, and patients with injuries not associated with workplace injury claims all having better scores. The ability to return to work was also affected by the type of work and level of education, as those with higher levels of education performed in less physically demanding jobs and were therefore not as limited by their ankle injury. 
Using validated outcome measures, Pollak evaluated patients with tibial plafond fractures managed with either ORIF or external fixation with or without limited internal fixation after a mean of 3.2 years.150 A majority of patients (74%) who were enrolled had sustained AO/OTA C-type tibial plafond fractures. Although the cohort treated with ORIF had significantly better outcomes that the external fixation group with regard to pain, walking and ankle range of motion, ultimate outcomes for both groups were less than optimal. As reflected by the SF-36 scales, patient scores were significantly lower than age-matched controls, especially for role disability due to physical health problems and physical function. In fact, SF-36 scores after pilon fracture were worse than after pelvic fracture or with chronic illness such as AIDS, diabetes, or coronary artery disease. Forty-three percent of previously working individuals remained unemployed at the time of follow-up and 68% of those patients attributed their inability to work to the sequelae of their tibial plafond fracture. As noted by others,1,10,68,204 patients with a lower income level or lower level of education were significantly more likely to report and/or demonstrate poorer health and function than were patients who had more financial resources and education. 
In an earlier study, Sands reported findings similar to those of Pollak using the validated SF-36 General Health Questionnaire.169 In their cohort of 64 patients treated with ORIF of their tibial plafond fractures, the SF-36 demonstrated significant negative differences when compared with age-matched general population and patients with tibial plateau fractures in the physical functioning and the role of physical functioning categories. 
Marsh reviewed 31 patients a minimum of 5 years after treatment with a monolateral hinged transarticular external fixator coupled with screw fixation of the articular surface.115 Using validated outcome measures, the authors found that tibial plafond fractures have a long-lasting negative effect on ankle function, work, recreation, and health-related quality of life. Despite arthrosis being evident in the majority of ankles, the effect on clinical outcome was not clear, as the presence of arthrosis had only weak correlations with clinical outcome as measured with the Iowa Ankle Score, the Ankle Osteoarthritis Scale, and the SF-36. Despite this long-lasting negative impact, few ankles in this series required late arthrodesis, or subsequent ankle surgical procedures. The protracted time to improvement (2.4 years postinjury) is similar to the results of Ruedi,159 who noted that most patients had improved or had a stable outcome after being evaluated at a longer follow-up interval. Chen evaluated 128 tibial plafond fractures treated with ORIF at a mean of 10 years postinjury.43 The authors noted that posttraumatic arthrosis was a progressive disease, with increasing incidence evident on plain radiographs, but still demonstrated that rather few of these patients required later arthrodesis. The authors similarly noted that patients with worse soft tissue injury at presentation had poorer clinical outcomes. 
Despite the advances in the management of these challenging injuries, the outcome of tibial plafond fractures remains problematic, with approximately one-third of patients reporting difficulty with ankle stiffness, swelling, or pain.150 Major physical and psychosocial health problems are evident long after the initial injury (Table 58-9). 
 
Table 58-9
Tibial Pilon Fractures
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Table 58-9
Tibial Pilon Fractures
Common Adverse Outcomes and Complications
Superficial wound complications: cellulitis, wound slough
Deep wound complications: septic arthritis, osteomyelitis, deep soft tissue abscess
Posttraumatic stiffness
Posttraumatic arthrosis
Metaphyseal nonunion
Chronic pain, limp, and limitation of function and activities
X
Importance of Articular Reduction
The attainment of an anatomic articular reduction is, perhaps, the most fundamental treatment philosophy of ORIF of periarticular fractures. Proponents of ORIF strongly link the ability to obtain and maintain an anatomic articular reduction with the best outcome possible, including functional outcome and minimization of arthrosis and the subsequent need for arthrodesis. As noted though, the data supporting this is minimal.111 Questions such as to what degree does an articular surface need to be reduced, how can one accurately assess the amount of displacement after reduction and internal fixation, and how to account for difficult-to-measure biologic differences between individuals with seemingly similar injuries remain unanswered. In addition, although accurate surgical reconstruction with minimization of iatrogenic complications should remain the goal in the treatment of these fractures, certain socioeconomic factors well outside of the surgeon’s control appear to have substantial influence on patient outcomes after these injuries. The obvious inference is that the effort to attain an accurate surgical reduction does not matter since it does not appear to affect the current functional and wellness outcome scores. 
Recent evidence, however, has refocused the attention on those factors that the surgeon may actually have under their control. Anderson and colleagues used finite element modeling in a small group of patients with operatively treated tibial plafond fractures. Their results support the existence of a contact stress exposure threshold above which incongruously reduced tibial plafond fractures are highly likely to develop posttraumatic osteoarthrosis.5 Similarly, Thomas and associates used novel CT-based image analysis to quantify acute pilon injury characteristics. Using a combined severity score made up of articular disruption and fracture energy, the authors were able to predict posttraumatic arthrosis severity.183 Graves and colleagues have also recently illustrated the limitations of fluoroscopic imaging in identifying malreduced tibial plafond articular fragments, and stressed the importance of direct visualization in confirming an accurate articular reduction.83 These recent publications would indicate that there is a significant role in the surgical assessment and management of the articular injury associated with these fractures. Although an anatomic reduction of a patient’s tibial plafond fracture may not improve their overall health or socioeconomic status, it may still result in an important component of minimizing later disability and further health care burdens required to manage posttraumatic arthrosis. The subsequent question should relate to the best technique to achieve the desired result with the least risk to the patient. 
Comparative Studies
A number of studies have attempted to directly compare the results of tibial pilon fractures treated with external fixation or open methods. Several of these studies share one or more of these significant limitations: retrospective data assessment, nonrandomized patient allocations, differing injury severity, limited patient follow-up, relatively small patient sample sizes that result in underpowered statistical analyses, and variations in surgical treatments. 
In 1996, Wrysch reported a prospective surgeon-randomized study alluded to earlier.207 Eighteen patients were randomized into ORIF and 20 were randomized into external fixation with minimal incision articular reductions. The authors noted that the complications after ORIF tended to be more severe (with three of the ORIF patients ultimately requiring amputation) than those encountered in the external fixator group, though no formal statistical analysis was done. In addition, they noted that there was no significant difference in the degree of osteoarthrosis or clinical scores based on the treatments provided, but that more displaced and comminuted fractures had lower scores. Given the higher complication rate and similar outcomes, the authors concluded that external fixation is a satisfactory treatment method for tibial plafond fractures. Methodologic problems with this study include the timing of surgery in the ORIF group and the relatively underpowered study groups. 
Anglen evaluated 63 patients who were treated with either hybrid external fixation or open reduction and plate fixation.6 Patients were allocated to these treatment groups based on the status of their soft tissue status, fracture pattern, or systemic injury level. The author concluded that those patients with hybrid fixation had lower clinical scores, slower return to function, a higher rate of complications, more nonunions and malunions, and more infections. However, because of the pre-existing treatment protocol, the study group allocation tended to result in a subjective distinction between the two groups with a greater proportion of pilons treated with hybrid external fixation to have more fracture comminution, greater soft tissue injuries, or more multisystem injury. 
Pugh evaluated 60 patients with pilon fractures, 21 were treated with an ankle-spanning half-pin external fixator, 15 with a single ring hybrid fixator, and 24 with ORIF.151 Although no significant differences were noted between the external fixation group and the open plating group in overall complications, a greater number of malunions occurred in the fractures treated with external fixation when compared with ORIF. Also, the authors noted that the loss of the initial adequate reduction in the fixator groups was independent of bone grafting or fibular fixation. 
Watson and colleagues developed a treatment protocol based on the severity of the soft tissue injury in 107 patients with tibial plafond fractures.199 For all fracture types according to the AO/OTA classification, 81% of those treated with external fixation and 75% of those treated with open plating procedures had a good or excellent result. However, those with more severe fracture patterns (AO/OTA C-type), regardless of which treatment group they belonged to, demonstrated significantly poorer results than patients with type A or B fractures. In this study, patients with C-type fractures had higher rates of nonunion, malunion, and severe wound complication rates in the open plating group than those in the external fixation group. As in the previous studies, however, a predetermined treatment protocol results in groups that may be disparate in injury severity, and therefore strong conclusions regarding treatment cannot be strongly made. 
Blauth evaluated 51 patients over a 10-year span treated in three different ways: primary plate internal fixation, one-stage articular ORIF with long-term transarticular external fixation for at least 4 weeks, and a two-stage procedure with primary articular ORIF, short-term transarticular external fixation followed by secondary medial plate stabilization using limited skin incision technique.18 Strong recommendations could not be made because of the limited number of patients within the groups and other methodologic problems, but the authors felt that the two-stage procedure provided the most satisfactory results. It should be noted that there were only eight patients in the two-staged procedure group. 
Pollack performed a retrospective cohort analysis of pilon fractures treated at two Level-1 trauma centers.150 One center primarily treated tibial pilon fractures with ORIF and the other with external fixation with or without limited internal fixation. The purpose was to assess midterm health, function, and impairment after pilon fractures and to examine patient, injury, and treatment characteristics that influence outcome. This study demonstrated a number of interesting results including: (1) that a substantial amount of disability persists after tibial pilon fracture, (2) many social variables that relate to functional and general health measures are out of the surgeon’s control, and (3) the only injury or treatment characteristic that was significantly related to several of the selected outcomes was treatment method. After controlling for other patient and injury characteristics, participants treated with external fixation with or without limited internal fixation had more overall range-of-motion impairment and reported more pain and ambulatory dysfunction than did participants treated with ORIF. This study has arguably the highest quality of the retrospective comparative studies reviewed. 
Koulouvaris used a case-control methodology to evaluate 55 patients with pilon fractures treated with three different techniques: half pin ankle spanning external fixation; ankle sparing hybrid external fixation with limited arthrotomy; and two-staged ORIF.101 The authors concluded that the hybrid group and the ORIF group were equally efficacious in achieving bone union but those with ankle spanning external fixation had a significantly higher rate of delayed union and reduced activity level. No significant difference in complications was identified. 
Bacon performed a retrospective analysis of tibial plafond fractures treated with either open plating or Ilizarov fixation.11 Based on their extensive review, the authors found no statistically significant differences in overall complication rates, deep sepsis, time to union, nonunion, and malunion. The authors concluded that no clinical recommendation could be made as to which procedure is better and safer for the patient, citing the need for future randomized trials. 
Wang evaluated 53 closed B- and C-type tibial pilon fractures randomized to either two-stage ORIF of limited incision and external fixation.198 The incidence of superficial soft tissue infection (involved in wound infection or pin-tract infection) in the ORIF group was significantly lower than that in external fixation group. The external fixation group had higher rates of malunion, delayed union, and arthritis symptoms, but no statistical significance was demonstrated. Both groups resulted similar ankle joint function. Logistic regression analysis indicated that smoking and fracture pattern were the two factors significantly influencing the final outcomes. 
Most recently, Richards reviewed sixty patients sustaining tibial plafond fractures following treatment with definitive external fixation versus those managed with delayed ORIF.154 There were no differences noted between the two treatment groups in terms of age, smoking, presence of comorbidities, injury mechanism, incidence of open fractures, or OTA fracture classification. Of the patients who had complete 12-month follow-up, the authors noted no difference in articular reduction between the two groups. A significant increase in delayed or nonunion occurred in the external fixation group as compared with the ORIF group (22% vs. 3.7%), with deep infection noted to be equally likely in either group. The ORIF group had significantly improved Iowa Ankle Scores and SF-36 Physical Function scores at both the 6 and 12 months postoperatively. 
When considered overall, there is no clear treatment that can be strongly recommended. External fixation appears to have less associated deep wound complication rates than ORIF, but may be more prone to problems with union (nonunion, malunion) than ORIF. Pollak’s well-done retrospective study, and Richards prospective cohort trial, however suggests a treatment advantage with ORIF over external fixation when union rates, general health, functional outcome, and pain assessments are considered. Pollack’s study, and others, also illustrate that a number of social variables that are important to the final outcome are outside the control of the surgeon, in addition to the degree of fracture comminution. 

Management of Expected Adverse Outcomes and Unexpected Complications after Tibial Pilon Fractures

Complications associated with the open management of tibial plafond fractures can be grouped as septic and nonseptic. As evidenced by the soft tissue envelope having been a primary driver in the evolution of the operative care of these injuries, the most significant complications after operative management of tibial plafond fractures involves those of the soft tissue envelope. Septic complications include superficial and deep wound infections, and osteomyelitis. Nonunion, stiffness, and painful posttraumatic arthrosis are the most commonly encountered nonseptic complications. 

Superficial Wound Complications After Tibial Pilon Fractures

Superficial wound necrosis, or partial-thickness skin slough, is the most common wound complication after open reduction and internal stabilization of tibial plafond fractures. Using staged protocols and formal open exposures, contemporary partial-thickness skin necrosis rates have ranged from 5% to 17%,93,172 though this figure is likely under-reported in studies that are not particularly evaluating this as a complication. Partial-thickness skin necrosis typically develops a dry eschar that will slowly elevate and slough revealing an underlying epithelialized layer. Treatment is typically supportive with local wound care and patience resulting in resolution. Occasionally wet-to-dry dressing changes are required if the eschar is debrided or removed prematurely. Often, these wounds are accompanied by mild surrounding cellulitis with an erythematous margin,167 which represents an appropriate inflammatory response, not an infection. At this point, the limb is placed at rest and motion across the ankle joint is stopped to allow maturation of the eschar and the underlying skin. Close clinical follow-up is warranted to ensure adequate healing. Antibiotics are initiated, however, if the surrounding erythema that is present as an inflammatory response to the necrotic skin devolves into a cellulitis secondary to superficial bacterial infection. Wound cultures are not indicated because the surface of the leg is contaminated by normal skin flora and is not representative of a causative organism. Failure to respond to this treatment requires consideration for inpatient therapy and intravenous antibiotics guided by an infectious disease consultant. 

Deep Wound Complications After Tibial Pilon Fractures

A full-thickness skin slough or significant wound dehiscence should be regarded as an urgent situation that requires hospital admission and operative treatment. The goal of operative treatment in this situation is to convert the contaminated surgical field into a sterile wound that can undergo soft tissue closure, and to obtain deep tissue cultures to guide antibiotic treatment. In all of these significant wound complications, the author strongly recommends obtaining radiographs to ensure that there has not been a subtle or obvious loss of fixation or implant failure. Irrigation and debridement should be performed as soon as possible to remove all necrotic tissue and cleanse the wound. Stable implants are left in place, but loose implants should be removed as they are of no benefit to facilitating fracture union and simply represent a contaminated foreign body. Often, a small dehiscence can undergo primary suture repair, but most often skin retraction prevents closure. In these cases, the remaining wound is covered with a vacuum-assisted closure device (VAC) to seal the open wound from the hospital environment, eliminate the formation of wound seromas or hematomas, and to facilitate granulation and wound contraction.90,174 Culture-specific antibiotics are administered and, once the wound is free of necrotic tissue and clean, a plan for definitive closure of the wound is required. In small wounds without exposed metal, bone, or tendon, the wound can be allowed to heal by secondary intention. Occasionally, a short period of repeated VAC changes can expedite healing. If the area is larger, skin grafting can be performed to expedite closure. Larger wounds, however, or those with exposed tibialis anterior tendon or metal, require formal soft tissue coverage and a surgeon trained in microvascular techniques should be consulted. Occasionally, local fasciocutaneous flaps are sufficient, but because of the limited tissue availability in the distal tibial region free tissue transfer may be required.191 Despite a clean looking wound at the time of coverage or closure, a delayed septic process may still occur, particularly if the implants that have been left in situ have become colonized with bacteria. 
In patients who present with early overt postoperative wound infections, as evidenced by purulent open wound drainage, elevated inflammatory markers, and clinical signs of deep sepsis, treatment decisions become extremely complex. Similar to the goals described above, operative debridement is urgently performed to decrease the bacterial load, obtain deep tissue cultures to guide antibiotic treatment, and to removed devitalized tissue. In the setting of an acute fracture and stable fixation, the goal of treatment is to suppress the infectious process until there is fracture union, at which point the implants can be removed.155 In these cases, draining wounds are packed and definitive soft tissue coverage is typically delayed until the fracture is healed and implants are removed. In patients with an acute infection and grossly unstable implants and fracture, the treatment strategy is similar to that of an infected nonunion, with staged reconstruction of the distal tibia. 

Osteomyelitis After Tibial Pilon Fractures

Chronic tibial osteomyelitis that develops after a pilon fracture is a complex management problem. In situations where there has been an acute wound infection, the septic process is suppressed and implant removal occurs when there is radiographic and clinical union. This scenario is simplified because the fracture has united. The surgical goals after union has occurred are the removal of all potentially contaminated material, including stabilizing implants and devitalized soft tissue and bone, deep tissue cultures, and secure closure of the soft tissue envelope if needed. Adequate bone debridement is facilitated with a high-speed burr, with decortication guided by the occurrence of bleeding bone. Laser doppler flowmetry has been advocated as an adjunctive technique for the determination of viable and nonviable bone in the treatment of osteomyelitis.63,176,177,179 Often patients may need soft tissue coverage to eliminate a densely scarred area, or a previous sinus tract that is not amenable to primary closure. A course of antibiotic treatment is then administered, guided by an infectious disease specialist and the deep culture results.180 
Chronic osteomyelitis associated with nonunion of the distal tibia is an extremely challenging management problem (Fig. 58-24). Treatment principles include radical debridement of infected and nonviable tissue, bony reconstruction, soft tissue reconstruction, and medical therapy.186 In these situations therefore, formal debridement, with implant removal, medullary debridement, and cortical debridement of nonviable bone must be performed. If necessary, repeated debridements are performed to ensure that all necrotic and infected tissue is removed. Bone defects are filled with nonbiodegradable drug delivery systems, such as antibiotic-impregnated beads or cylinders. Soft tissue defects are covered with local, or more commonly distant, tissue transfer, and the skeleton is stabilized with external fixation. Culture specific antibiotics are administered according to an infectious disease specialist, with the duration of treatment typically between 6 and 12 weeks, depending on the virulence of the organism, health of the host, and available antibiotic regimens. Once the soft tissue healing has stabilized, with complete epithelialization of muscle flaps reconstruction is directed at achieving union with bone grafting, consideration of definitive treatment with continued external fixation or conversion to internal fixation. An important factor to consider is whether the articular surface of the distal tibia is involved or not, and whether ankle joint function is expected to be satisfactory. If the articular surface is involved and the ultimate function of the tibiotalar joint is anticipated to be poor, then reconstruction efforts are directed toward achieving a well-aligned tibiotalar arthrodesis. In recalcitrant situations, those patients who are not candidates for soft tissue transfer, or those patients who choose not to proceed with repeated surgical interventions in the hopes of obtaining a functional lower extremity, a well-timed below knee amputation remains an important therapeutic option. 
Figure 58-24
 
Clinical photo (A) and anteroposterior (B) radiograph of the ankle of a 38-year-old male 6 weeks after open treatment of a tibial plafond fracture at an outside facility. Gross purulence, loss of fixation, malalignment, and deep sepsis are evident.
Clinical photo (A) and anteroposterior (B) radiograph of the ankle of a 38-year-old male 6 weeks after open treatment of a tibial plafond fracture at an outside facility. Gross purulence, loss of fixation, malalignment, and deep sepsis are evident.
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Figure 58-24
Clinical photo (A) and anteroposterior (B) radiograph of the ankle of a 38-year-old male 6 weeks after open treatment of a tibial plafond fracture at an outside facility. Gross purulence, loss of fixation, malalignment, and deep sepsis are evident.
Clinical photo (A) and anteroposterior (B) radiograph of the ankle of a 38-year-old male 6 weeks after open treatment of a tibial plafond fracture at an outside facility. Gross purulence, loss of fixation, malalignment, and deep sepsis are evident.
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Nonunion After Tibial Pilon Fractures

The vast majority of distal tibial nonunions after a fracture of the tibial plafond occur within the metaphysis or the metadiaphyseal junction. Rates of nonunion range from 0% to 16%.11,85,106,149,169,172 In a review of tibial plafond fractures treated with external fixation or ORIF, Richards recently identified a delayed or nonunion rate of 22% in the external fixation group and 3.2% in the ORIF group.154 Intra-articular nonunions are extremely rare. The preoperative work-up should include an assessment of the soft tissue envelope, particularly the location of previous surgical incisions or traumatic wounds, ankle and subtalar range of motion, clinical malalignment, and an evaluation of potential causes for the nonunion, such as medications, infection, poor osseous vascularity, fracture instability, or other factors that may have been technique related. Distal tibial metaphyseal nonunion can be managed with medullary nails, plates, or external fixation, depending in part on the location of the nonunion relative to the articular surface, local soft tissue conditions, previous treatment methods, co-existing malalignment, and the biologic potential of the region. In most cases, especially with broken plates, the original incision should be utilized to retrieve the failed implant and to access and treat the nonunion according to current methods.167 
Regardless of the type of implant used, restoration of frontal, sagittal, and transverse plane alignment is required. A typical scenario is the varus, extended, malaligned nonunion. Restoration of appropriate alignment often requires the use of a medially based universal distractor or external fixator, followed by plate or nail stabilization. Because correction of this deformity will result in the creation of a bone defect, the surgeon must be prepared for the use of bone graft. In addition, the surgeon must carefully evaluate the status of the soft tissue envelope prior to repair as acute correction of the varus and extension may substantially compromise the medial soft tissue envelope, particularly if there has been significant scarring secondary to the initial trauma and/or previous surgical interventions. In these situations, preoperative consultation with a microvascular surgeon will facilitate their understanding of the soft tissue coverage possibilities that may arise, and importantly, the patient will understand these possibilities preoperatively. Last, the surgeon and patient should appreciate that once limb alignment is restored, the location of the arc of motion of the ankle may be substantially altered compared to that preoperatively. In particular, those patients who present with an extension deformity of the distal tibia may require a tendo Achilles lengthening or gastrocnemius recession procedure to eliminate the pre-existing equinus contracture that will be made evident with accurate sagittal plane realignment of the distal tibia. Severely malaligned nonunions may be best managed with circular ring fixation that allows gradual restoration of alignment and concomitantly creating a gradual accommodation of medial soft tissue envelope.69,157,158 By incorporating the foot into the frame, the potential equinus contracture can also be managed with gradual realignment. 

Posttraumatic Arthritis After Tibial Pilon Fractures

Radiographic changes indicative of posttraumatic arthritis are common after fractures of the tibial plafond but because of the lack of significant long-term follow-up, and the varied criteria for diagnosis, exact incidences remain unknown. Marsh noted that the majority of ankles in his study demonstrated radiographic arthrosis changes such as joint space narrowing, but only weak correlations were noted with clinical outcome.115 Although the foundation of ORIF is, in part, to obtain an anatomic articular reduction, posttraumatic arthrosis may still develop despite an anatomic reduction secondary to chondral injury of the tibia, the talus, or both.30,31,32,115,124,125,150,152 Many patients can be successfully treated with anti-inflammatory medications, activity modification, and periodic bracing. Provided that the distal tibia is well aligned and the fracture is healed, treatment for severe posttraumatic end-stage ankle arthritis is best treated with an in situ arthrodesis.167 In situations with malalignment secondary to bone destruction or loss, realignment often produces substantial periarticular defects that may require cancellous and/or structural bone graft, or other space-filling materials. Marsh reported an arthrodesis rate of 13% in 40 ankles after a minimum follow-up of 5 years.115 Chen noted a 4.7% arthrodesis rate in plated tibial plafond fractures followed an average of 10 years.43 Historically, reported arthrodesis rates with operative management of tibial plafond fractures have ranged from 5% to 26%, with most of this data being obtained in patients followed for less than 5 years.18,35,143,159,162,169 In patients with significant erosions or juxta-articular deformity custom-shaped tricortical allograft or autograft shims should be used to place the hindfoot in the proper position.132 Numerous arthrodesis techniques have been reported with successful results, including the use of blade plates, hindfoot fusion nails, and circular external fixators.36,67,113,130,131,166,171,201 Total ankle replacement is a relative new alternative to arthrodesis for posttraumatic ankle arthrosis. Despite the intuitive reconstruction of joint mechanics, total ankle replacement remains unproven in this patient population, and may be associated with substantially higher rates of complications and revision procedures.44,56,168 

Author’s Preferred Treatment of Tibial Pilon Fractures

 
 

The author prefers to treat the vast majority of tibial pilon fractures with staged ORIF using the general principles outlined by Ruedi and Allgower four decades ago. Conceptually, however, pure isolated medial buttress plating, as originally described by Ruedi and Allgower, is far less important as choosing an implant, or implants, that are appropriate to support the anticipated loads that the articular and metadiaphyseal fracture components may encounter. Occasionally acute ORIF is performed, but only when the injury is of low energy, presents with little soft tissue swelling, and the injury pattern and surgical tactic can be discerned with plain radiographs and a comprehensible distal tibial CT scan. Treatment with definitive external fixation with or without small incision articular reduction and fixation is rarely utilized but when used, is typically reserved for those situations with severe associated soft tissue compromise, and/or patients and/or limbs that cannot tolerate open methods.

 

Each step of the treatment process is important and can have a substantial impact on the final operative result.

 
Stage 1: Fibular Open Reduction and Internal Fixation and Tibiotalar External Fixation
 

The initial evaluation of the fibula assesses:

  1.  
    The mechanism of fibular fracture, such as tension or compression failure,
  2.  
    The degree of comminution.
 

The mechanism of fibular fracture often dictates not only the fibular fixation construct but may also suggest the direction from which the tibia should be primarily buttressed. Valgus, compression-failure fibula fractures often suggest that subsequent distal tibial metadiaphysis may be best supported with a laterally based tibial plate, whereas a tension-failure fibula frequently suggest that a medial tibial buttress plate may be preferred. The degree of comminution can help determine whether a periarticular fibular plate is best or whether simpler tubular-type implants can be utilized. As noted earlier, simple transverse fractures in the distal third of the fibula shaft can also be successfully managed with medullary fixation and avoid significant soft tissue dissection. For the reasons stated earlier, the author strives for anatomic fibular length, alignment, and rotation.

 

The initial evaluation of the tibia assesses:

  1.  
    The posterolateral plafond injury (the Volkmann fragment) and,
  2.  
    Any metadiaphyseal extensions that can be acutely manipulated to convert an OTA C-type injury pattern to a B-type injury.
 

The importance of assessing the Volkmann fragment is that it may be best managed concomitantly and acutely with ORIF of the fibula fracture thereby substantially increasing the ease of the subsequent definitive treatment stage. Similarly, long spiral metadiaphyseal extensions or large oblique fragments that present a substantial amount of articular surface at their distal portion are considered for acute ORIF as their acute reduction can provide several benefits including:

  1.  
    Accurate reduction with minimally invasive methods, such as percutaneous or mini-incision techniques,
  2.  
    Provides for a more accurate reduction of the talus relative to the tibia with subsequent external fixation,
  3.  
    Increases the stability of the distal tibia which facilitates recovery of the soft tissue envelope,
  4.  
    Provides a reduced, stable articular segment to “build to” at the time of the remainder of the definitive fixation.
 

Acute partial tibial reduction and fixation is typically with short length small or mini-fragment plates and/or independent screws, and must avoid inadvertent fixation of other unreduced fracture fragments. This treatment strategy should be performed only when all of the definitive fixation construct has been thought through so as to not jeopardize the final choice of surgical approaches, implant placement, and soft tissue injury. If the operative plan cannot be completely delineated at the outset, either because of lack of or inadequate understanding of the CT scan, or the soft tissue envelope is not appropriate for acute interventions, then the author prefers to apply a simple external fixator, achieve as accurate reduction as possible, and repeat or perform imaging as needed. In the author’s opinion, it is far better to provide the best surgical tactic, reduction, and fixation in three or more stages than proceeding with a poorly planned and subsequently executed surgical plan in two stages.

 

After accurate fibular fixation, the author currently prefers to apply a biplanar tibiotalar spanning external fixator. A transcalcaneal pin is used, in addition to two tibial and a single cuneiform pin. The biplanar external fixator is subsequently used as the distraction device for the definitive tibial reduction and fixation stage, and therefore requires accurate placement of the talus beneath the anatomic axis of the tibia in the frontal plane, slight posterior translation in the sagittal plane, and satisfactory tibiotalar distraction in the horizontal plane. After fibular fixation and tibiotalar external fixation, a CT scan is obtained.

 
Stage 2: Definitive Tibial Open Reduction and Internal Fixation
 

Definitive tibial reduction and fixation occurs after resolution of soft tissue edema, when wrinkles are present, and blisters have epithelialized. The axial, sagittal, and coronal CT scan images are very carefully reviewed to understand the articular injury. Important features are the location of comminution, impaction, and how the articular fragments relate to the metadiaphysis. On the CT scan, a clear understanding of the position, size, and relationship of the Volkmann fragment to the fibula, the tibia, and the rest of the articular surface is one of the initial assessments. This determines the best surgical approach, typically a choice between an anterolateral exposure or an anteromedial exposure. Valgus or abduction injuries with anterolateral plafond comminution and/or impaction without medial articular plafond comminution are ideal patterns for the anterolateral exposure. Increasing medial plafond comminution, and varus or adduction injuries are indications for an anteromedial exposure. Supplemental posteromedial or medial malleolar-type exposures can also be safely performed in conjunction with the anterolateral approach to manage coexisting medial malleolar or medial metaphyseal fractures, and are powerful adjunctive exposures. The anterolateral and anteromedial incisions are made to allow satisfactory visualization of the articular surface and the metaepiphyseal fracture lines, and retrograde plate insertion with proximal plate fixation often occurring percutaneously. Reduction of the articular surface utilizes all techniques, including anatomic reduction of any available cortical interdigitations, direct visualization of the articular surface, and fluoroscopic confirmation. A common sequence is accurate reduction of the posterolateral Volkmann fragment relative to the fibula, followed by correction of any dorsiflexion impaction of the articular surface. The Volkmann fragment is then reduced to the medial malleolar fragment along the posteromedial fracture line. Central plafond comminution is reduced and bone graft (if needed) is applied. The anterolateral Chaput fragment is subsequently reduced. Liberal use of K-wires of small diameter and occasional mini-fragment screw/plate devices are used to provide provisional fixation. The external fixator is useful for providing distraction and allowing visualization of the articular surface as it can maintain the talus in a slightly posterior, distracted, and plantarflexed position. After reduction and provisional fixation of the articular surface, the modularity of the external fixator allows it to indirectly reduce axial metadiaphyseal alignment if needed. Specifically, the distraction can be lessened and the metadiaphyseal fracture more accurately reduced and provisionally held with the external fixator. The choice of implant depends on the job that it is required to do. Coronal plane articular fracture lines are best secured with anterior–posterior fixation, whereas sagittal plane articular fracture lines are best secured from medial to lateral. Valgus injuries often require stiffer lateral buttress implants and the reverse is required for varus or adduction injuries. In those with significant metadiaphyseal injury, stiff lateral (typically anterolateral, but occasionally posterolateral) and medial implants are required. As noted, morselized allograft bone graft is occasionally required to fill epiphyseal bone voids to support articular surface fragmentation. Radiographic representation of the reduction and fixation sequence is provided in Figure 58-25.

 
Figure 58-25
Injury radiographs (A, B) of a 46-year-old man involved in a motor vehicle collision.
 
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
Figure 58-25
Injury radiographs (A, B) of a 46-year-old man involved in a motor vehicle collision.
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
After operative fixation of his fibula fracture and spanning external fixation of the tibial component, his axial (C), coronal (D), and sagittal (E) CT scans demonstrate substantial articular comminution. The medial malleolus was reduced initially and secured with K-wires (F). A small maxillofacial implant was then used to securely stabilize the medial malleolar reduction to the distal tibia, allowing distraction to further visualize the articular surface (G). Once the provisional reduction of the articular and metaphyseal components was secured, definitive plate stabilization was applied (H). Final immediate postoperative radiographs demonstrate satisfactory articular and metadiaphyseal reductions (I, J).
View Original | Slide (.ppt)
X
 

The wounds are closed in layers with a monofilament absorbable suture for the deep layers and nylon modified Allgower–Donati suture for the skin. Patients are typically placed into a below knee splint with the foot in a neutral plantigrade position. Postoperative pain control is facilitated by a sciatic and femoral nerve block performed at the conclusion of the surgical procedure. The postoperative care plan previously outlined is utilized.

Summary, Controversies, and Future Directions for Tibial Pilon Fractures

High-energy fractures of the tibial plafond continue to be one of the most challenging and controversial injuries that we treat. Much of the controversy resides in treatment techniques and balancing the benefits of surgical restoration of anatomy versus the potential risk of further soft tissue injury and iatrogenic complication. The development of staged ORIF has recognized the important role of the soft tissue envelope, and the problems that are faced with performing extensive surgical dissections during the time of maximal soft tissue swelling. An appreciation of surgical timing, however, continues to evolve and the role of immediate fixation is an area for continued study. As more validated clinical patient-oriented outcome data has become available, the surgical community is understanding that a number of factors that affect the final outcome in these patients are out of our control; however, those factors that are within our control still need considerable evaluation. 
Differentiating the effect of surgical reduction and fixation remains an area that, although the foundation of fracture care, continues to be controversial. In part, this is due to the inability to accurately assess the adequacy of reduction. Methods that demonstrate high observer agreement in the accurate assessment of the quality of reduction will greatly help in teasing out the relative contributions that injury severity and surgical reduction have to patient outcome. Based on the findings of Pollak150 and others,52,115,169,204 clinical research should be devoted to understanding improved methods of pain control, minimization of stiffness, and understanding the microscopic injury of the cartilage and other supportive ankle tissues. It is likely that the frontier for the management of these injuries will be less focused on the technical apparatus than on the regenerative sciences and biologic alternatives. Recent evidence suggests an increasingly clear relationship between residual articular incongruity, fracture energy, and magnitude of articular reduction on the development of posttraumatic arthrosis severity.5,183 
In summary, tibial pilon fractures have long-term effects on physical and mental functions as determined using patient-oriented functional and general health measurement tools. This translates into significant detrimental effects on patients’ recreation, activities of daily living, and employment. Many of these outcomes are driven by pre-existing social factors such as the level of education, gender, and the presence of a work-related injury, and the degree of injury severity (such as fracture comminution) rather than the specific surgical interventions. Increasingly, factors that are under the surgeon’s control, such as quality of reduction, method of stabilization, residual articular incongruity, as well as understanding the magnitude of the injurious forces and comminution are slowly becoming delineated with respect to the final outcome but require further quality research to assess their impact, both at the clinical and basic science levels.122 It is likely that a slow improvement occurs over the first 2 to 3 years reaching a plateau at that time. The arthrodesis rate within the first 10 years is likely 7% to 12%, but outcomes beyond this time frame are largely unknown. 

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