Fractures of the distal tibia can be challenging to manage. They are as notorious for the difficulty they can generate in obtaining an adequate reduction as they are for provoking morbidity resulting from soft tissue compromise and infection. Although some investigators have reported 74-90% good or excellent results with open treatment of lower energy pilon fractures,511 the same results have been difficult to duplicate in the treatment of high-energy or open pilon fractures.2,4,6,9 In fact, Teeny and Wiss, in their retrospective study of plafond fractures treated with open reduction and internal fixation, found 50% poor results including a 37% deep infection rate for Ruedi type III fractures that did not correlate with whether the injury was open at presentation.13 A review of the recent literature demonstrates a trend toward increasingly limited open reduction and internal fixation, usually associated with some form of external frame stabilization.1,10,12,14 More recently, a prospective study comparing open reduction and internal fixation to external fixation and limited open reduction emphasized the disparity in major complications.15
Ruedi and Allgower introduced the modern era of tibial pilon fracture treatment in 1969 with their treatise, “Fractures of the Lower End of the Tibia Into the Ankle Joint.”11 In obtaining their excellent results, they discussed the four basic principles of pilon fracture treatment heralded by the Swiss Study Group, which included: (1) restoring the appropriate length of the fibula; (2) careful reconstruction of the articular surface of the tibia; (3) augmentation of metaphyseal defects with cancellous autograft; and (4) medial stabilization of the tibia with a plate.11 In 1988, Mast et al. further outlined the “biologic principles” of tibial pilon fracture treatment, including meticulous soft tissue dissection, limited soft tissue stripping, indirect reduction, and stable fixation.8 In addition, Brumback and McGarvey, in their review of the literature, reiterated that restoration of the articular anatomy is paramount in diminishing long-term complications such as posttraumatic arthritis.3 It is on the basis of these tenets that a technique for minimally invasive osteosynthesis of the distal tibia has been used at our institution for the last several years. This report is a detailed review of this technique, which is used as part of a protocol for the injury patterns described below. An examination of this technique on an early cohort of patients has been elaborated on previously. 7.
© 1999 Lippincott Williams & Wilkins, Inc.