Although the initial description of the tibial pilon fracture treated with open reduction and internal fixation (ORIF) demonstrated excellent surgical outcomes with minimal complications,1 subsequent reports of their treatment held tempered enthusiasm.2–4 In addition to the advent of a 2-stage approach to these fractures,5,6 detailed understanding of the fracture patterns7,8 and the detailed microvascular anatomy about the ankle9,10 have led to the development of safe and effective ORIF tactics for anatomic reconstruction of high-energy tibial pilon fractures.
A 44-year-old man presents after a second-story fall with isolated left ankle pain and deformity (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A390). The patient has a mildly deformed left ankle without skin laceration or blanching, moderate ecchymosis, and severe ankle swelling. His distal neurovascular status is intact. Initial ankle radiographs demonstrate an Orthopaedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen 43C3 fracture with anterior impaction and comminution and a minimally displaced transverse distal fibula fracture. Because of soft-tissue swelling, the patient was treated with a 2-stage approach with initial reduction and ankle spanning external fixation. Computed tomography demonstrates the C-type fracture in more detail. The Volkmann (posterior/lateral) fragment extends medially into the posterior tibial tendon groove, and the medial malleolar fracture is separate from this fragment. These are less displaced relative to the thin Chaput tubercle fragment and the large central impaction fragment that involves the anterior half of the plafond. There is comminution between the Chaput tubercle fragment and the medial malleolar fragment anteriorly, allowing for entry into the articular fracture zone lateral to the course of the tendons in the anterior compartment. Preoperative planning includes an anterolateral and posteromedial approach to visualize, clean and reduce the components of the fracture, and apply fixation to resist deforming forces and minimize soft-tissue injury.
On soft-tissue swelling resolution with demonstration of wrinkles in the skin, the patient is taken to the operating room for ORIF. The patient is positioned supine on a radiolucent table with an ipsilateral hip bump and the limb on a foam ramp. The external fixator is prepped in to maintain stability during positioning, prepping, and draping, as well as to provide some joint distraction in certain cases. The posteromedial approach is taken sharply along the posteromedial edge of the tibia and follows the course of the posterior tibial tendon distally to the posterior border of the medial malleolus. The greater saphenous vein and saphenous nerve are identified and protected. A portion of the posterior tibial tendon sheath is incised to allow displacement of the tendon. This portion of the fracture is cleansed and the entrapped periosteum is excised. The anterolateral approach is then made in line with the fourth ray of the foot and extends proximally in line with the fibula. The superficial peroneal nerve is identified, dissected, and protected. The retinacular incision over the anterior compartment is made lateral to the skin incision to allow for a potential healthy layer to be present if the skin should dehisce. The contents of the anterior compartment are retracted from lateral to medial, and the Chaput tubercle is visualized. The medial border of this fracture fragment is identified, and the fracture rotated around the anterior syndesmotic ligaments to visualize the articular portion of the fracture. The anterior portion of the impacted plafond is displaced to visualize, clean, and reduce the smaller medial and posterior impaction and to mobilize the Volkmann fracture fragment through its metaphyseal fracture line. The anterior and central impaction is reduced first to the Volkmann fragment in this case and secured with Kirschner wires. The medial malleolar fragment and the medial metaphysal portion of the posterior fragment are then reduced and fixed using 2 buttress plates. The Chaput tubercle fragment is reduced, and a mini-fragment rim plate is applied with intrafragmentary screw compression, completing the restoration of the articular block. The metaphyseal void is filled with cancellous allograft. A precontoured, anterolateral locking plate was chosen and placed in a submuscular plane from distal to proximal. Cortical screw fixation was applied first to the metaphysis proximally and the articular block distally. Then the fixation was completed with locking screws in the articular block and additional cortical screws in the diaphysis. Finally, an intramedullary screw was placed percutaneously in the fibula to stabilize the minimally displaced fibula fracture. The wounds were cleaned, closed, and dressed before Schantz pin removal, and the pin sites underwent curettage and irrigation before dressing and splint application. Postoperatively, the patient was non–weight bearing on the injured extremity for 8 weeks; active range of motion was started after splint and suture removal at 2 weeks.
1. Ruedi T. Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation. Injury. 1973;5:130–134.
2. Kellam JF, Waddell JP. Fractures of the distal tibial metaphysis with intra-articular extension–the distal tibial explosion fracture. J Trauma. 1979;19:593–601.
3. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res. 1993:108–117.
4. Wyrsch B, McFerran MA, McAndrew M, et al. Operative treatment of fractures of the tibial plafond. A randomized, prospective study. J Bone Joint Surg Am. 1996;78:1646–1657.
5. Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999;13:85–91.
6. Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;13:78–84.
7. Cole PA, Mehrle RK, Bhandari M, et al. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma. 2013;27:e152–e156.
8. Mehta S, Gardner MJ, Barei DP, et al. Reduction strategies through the anterolateral exposure for fixation of type B and C pilon fractures. J Orthop Trauma. 2011;25:116–122.
9. Taylor GI, Palmer JH. “Angiosome theory”. Br J Plast Surg. 1992;45:327–328.
10. Attinger C, Cooper P, Blume P, et al. The safest surgical incisions and amputations applying the angiosome principles and using the Doppler to assess the arterial-arterial connections of the foot and ankle. Foot Ankle Clin. 2001;6:745–799.