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CASE REPORTS

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Distal Tibia Pilon Fracture Operatively Treated With VariableAngle Locking Small Fragment Fixation: A Case Report

Erik Lund, MD and Hassan Mir, MD, MBA, FACS

Summary: Intraarticular distal tibia (pilon) fractures occur withlimited frequency, but can present substantial morbidity topatients and clinical challenges to the treating orthopaedicsurgeon. With the advent of modern surgical techniques andimplants, open reduction and internal fixation is now the standardof care. Staged protocols were developed to allow soft tissueswelling to improve before definitive internal fixation, reducingcomplications. Below, we present a case of an OTA/AO 43Cpilon injury treated with a staged protocol. Fixation included lowprofile small fragment distal tibial and fibular plates with variableangle locking screws, accommodating trajectories to fix the keyarticular fragments. This construct limited the dissection neces-sary to achieve the goals of anatomical joint reconstruction andrigid fixation, allowing for early motion.

Key Words: distal tibia, pilon, small fragment, variable angle,locking

INTRODUCTIONIntraarticular distal tibia fractures (pilon fractures) constitute

approximately 1% of all lower extremity fractures. They presentwith a wide range of severity that correlates with the mechanism ofinjury, level of energy, and quality of bone.1,2 Evaluation of theseinjuries includes a complete neurovascular examination of theinjured extremity in addition to ruling out associated injuries ofthe ipsilateral extremity, pelvis, and spine. Radiographs and typi-cally computed tomography (CT) provide fracture visualizationand allow for preoperative templating. Treatment of these injuriesremains a challenge even to the experienced orthopaedic traumasurgeon. If severe medical comorbidities preclude safe generalanesthesia, nonoperative treatment can be chosen. However, thefunctional results after nonoperative management are poor and itsuse is limited to the most infirm patients.3 In the 1960s and 1970s,surgical techniques advanced and better implants were developed,thus operative treatment gained popularity as outcomesimproved.3,4 However, even at high volume centers with experi-enced orthopaedic surgeons, open reduction and internal fixation(ORIF) has high risks of complications, infection, malunion, non-union, and posttraumatic arthritis.1,5–7 Operative timing, surgicalapproach, and fixation construct depend on host comorbidities,fracture pattern, and soft tissue status.5 A commonly practicedalgorithm follows a staged protocol with initial external fixation,followed by a period of soft tissue rest to reduce swelling, CTscanning, and later definitive fixation. Numerous studies reportimproved outcomes with a staged protocol, resulting in more pre-dictable wound healing and fewer infections.8,9 More recently,multiple studies report good outcomes in selected pilon fracturesfixed acutely by experienced surgeons at high volume traumacenters.10,11

CASE REPORTA 20-year-old woman fell with a twisting injury to the right

ankle, resulting in immediate pain and mild deformity. Shepresented to the emergency department with a closed right

Accepted for publication September 24, 2018.

From the Orthopaedic Trauma Service at Florida Orthopaedic Institute,Tampa, FL.

Dr. Mir is a consultant for Smith and Nephew, Zimmer-Biomet andshareholder of Orthogrid. The remaining author reports no conflict ofinterest.

Reprints: Hassan Mir, MD, MBA, FACS, Orthopaedic Trauma Service atFlorida Orthopaedic Institute, 5 Tampa General Circle, Suite 710, Tampa,FL 33606 (e-mail: hmir@floridaortho.com).

The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Smith & Nephew, Inc.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

DOI: 10.1097/BOT.0000000000001349

J Orthop Trauma � 2018 www.jorthotrauma.com e1

intraarticular distal tibia pilon fracture with an associated fibularfracture. Her right lower extremity showed no gross neurovasculardeficits and no evidence of compartment syndrome. Shewas placedinto a short leg splint with cotton padding. Given the amount ofsoft tissue swelling, but limited amount of deformity withoutshortening, the patient’s leg was elevated in the splint. Nine dayslater, definitive ORIF was performed, as there was resolution of theedema and a positive wrinkle sign.

The patient was brought to the operating room and placed supinewith a bump under the ipsilateral hip, a nonsterile tourniquet, andbone foam. General endotracheal anesthesia was obtained tofacilitate full muscle paralysis. After prepping, direct medial andposterolateral approaches were made to the ankle with care to avoiddamage to neurovascular structures. These approaches wereselected based on preoperative CT scan imaging that showed thekey fragments that necessitated direct visualization, and theavailability of variable angle locking small fragment implants thatwould allow for fixation of these key fragments (Figs. 1 and 2). Themetadiaphyseal dissociation necessitated long fixation to span wellabove the injury in the diaphysis.

The distal fibula was reduced anatomically with small standardand pointed reduction clamps to help restore length and alignment ofthe metaphysis. An interfragmentary positional screw and neutral-ization plate were applied. The distal tibial articular block andmetaphysis were then reduced with a combination of small and largeWeber clamps and provisionally held with Kirschner wires. Aprecontoured small fragment distal tibial plate was secured to thedistal segment with multiple nonlocking and variable angle lockingscrews into the key articular fragments. The plate was then secured tothe shaft with multiple nonlocking screws. The alignment of thelimb, the reduction of the joint, and the position of the implants wereverifiedwith direct visualization andfluoroscopy (Figs. 3 and 4). Theincisionswere irrigated, closed in layerswith0-vicryl deep, 2-0vicrylsubcutaneous, and 3-0 nylon mattress sutures. A sterile dressing wasapplied along with a bulky Jones–padded plaster splint.

She was instructed to remain non–weight-bearing on the rightlower extremity for 12 weeks. After 3 weeks, her wound healeduneventfully. Her splint and sutures were removed, and she beganrange of motion exercises in a removable fracture brace. Sheadvanced to weight-bearing as tolerated after follow-up radio-graphs confirmed fracture union at 12 weeks. At 6 months, shehad returned to all activities without any limitations and with nopain (Fig. 5).

FIGURE 1. Initial ankle injury ra-diographs. A, Mortise. B, Lateral.

FIGURE 2. Representative axial CT slice demonstrating articularfracture pattern.

Lund and Mir

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DISCUSSIONAlthough pilon fractures represent a small proportion of lower

extremity injuries, they present major challenges to both the patientand treating orthopaedic surgeon. Patients can experience persis-tent pain, posttraumatic arthritis, infection, amputation, and even43% may never return to work.12 These injuries significantlyreduce the quality of life, physical, and mental health scores ofpatients.13–15 At 6 months, 1 and 2 years after injury and surgery,most patients fail to reach their preinjury pain and quality of life asmeasured by pain Visual Analog Score and EQ-5d, respectively.16

Outcome studies show patient factors and fracture patternscorrelate with functional and radiographic results. A recent articlereported on 102 complete articular type C pilon fractures. Theyfound that 28%were unsatisfied.17 This article also cited a high rate

of infections occurring in 17.6%, correlating with comorbiditiesand open fractures. Another series of 46 patients found fractureseverity correlated closely at 5 years postinjury with worse ShortForm-36 scores. They reported SF-36 averages of 65.3 and 41.9 forB- and C-type fractures, respectively, compared with 90.3 nationalstandard for those of age-matched healthy controls.15 Anotherreport of 76 B- and C-type fractures found that type C3 fracturesalso exhibited higher complications and greatest impairment up to 8years later.18 Older patients tend to develop more posttraumaticarthritis and recovery to a lower functional status. Patients olderthan 55 years scored worse (higher) on aMusculoskeletal FunctionAssessment of 33.5, compared with 24.1 in patients younger than55 years. Comorbidities, especially diabetes mellitus, dramaticallyincrease the rate of complications for operatively treated pilonfractures. In a retrospective cohort of diabetics compared with non-diabetics, infection occurred in 71% versus 35% (P5 0.011), 43%deep versus 9% (P, 0.001).19 Nonunion occurredmore frequentlyin diabetics, 43% versus 16% (P5 0.015). One publication testedthe theory that obesity may provide a better soft tissue envelope forhealing around the ankle.20 In 31 obese pilon fractures, 4 experi-enced major wound-healing complications (13%), compared with4/86 in the nonobese group (5%).

Although patient and injury characteristics affect outcome,a surgeon can improve and enhance outcome with a carefullyplanned and executed procedure. Early treatment techniques variedwidely, with simple immobilization the treatment of choicecenturies and even decades ago. With technical and implantadvances, the current standard of care is operative fixation in someform. The pioneers of internal fixation recommended applyinga medial tibial plate.3 However, the medial tibia is subcutaneous,and platingwith traditional thicker implants has shown high rates ofskin necrosis.14 Modern accepted techniques focus on patient andfracture-specific constructs, using a variety of approaches and platepositions.9,13,21 Staged external fixation, followed by delayed ana-tomical ORIF can minimize complications.8,13,18 One seriesdescribe staged ORIF of the posterior fracture fragments first, fol-lowed by later supine anterior approach to complete the construct.9

Others describe combining simultaneous limited internal withexternal fixation as definitive treatment.18,22,23

In addition to judicious soft tissue management and operativetiming, a critical evaluation of the fracture pattern to plan ananatomical articular surface, restoration of length, alignment, and

FIGURE 3. Intraoperative fluoroscopicimages.

FIGURE 4. Immediate postoperative CT axial slice demonstrat-ing reduction and spread of variable angle screw fixation cap-turing anterior and posterior articular fragments.

Distal Tibia Pilon Fracture

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rotation will give the best results. Multiple series report statisticallybetter functional and radiographic outcomes with better articularreductions.16,24–26 The surgical approach selected confers directvisualization of the fracture fragments, and windows to facilitatereduction and fixation.27 Once the surgeon obtains an anatomicalreduction, rigid fixation facilitates healing with maintenance ofreduction while allowing for early motion. Internal fixation im-plants are typically mini or small fragment plates and screws. New-er implants that are low profile and offer the advantage of variableangle locked screws facilitate plate positioning to minimize softtissue irritation and screw positioning to secure key articular frag-ments rigidly. Single or even double plate small fragment osteosyn-thesis is a commonly practiced technique and reported in theliterature.6,28 Kirschnerwires and bioabsorbable nails/pins can sup-plement larger internal or external fixation constructs.

In the aforementioned case report, the surgeon selected lowprofile precontoured small fragment plates with variable anglelocked screws. This construct allowed for limited soft tissuedissection and minimal irritation, while offering rigid fixation ofthe anatomically reduced fragments. The distal articular fragmentwas provisionally reduced with clamps and K-wires, and thenstabilized using variable angle locking screws to maintain align-ment. Polyaxial locking screws have been tested and shown to holdfragments comparatively to fixed angle screws in biomechanicalstudies.29

CONCLUSIONPilon fractures present substantial clinical challenges for both

the patient and surgeon. The surgeon-controlled treatment optionsfortunately allow, in part, for improving short- and long-termpatient subjective and objective outcomes. Once the soft tissues

allow for an open approach, the keys to a successful result includeanatomical reduction of the articular surface, restoration of themetadiaphyseal alignment, and rigid fixation to allow for earlymotion. Low profile, precontoured small fragment implants withvariable angle locked screws can facilitate these treatment goals.

REFERENCES1. Helfet DL, Koval K, Pappas J, et al. Intraarticular “pilon” fracture of thetibia. Clin Orthop Relat Res. 1994:221–228.

2. Topliss CJ, Jackson M, Atkins RM. Anatomy of pilon fractures of thedistal tibia. J Bone Joint Surg Br. 2005;87:692–697.

3. Ruedi TP, Allgower M. The operative treatment of intra-articularfractures of the lower end of the tibia. Clin Orthop Relat Res. 1979:105–110.

4. Heim U, Naser M. Operative treatment of distal tibial fractures: techniqueof osteosynthesis and results in 128 patients (author’s transl). Arch OrthopUnfallchir. 1976;86:341–356.

5. Mast JW, Spiegel PG, Pappas JN. Fractures of the tibial pilon. Clin OrthopRelat Res. 1988:68–82.

6. Thordarson DB. Complications after treatment of tibial pilon fractures:prevention and management strategies. J Am Acad Orthop Surg. 2000;8:253–265.

7. Kline AJ, Anderson RB, Davis WH, et al. Minimally invasive techniqueversus an extensile lateral approach for intra-articular calcaneal fractures.Foot Ankle Int. 2013;34:773–780.

8. Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissuemanagement in the treatment of complex pilon fractures. J OrthopTrauma. 1999;13:78–84.

9. Ketz J, Sanders R. Staged posterior tibial plating for the treatment ofOrthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures. JOrthop Trauma. 2012;26:341–347.

10. White TO, Guy P, Cooke CJ, et al. The results of early primary openreduction and internal fixation for treatment of OTA 43.C-type tibial pilonfractures: a cohort study. J Orthop Trauma. 2010;24:757–763.

11. Tang X, Liu L, Tu CQ, et al. Comparison of early and delayed openreduction and internal fixation for treating closed tibial pilon fractures.Foot Ankle Int. 2014;35:657–664.

FIGURE 5. Latest follow-up 6-monthpostoperative ankle radiographs.

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12. Bonato LJ, Edwards ER, Gosling CM, et al. Patient reported health relatedquality of life early outcomes at 12 months after surgically managed tibialplafond fracture. Injury. 2017;48:946–953.

13. Boraiah S, Kemp TJ, Erwteman A, et al. Outcome following open reduc-tion and internal fixation of open pilon fractures. J Bone Joint Surg Am.2010;92:346–352.

14. Carbonell-Escobar R, Rubio-Suarez JC, Ibarzabal-Gil A, et al. Analysis ofthe variables affecting outcome in fractures of the tibial pilon treated byopen reduction and internal fixation. J Clin Orthop Trauma. 2017;8:332–338.

15. De-Las-Heras-Romero J, Lledo-Alvarez AM, Lizaur-Utrilla A, et al. Qual-ity of life and prognostic factors after intra-articular tibial pilon fracture.Injury. 2017;48:1258–1263.

16. Sommer C, Nork SE, Graves M, et al. Quality of fracture reduction as-sessed by radiological parameters and its influence on functional results inpatients with pilon fractures-A prospective multicentre study. Injury. 2017;48:2853–2863.

17. Duckworth AD, Jefferies JG, Clement ND, et al. Type C tibial pilonfractures: short- and long-term outcome following operative intervention.Bone Joint J. 2016;98-B:1106–1111.

18. Harris AM, Patterson BM, Sontich JK, et al. Results and outcomes afteroperative treatment of high-energy tibial plafond fractures. Foot Ankle Int.2006;27:256–265.

19. Kline AJ, Gruen GS, Pape HC, et al. Early complications following theoperative treatment of pilon fractures with and without diabetes. FootAnkle Int. 2009;30:1042–1047.

20. Graves ML, Porter SE, Fagan BC, et al. Is obesity protective againstwound healing complications in pilon surgery? Soft tissue envelopeand pilon fractures in the obese. Orthopedics 2010;33. doi: 10.3928/01477447-20100625-27.

21. Liporace FA, Yoon RS. An adjunct to percutaneous plate insertion toobtain optimal sagittal plane alignment in the treatment of pilon fractures.J Foot Ankle Surg. 2012;51:275–277.

22. Meena UK, Bansal MC, Behera P, et al. Evaluation of functional outcomeof pilon fractures managed with limited internal fixation and externalfixation: a prospective clinical study. J Clin Orthop Trauma. 2017;8(suppl2):S16–S20.

23. Davidovitch RI, Elkhechen RJ, Romo S, et al. Open reduction with inter-nal fixation versus limited internal fixation and external fixation for highgrade pilon fractures (OTA type 43C). Foot Ankle Int. 2011;32:955–961.

24. Korkmaz A, Ciftdemir M, Ozcan M, et al. The analysis of the variables,affecting outcome in surgically treated tibia pilon fractured patients.Injury. 2013;44:1270–1274.

25. Prieto-Alhambra D, Premaor MO, Fina Aviles F, et al. The associationbetween fracture and obesity is site-dependent: a population-based study inpostmenopausal women. J Bone Miner Res. 2012;27:294–300.

26. Chen SH, Wu PH, Lee YS. Long-term results of pilon fractures. ArchOrthop Trauma Surg. 2007;127:55–60.

27. Cole PA, Mehrle RK, Bhandari M, et al. The pilon map: fracture lines andcomminution zones in OTA/AO type 43C3 pilon fractures. J OrthopTrauma. 2013;27:e152–e156.

28. Penny P, Swords M, Heisler J, et al. Ability of modern distal tibia plates tostabilize comminuted pilon fracture fragments: is dual plate fixation nec-essary? Injury. 2016;47:1761–1769.

29. Yenna ZC, Bhadra AK, Ojike NI, et al. Polyaxial screws in locked platingof tibial pilon fractures. Orthopedics. 2015;38:e663–e667.

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Distal Tibia Pilon Fracture

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