Staged Treatment and Associated Complications of Pilon...

Staged Treatment and Associated Complicationsof Pilon Fractures

Frank A. Liporace, MDSamir Mehta, MD

Anthony S. Rhorer, MDRichard S. Yoon, MDMark C. Reilly, MD

Named after its characteristic shape,the pilon or plafond fracture pattern isdefined by intra-articular involvementof the distal tibia with metaphysealextension.1-3 Although pilon fracturesaccount for only a small percentage oftibial and lower extremity injuries,more than 30% of pilon fractures arecaused by high-energy injury mecha-nisms and are often associated withconcomitant polytrauma with thepresence of open wounds, deglovinginjuries, and severe soft-tissue trauma.These circumstances make injurymanagement difficult.4-9

Historically, treatment involvedearly acute open reduction and inter-nal fixation (ORIF), which led to dis-mal clinical outcomes and high com-plication rates4,6,8,10-13 (Table 1). In

Dr. Liporace or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy, Osteotech, Synthes, and Smith &Nephew; serves as a paid consultant to DePuy, Osteotech, Synthes, Smith & Nephew, and Stryker; serves as an unpaid consultant to AO North America; and has receivedresearch or institutional support from Synthes, Smith & Nephew, and Acumed. Dr. Mehta or an immediate family member is a member of a speakers’ bureau or has madepaid presentations on behalf of Zimmer, Smith & Nephew, and AO North America; serves as a paid consultant to Smith & Nephew and Synthes; has received research orinstitutional support from Amgen, Medtronic, and Smith & Nephew; and serves as a board member, owner, officer, or committee member of the Pennsylvania Orthopae-dic Society. Dr. Rhorer or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew; serves as a paidconsultant to Smith & Nephew; has received research or institutional support from Smith & Nephew; and has received nonincome support (such as equipment or services),commercially derived honoraria, or other non–research-related funding (such as paid travel) from Synthes. Neither Dr. Yoon nor any immediate family member has re-ceived anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this chapter. Dr. Reilly or an immediatefamily member is a member of a speakers’ bureau or has made paid presentations on behalf of Synthes, Smith & Nephew, and Stryker; and serves as a board member, owner,officer, or committee member of the AO Foundation.

AbstractHistorically, the treatment and outcomes related to pilon fractures have been vari-able despite anatomic reduction and fixation. Early results with treatment viaearly primary open reduction and internal fixation yielded mixed clinical out-comes, especially suboptimal complication rates, including infection, malunion,and nonunion. Treatment with external fixation also exhibited similar outcomeswith mixed support reported in the literature. Despite continued controversy, theadvent of newer implant technologies, improved surgical techniques, and manage-ment with a staged protocol have resulted in encouraging clinical outcomes withminimization of postoperative complications. Crucial decisions made during treat-ment can help to maximize outcomes while minimizing complication rates. Par-ticular attention to the fracture pattern with radiographic guidance can help directsurgical decision making with appropriate care given to optimize soft-tissue status.A variety of available incisions can facilitate proper bony and articular reduction.During the late and failed stages of fracture management, additional treatmentoptions include external ring fixation, arthrodesis, and arthroplasty. As complica-tions arise, meticulous, prompt care can help to achieve the best possible outcomes.

Instr Course Lect 2012;61:53-70.

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© 2012 AAOS Instructional Course Lectures, Volume 61 53

Table 1Summary Regarding Treatment and Complications for Pilon Fractures

Author (Year) Management/TreatmentNumber ofFractures Reported Complications and Rates

Bourne et al4 (1983) Primary ORIF 42 Infection: 4.8%Nonunion/malunion: 33%

Teeny and Wiss13 (1993) Primary ORIF 60 Major complication: 50% (at least one of the follow-ing: skin slough, wound dehiscence, infection, non-union, malunion, or implant failure)

Helfet et al6 (1994) Primary ORIF 34 Pin tract infection: 2.9%Deep infection: 5.9%Malunion: 8.8%

White et al33 (2010) Primary ORIFWithin 48 hours: 98%

95 Wound dehiscence or deep infection: 6%Delayed or nonunion: 6%

Marsh et al18 (1991) External fixation (unilateral) 101 Reoperations: 5%Infection: 6%Loss of reduction during external fixation: 21%Malunion: 3%

Tornetta et al19 (1993) Limited internal fixation, hy-brid external fixation

26 Superficial infection: 3.8%Deep infection: 3.8%Pin tract infection: 12%Malunion: 3.8%

Bone et al16 (1993) Delta-framed externalfixation

20 Infection: 0%Delayed union/nonunion: 15%Malunion: 4.8%

Barbieri et al15 (1996) Hybrid external fixation 37 Skin slough: 2.7%Pin tract infection: 13.5%Deep infection: 8.1%Nonunion: 8.1%Loss of reduction during external fixation: 8.1%

Wyrsch et al20 (1996) Randomized controlled trial:primary ORIF versus ex-ternal fixation (with andwithout limited internalfixation)

ORIF: 18External fixation: 20

ORIF:wound dehiscence/infection: 67%amputation: 17%

External fixation:nerve injury: 5%pin tract infection: 5%deep infection: 5%malunion: 5%

Anglen14 (1999) Comparative, ORIF versushybrid external fixation(some soft-tissue optimiza-tion in both groups viatemporizing external fixa-tion)

ORIF: 19External fixation: 29

ORIF:amputation: 5.3%skin slough: 5.3%sensory deficit: 5.3%

External fixation:wire site infection: 24%half-pin site infection: 10.3%wound healing problems: 10.3%tethered flexor tendon: 3.4%nerve deficit: 3.4%nonunion: 21%

Sirkin et al67 (1999) Staged protocol, soft-tissueoptimization

Closed: 30Open: 19

Closed:partial-thickness skin necrosis: 17%osteomyelitis: 3.4%

Open:wound dehiscence: 5.2%osteomyelitis: 5.2%

Patterson and Cole31

(1999)Staged protocol, soft-tissue

optimization22 Infections/soft-tissue complications: 0%

Malunion: 4%Nonunion: 4%

Grose et al5 (2007) Staged protocol, soft-tissueoptimization, lateral ap-proach study

44 Deep infection: 4.5%Wound dehiscence: 4.5%Nonunion: 9%

Boraiah et al69 (2010) Staged protocol, soft-tissueoptimization

59 (all open) Amputation: 1.7%Deep infection: 3%Superficial infection: 5%

ORIF = open reduction and internal fixation.

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54 © 2012 AAOS Instructional Course Lectures, Volume 61

an effort to minimize soft-tissue com-plications, limited approaches andtreatments involving external fixationresulted in minimal improvement andgenerated little enthusiasm.13-21 How-ever, with the implementation of a de-layed, staged surgical treatment proto-col, along with improvements inimaging, implant technology, and sur-gical technique, complication rateshave decreased with a coinciding im-provement in clinical and functionaloutcomes.5,7,9,22-32 Although it hasbeen suggested that early definitiveORIF can achieve results comparableto those of staged protocols, it shouldbe stressed that definitive ORIFshould be performed by experiencedtrauma surgeons and may not be ap-propriate in all cases.33 Experts haveindicated that a delay in definitivetreatment is necessary for some pa-tients.33 In the late and failed stages oftreatment, options become more lim-ited as complications, including infec-tions, malunions, and nonunions, be-come more prevalent and difficult tomanage. At this juncture, external fixa-tion, ankle arthrodesis, and ankle ar-throplasty become more viableoptions.34-46

This chapter reviews the currentstate of the decision-making process,staging, and the choice of surgical op-tions for the definitive treatment of pi-lon fractures and associated complica-tions, especially in the late and failedstages of fracture management.

Imaging and ClassificationInitial assessment and thorough preop-erative planning begins with radio-graphic imaging. Analysis of the frac-ture pattern is performed with thethree standard views of the ankle (AP,lateral, and mortise), along with cen-tered, orthogonal views above and be-low the joint, which are needed be-cause of the high rate of concomitantpolytrauma in patients with pilon frac-

tures. Full-length tibia and fibula ra-diographs can provide information ongeneral alignment.2,4,9,10 In select pa-tients, radiographs of the contralaterallimb also can be helpful to provide atemplate for reconstruction for morecomplex pilon fractures and detect anypreexisting anatomic or congenitalvariants that indicate a different “nor-mal” baseline.

Theoretically, fracture classificationsystems are a tool for communicationand providing information relative totreatment decisions and prognoses;however, to achieve those goals, thesystem must allow consistent, reliable,and reproducible classification of vari-ous fracture patterns. Rüedi and All-göwer12 offered the original founda-tion for pilon fracture classification,indicating three fracture types that in-creased in severity from low-energy,nondisplaced fractures of the tibia pla-fond to high-energy, severely commi-nuted and impacted articular fracturepatterns. However, poor reliability andagreement have been reported.47-49

Based on plain radiographs alone,Martin et al48 reported poor interob-server reliability of the Rüedi and All-göwer classification system, with meankappa values of 0.46 for all observers,0.38 for more experienced observers,and 0.56 for less experienced observ-ers. Similarly, Dirschl and Adams47 re-ported a mean kappa value of 0.46,which indicated poor reliability. Re-moving the data from third-year resi-dents resulted in a slight increase in thekappa value to 0.52.

Minimal improvements to classifi-cation agreement were observed withthe development of the AO/Orthopaedic Trauma Association(OTA) classification system. Despiteexhibiting higher reliability than theRüedi and Allgöwer system, only mod-erate agreement between observers hasbeen reported.12,47,48,50 Regardingfracture type, group agreement, and

subgroup agreement, Swiontkowskiet al50 reported only modest values,with agreement occurring 57%, 43%,and 41% of the time, respectively. De-spite the use of CT, Ramappa et al49

reported similar reliability and agree-ment values for both the Rüedi andAllgöwer and AO/OTA classificationsystems.

Realizing the inherent difficulty instratifying outcomes based on unreli-able classification systems, DeCosteret al51 developed a rank order method,classifying patients based on injury se-verity and reduction quality. The re-sults exhibited 94% agreement inranking the severity of the articularsurface, 89% agreement in ranking theseverity of the fracture pattern, 89%agreement in ranking the reductionconsidering only the articular surface,and 88% agreement in ranking the re-duction when considering the entirefracture pattern.

Although orthopaedic surgeonsmight not agree on the specific classifi-cation of the pilon fracture patternpresented, there is reliably high agree-ment on assessing the severity of theinjury and in determining the qualityof a poor or good fracture reduction.

Decision Making in theInitial PeriodManagement in the immediate periodfollowing a pilon fracture should focuson expedited medical optimizationand clearance and soft-tissue stabiliza-tion. Important considerations includethe presence of an open wound and/ora vascular injury.52,53 A history of dia-betes or smoking also may be a crucialconsideration in decision making andin avoiding potential wound complica-tions.11,33,54,55 In patients with pri-marily indirect ankle fractures andcomplicated diabetes (diabetes associ-ated with end organ damage), Wukichet al56 reported a 3.8 times increasedrisk of overall complications and a

Staged Treatment and Associated Complications of Pilon Fractures Chapter 5


5 times increased risk of revision sur-gery when compared with patientswith ankle fractures and tightly con-trolled diabetes. A recent meta-analysisanalyzing 6 randomized trials and 15observational studies reported a signif-icant decrease in total complications,wound complications, and pulmonarycomplications with prolonged smok-ing cessation.55

The amount of energy absorbed inthe fracture is indicated by the degreeof comminution, the Tscherne class ofinjury, and the presence of significantopen wounds or a fibular fracture. Thepresence of a fibular fracture providesclues into the mechanism of injury andfracture pattern.57 A fibular fracturetypically is associated with higher en-ergy injuries; however, if the injury isknown to have been caused by a high-energy mechanism, the presence of thefracture contributes information onthe direction of the mechanism (typi-cally a valgus and an axial load).57

Conversely, the absence of a fibularfracture or a tension failure of the fib-

ula is associated with an injury patterncaused by a varus and an axial load.57

Following medical clearance andbefore definitive fixation, temporizingthe extremity and restoring the me-chanical axis, length, and alignmentare pivotal to soft-tissue stabilization.Dunbar et al58 described a techniquethat offered early, limited ORIF forAO/OTA type C fractures that typi-cally present with a long, obliquemetadiaphyseal spike. The authorspresented data to suggest that early,limited restoration of length, align-ment, and rotation with ORIF of theoblique fracture spike not only pro-vides soft-tissue protection but alsohelps to simplify later definitive recon-struction without an increase inwound breakdown or complications(Figure 1).

It has been popularized that acutefibular fixation provides safe restora-tion of length in the initial periodwithout an increased risk of complica-tions.7,53 However, preoperative plan-ning, including determination of the

“workhorse” surgical incision is of par-amount importance, especially whenconsidering additional incisions withan appropriate skin bridge.7,33,59

Many surgeons have recommended aminimum 7-cm skin bridge to mini-mize soft-tissue and wound complica-tions.45,60,61 However, in a recent pro-spective study using at least two skinincisions with an average width of5.9 cm, Howard et al59 reported a lowrate of soft-tissue complications in 42patients with 46 pilon fractures. In es-sence, the “workhorse” incision is themain distal tibial incision that will al-low definitive ORIF, even if smallerancillary incisions are used.7 However,it is important to understand that theratio of the length of the incision tothe width of the skin bridge is directlyrelated to the soft-tissue complicationrate.7

If the surgeon is unsure of thelength of the “workhorse” incision or isnot providing definitive treatment, itmay be prudent to defer fibular fixa-tion until an external fixator has beenplaced to restore the general mechani-cal axis and length and obtain a CTscan. In such instances, the applicationof a simple joint-spanning external fix-ator can achieve the initial goals anddecrease the initial surgical time (Fig-ure 2). This chapter’s authors typicallyuse a delta frame construct with two5.0-mm pins in the tibial shaft placedout of the zone of injury and a 6.0-mmcalcaneal transfixation pin in the pos-terior tuberosity of the calcaneus. Pos-terior splint supplementation or sup-plementary 4.0-mm metatarsal pinsattached to the main delta frame canbe used to maintain a plantigrade footand avoid anteriorly prominent meta-physeal spikes of bone, which maycause deep soft-tissue pressure whilewaiting for definitive internal fixa-tion.7,13,15,16,18,19,61

Knowledge gained during the pastfive decades makes it compelling to

Figure 1 Preoperative (A) and postoperative (B) radiographs showing res-toration of length, alignment, and rotation with ORIF to protect soft tissues,and simplify the pilon fracture for later definitive reconstruction.

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consider using multiple small incisionsand staging definitive fixation proce-dures from the time of the initial exter-nal fixator application. This may re-quire more than two total proceduresbased on the experience of this chap-ter’s authors and is relative to the qual-ity of the soft tissue. This may be thebest method to decrease complicationsand potentially improve outcomes forpatients with these injuries.

The anatomic placement of fixatorpins is paramount. Proximally, pinplacement should be just distal to thetibial tubercle to avoid the proximalmetadiaphyseal extent of the zone ofinjury, which will require surgical ma-nipulation at the time of the definitiveprocedure. Distally, pin placementmay be transcalcaneal to construct adelta frame or medially through the ta-lar neck and the medial calcaneus (Fig-ure 3). The lateral plantar nerve, themost posterior lateral plantar nerve,and the medial calcaneal nerve shouldbe avoided during transcalcaneal exter-nal fixator pin placement.62 When

considering medially based externalfixators, close monitoring of the statusof the medial talar neck pin is neededbecause infection in this pin may causecontamination within close proximityto the distal tibial incisions or the an-kle joint.

Decision Making forSurgical TimingIt had been suggested that definitivesurgical management within 6 hoursof injury can be safe. However, on re-evaluation and in the setting of high-energy injury mechanisms, ORIF un-dertaken in the acute period hasyielded suboptimal results with highcomplication rates and poor clinicaloutcomes.4,10-13,61 It has been shownthat the risks of soft-tissue impairmentcaused by inflammatory processes ishighest for up to 6 days after injury.63

Proponents of definitive externalfixator constructs have cited slightimprovements.14-16,20 In a prospec-tive, randomized study comparing ex-ternal fixation to ORIF, Wyrsch et al20

reported superior results in the cohorttreated with external fixation; however,the ORIF cohort was operated onwithin 3 to 5 days of injury, whereas

the external fixator cohort with limitedopen fixation was definitively treatedmore than 7 days after injury.20 Theimportance of soft-tissue managementhas been emphasized.64,65 The Tsch-erne soft-tissue classification systemoffers graded indicators of severe soft-tissue damage ranging from minimalsuperficial abrasions and degloving in-juries to deep muscular and subcutane-ous fat contusions, vascular injury, andcompartment syndrome.64 Despite de-termining two safe surgical win-dows—an early period within 6 hoursafter injury and a late period between 6and 12 days after injury—surgery dur-ing this high risk period still exhibitedconsistently high complication ratesand subpar clinical results.13,20,64-66

Staged management protocols haveyielded improved results, with lowercomplication rates and improved clini-cal outcomes.5,7,30,67 Sirkin et al,7 us-ing a staged protocol that consisted ofacute external fixation and delayed de-finitive reconstruction, placed particu-lar focus on soft-tissue optimization.The authors waited from 7 to 14 daysfor edema to subside, as indicated bysubsidence with the presence of skin

Figure 2 A spanning external fix-ator can help achieve the initialgoals of restoring the mechanicalaxis and length and stabilizing thebone as the soft-tissue swellingsubsides.

Figure 3 AP (A) and lateral (B) radiographic views of a pilon fracture afterexternal fixation.



wrinkling.7 Applying this staged pro-tocol on the management of 56 pilonfractures, the authors reported twodeep infections and the healing of allsurgical wounds, which representedcomplication rates significantly lowerthan those of previous reports.7,13,20

The presence of blisters, which oc-cur at a relatively high rate in pilonfractures, offer clues to the timing ofdefinitive management.20,68 In pa-tients with blood-filled blisters, whichindicate a complete separation of thedermis from the epidermis, Giordanoand Koval68 recommended waiting forfull reepithelialization before surgicalintervention. Resolution of edema isoften indicated by the absence of shinyskin, with normal skin creases or wrin-kles predominately exposed. Stagingtreatment and waiting for soft-tissueoptimization has achieved favorable re-sults in a more recent study that evalu-ated ORIF in open 59 pilon frac-tures.69 Boraiah et al69 reportedexcellent clinical outcomes at a mini-mum 2-year follow-up with 88%union and 9% delayed union, withonly three deep infections, two super-ficial infections, and one amputationafter a failed free-flap transfer.

Despite the success of the stagedprotocol, some surgeons remain pro-ponents for early ORIF. White et al33

performed ORIF within 48 hours in95 patients with tibial pilon fracturesand reported good clinical outcomes at1-year follow-up. The authors reportedan overall 19% complication rate inopen and closed type C fractures andexcluded fractures with “local soft-tissue factors” that were not specificallydefined. In closed fractures, the com-plication rate was only 2.7%. Of note,the authors stress that the proceduremust be done in “the right setting” andthat all the resources must be available.They advise that early ORIF shouldnot be done if resources are not avail-

able or if the patients present late orbeyond an early treatment window.The authors suggest that medical judg-ment is needed.33 It is important tonote that the study included only pa-tients who were deemed appropriatefor the procedure; no guidance wasprovided on the criteria used to selectsuitable patients.

When planning for definitive fixa-tion, CT is an invaluable tool. To bestdefine the articular fragments and thedefinitive surgical approaches that maybe required, this chapter’s authors rec-ommend that a CT scan should be ob-tained after external fixation is used torestore the length and mechanical axisof the extremity. Acquiring appropri-ate length with temporizing externalfixation will disimpact the talus fromthe distal tibia and allow for better vi-sualization of the articular injury.

Information on the specific areas ofarticular involvement, comminution,and impaction not seen on plain radio-graphs can be seen on CT scans32 (Fig-ure 4, A and B). Tornetta and Gorup32

studied the impact of CT on the man-agement of pilon fractures and re-ported that information from CTchanged management decisions in64% of the patients. The operatingsurgeons reported that information de-rived from the CTs bettered their un-derstanding of the fracture pattern in82% of patients and shortened the sur-gical time in 77% of patients.32 Analy-sis of the surrounding soft tissues viasoft-tissue windows on the CT scansalso can provide valuable information,such as potentially entrapped tendi-nous or neurovascular structures (Fig-ure 4, C and D).

Decision Making forDefinitive ManagementOver the past 40 to 50 years, the origi-nal principles set forth by Rüedi andAllgöwer12 concerning pilon fracturemanagement and reconstruction have

not drastically changed.70 The treat-ment algorithm, which emphasizes res-toration of length with fibular recon-struction, reconstruction of themetaphyseal shell and articular joint,bone grafting, and a medial buttress tostabilize the metaphysis to the diaphy-sis reconstruction, still applies. Someadvances in surgical approach op-tions and implant technology havehelped surgeons achieve thosegoals.5,22,24,26-29,58,71

Standard ApproachThe standard approach to the tibialplafond is described as a two-incisiontechnique—an anteromedial incisionfor the tibia and a posterolateral inci-sion for the fibula.12,70,72 However,depending on preoperative planningwith CT identification of the majorfracture fragments and lines and re-membering to use an adequate skinbridge, additional surgical approachescan be used to maximize exposureand address specific articularissues.7,27-29,32,59

Anterior ApproachesAnterior approaches to the tibial pla-fond are based on the principle of re-construction from posterior to anteriorafter “opening the book.”71-73 Use ofthe posterolateral (Volkmann) frag-ment as the “constant fragment” oftenrelies on the assumption that the fib-ula was anatomically and stably re-duced in terms of alignment, length,and rotation.2,73 Each anterior ap-proach (anteromedial, anterolateral,and direct anterior) has unique advan-tages and disadvantages.

With any of the anterior ap-proaches, an external fixator or femo-ral distractor can be helpful to aid inevaluating and reducing articular frag-ments (Figure 5). It should be remem-bered that relative to the midsagittalplane of the tibia, the position of thetranscalcaneal pin in a delta frame can

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cause a dorsiflexion moment of thefoot with significant attempted dis-traction. This can inhibit direct visual-ization of the joint when there issignificant anterior or central commi-nution. When the femoral distractor isapplied with a pin in the talar neck anda pin in the tibia, a plantar flexion mo-ment will yield excellent visualizationof the joint; however, after the articularsurface is stabilized, excessive distrac-tion must be removed to allow appro-priate reduction of the metadiaphyseal

component that may have been de-formed in the sagittal plane with thedistractor. When applying the distrac-tor, care must be taken to have the ta-lar neck pin parallel to the superiordome of the talus to avoid “dialing-in”a coronal plane deformity.

Anteromedial ApproachThe classic anteromedial approach de-scribed by Tile is typically used forAO/OTA type 43B and C frac-tures.6,61,70,72,73 Starting approxi-

mately 5 cm proximal to the tibiotalarjoint line and just lateral to the tibialcrest, the anteromedial incision can ex-tend distally to form around the medi-al malleolus or continue distally withthe tibialis anterior tendon toward thetalonavicular joint.2,73,74 Care must betaken to avoid violating the tibialis an-terior tendon sheath because, unlikethe tendon itself, it will readily acceptgrafts (especially in the case of wounddehiscence).75 Preservation of the peri-osteum in an already vascularly tenu-ous area is a high priority. Althoughthis incision offers good access for me-dial and anterior hardware application,it does not allow ready access to the an-terolateral (Tillaux-Chaput) frag-ment71,73 (Figure 6).

Anterolateral ApproachThe Böhler anterolateral approach tothe tibial plafond allows direct accessto the Tillaux-Chaput fragment left bythe anteromedial approach.22,27 De-pending on concomitant foot and an-kle injuries, the approach can be ex-tended to provide direct visualizationof the anterior talar dome and talarneck and lateral talonavicular, subtalar,and calcaneocuboid joints.27 The inci-sion is in line with the fourth metatar-sal when the foot is in neutral dorsi-flexion, and it starts 5 cm proximal tothe tibiotalar joint.27 Identifying andprotecting the superficial peronealnerve branches are imperative.27 Theorigin of the extensor digitorum brevisis divided, reflecting it distally. Thedorsalis pedis and the deep peronealnerve are reflected medially, and thecapsule is incised to provide access tothe ankle joint. Herscovici et al27 de-scribed this incision, noting that, ifneeded, the incision could be extendedin both the proximal and distal direc-tions with maintenance of straightfor-ward closure and without an increasein wound complications. Althoughsome surgeons have criticized the

Figure 4 Surgical planning can be enhanced as degrees of comminution,impaction, or displacement not seen on a plain radiograph (A) can be seen ona CT scan (B). Bone windows (C) may be enhanced with soft-tissue windows(D), which may reveal entrapped tendinous or neurovascular structures suchas the posterior tibialis tendon and flexor digitorum longus tendon (arrow).



approach because of a lack of access toposterior fracture elements, Mehta etal30 described successful total articularreconstruction with a bony distractor,headlamp, and intraoperative imagingvia the anterolateral and a second moremedially based incision. Grose et al,5

using an alternative extensile approachfrom the lateral plafond and crossingmedially to reach the anterior, reportedgood results and low complicationrates, especially regarding deep infec-tion (4.5%) and wound dehiscence(4.5%).

Direct Anterior ApproachThe direct anterior approach can pro-vide access to both the anteromedialand anterolateral fragments of a pilonfracture with a straightforward linearincision centered over the tibiotalarjoint. The approach is centered be-tween the malleoli, with protection ofthe superficial peroneal nerve. The in-cision is developed between the exten-sor digitorum longus (EDL) and ex-tensor hallucis longus (EHL), with

protection of the deep neurovascularbundle using medial retraction. Tradi-tionally used for ankle arthrodesis, thedirect anterior approach can be used totreat pilon fractures and, if necessary,for future fusion (Figure 7). In a re-cent retrospective review of 49 pilonfractures, McCann et al76 reported lowcomplication rates with minimal soft-tissue disturbance with the direct ante-rior approach.

Posterior ApproachesPosterior approaches to the pilon areused in select situations when the goalscannot be accomplished using the an-terior approaches. Of note, direct ar-ticular reduction is not possible andrelies on cortical reduction and fluoro-scopic assistance.29,65,77 Benefits of theposterolateral incision are its use in re-building the constant fragment, espe-cially if it has significant impactionand/or rotation2,29,73 (Figure 8). Re-building the constant fragment alsocan convert a C-type fracture to aB-type fracture. The surgeon can usean anterior approach to rebuild theplafond from posterior to anterior.58

Attention must be given to correcting

the sagittal plane deformity of articularfragments because direct joint visual-ization is not possible with the poster-ior approach; the surgeon must rely onfluoroscopic and direct cortical read-ings.

Posterolateral ApproachThe posterolateral approach, which ex-ploits the interval between the lateraland the posterior compartment mus-culature, was believed to offer a lowercomplication rate;2,29,73 however,Bhattacharyya et al77 noted a highcomplication rate with this approach,including nonunions and wound heal-ing problems leading to fusions andsuboptimal clinical outcomes. Ofnote, the authors attempted completefixation tibial pilon fractures throughthe one surgical approach.77 When re-quired, the posterolateral tibia can beaddressed between the peroneus lon-gus and the flexor hallucis longus,while the fibula can be addressed pos-teriorly by going anterior to the per-oneus brevis.

Posteromedial ApproachThe posteromedial approach is helpfulwhen treating tendon or neurovascularbundle entrapment.28 The incision ismade at the midpoint between the me-dial malleolus and the posteromedialaspect of the Achilles tendon. Identifi-cation of the tendinous and neurovas-cular structures is paramount to allowsafe development of intervals based onthe fracture pattern. Using both a pos-teromedial and a posterolateral ap-proach on the same patient should bedone with caution because of the rela-tive proximity of the approaches andthe need for extensive deep surgicaldissection. Typically, most of the pos-terior aspect of the distal tibia can beaddressed through either approach; thearea requiring more direct manipula-tion should be chosen. In select situa-tions when a small window is required

Figure 5 With an anterior ap-proach, a femoral distractor or anexternal fixator can assist in achiev-ing length and visualization. How-ever, important consideration mustbe paid to the potential plantar flex-ion moments (right arrow) or dorsi-flexion moments (left arrow) whenmanipulating along the midsagittalaxis (central line).

Figure 6 The anteromedial inci-sion offers access for medial andanterior hardware application, butdoes not allow ready access to theanterolateral (Tillaux-Chaput)fragment.

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for the placement of a reduction aid,the use of both approaches can be con-sidered.

DiscussionThe multitude of surgical approachesand advancements in small fragment,mini-fragment, and bioabsorbable fix-

ation have provided improvements inspecifically treating articular fragmentsin previously unreconstructablefractures.22-25,28,29,53,78 Locking-plateconstructs may obviate the need forbone grafting in select patients andprovide added stability in patients withcomminuted fractures or osteoporo-

sis.2 Such fixed-angle constructs canhelp decrease the number of plates re-quired based on the fracture patternand comminution while providing ad-equate stability to allow for protractedhealing.

Future implant modifications mayfurther improve the clinical results.

Figure 7 The direct anterior approach can be used to treat pilon fractures. A, An incision should be made at the cen-ter of the mortise, providing access to the anteromedial and anterolateral aspects of the joint. The branches of thesuperficial peroneal nerve should be avoided, and the extensor retinaculum should be incised. B, Intervals include theEHL/tibialis anterior, EHL/EDL, and the EDL/peroneus tertius. Note that proximal to the tibiotalar joint, the neurovascularbundle lies between EHL/tibialis anterior but distal to the tibiotalar joint. The bundle lies between the EHL and the EDL.The anterior ankle capsule and the intra-articular fat is excised to expose the joint. C, At times, the fracture pattern andlocation can dictate the use of a direct anterior approach. AP (D) and lateral (E) radiographs of definitive ORIF via a di-rect anterior approach. Using the direct anterior approach can help facilitate future ankle fusion if needed.



The role of intramedullary nailing(IMN) for pilon fractures has not beenextensively studied. In a study of theresults of IMN for distal tibial frac-tures, Vallier et al79 found complica-tion and union rates comparable toplating. When considering limitedORIF with IMN for fixation of frac-tures of the plafond, careful study ofthe CT scan and understanding thefracture is imperative. Stable articularreduction and independent screw fixa-tion are required, while leaving accessfor appropriate placement of an IMN.This technique is recommended onlyfor simple articular fractures withoutimpaction when performed by an ex-perienced surgeon. The metaphyseal

defects should be addressed primarilywith bone graft to limit the risks fornonunion.40,80 However, in select pa-tients with “unreconstructable” pilonfractures, severe soft-tissue injuries, orsignificant comorbidities precludingsafe direct fixation, external ring fixa-tion can be considered.

External Ring FixationThe application of external ring fixa-tion for pilon fractures requires carefulpatient selection, extensive knowledgeof fixation constructs, familiarity withthe ring fixation system being used,comprehensive knowledge of thecross-sectional anatomy, and diligentpostoperative maintenance.41 External

ring fixation can serve as a limb-salvagetechnique in scenarios where extensiveinternal fixation is not an option andthus should be used judiciously.34,81

External ring fixation for pilon frac-tures is indicated if the patient is notamenable to standard stable internalfixation or in the setting of combinedlimited ORIF.46,81,82 Ring fixation isbest suited to patients with severe soft-tissue injuries who are not candidatesfor plastic reconstructive surgery, suchas free vascularized muscle transfers orrotational flaps. Ring fixation is also anexcellent modality for late reconstruc-tion and salvage of pilon fractures withsegmental bone loss, infection, andpreexisting deformity.83 Advantages ofring fixation in pilon fracture manage-ment include earlier weight bearing,the ability to make postoperative frameadjustments, better soft-tissue man-agement, and no complications relat-ing to retained hardware.84

Many parts and components mustbe assembled to build a stable con-struct. Pilon fracture frames will typi-cally consist of two rings. The proxi-mal ring should always be placed abovethe zone of injury, which can be in theproximal third of the tibia. This ringcan be stabilized to bone with bicorti-cal half pins or fine wires. The entireinner surface of the ring should be atleast 3 cm from any skin or soft tissueto allow adequate expansion afterswelling. Half-pin and thin wire place-ment techniques are of utmost impor-tance. Improperly placed pins andwires will result in loosening, soft-tissue infection, and potentially evenosteomyelitis. A small stab incisionlarge enough to allow placement of thedrill tip, followed by careful drilling ofboth cortices of bone is imperative.Bone should not be drilled so aggres-sively as to allow smoke or burnt bone.Irrigation and cleaning of the drillflutes should be done frequently toprevent necrosis of the bone around

Figure 8 A and B, The posterolateral incision allows for reconstruction ofthe constant fragment, especially if it has significant impaction and/or rotation.Derotation (C) and rebuilding (D) of the constant fragment with limited fixationcan act as a bridge to staged anterior ORIF.

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the edge of the hole. Once the proxi-mal ring has been fastened to the halfpins, the distal ring may be appliedaround the fracture. The metaphysealbone is often not amenable to half-pinfixation secondary to comminutionand bone destruction. The distal seg-ments therefore are held by thin wiresat an optimal 60° angle from one an-other. If internal fixation of the joint isnot used, the articular surface can bereduced and stabilized with olive wires.The olive wires are tensioned from oneside and create a vector of force thatcompresses the bone fragments togeth-er (Figure 9). Similarly, olive wires andsmooth wires can be used to suspendthe metaphyseal bone and the jointsurface under the diaphysis in the cor-rect anatomic and mechanical axis.

Regardless of the decision to fix thejoint either with minimal internal fixa-tion or with wires alone, it is alwaysnecessary to perform an open reduc-tion of the joint with the goal of ana-tomic reduction. In cases where thereis severe comminution of the joint andmetaphysis and fixation with thinwires is tenuous, the application of afoot plate can be helpful. The footplate is connected to the distal ring,and the hind foot and forefoot are con-nected to the foot plate using thinwires and olive wires. The foot shouldbe held in a plantar-flexed position, es-pecially during application of the fore-foot wires.

Many ring fixation systems offer0.5 rings and 0.625 rings that can beused to afford access to soft tissue andallow movement of the ankle joint. Forexample, a 0.625 ring can be placedwith the open portion over the dorsumof the foot, thus allowing the patientto dorsiflex the ankle without imping-ing on the ring. Similarly, a ring open-ing can be oriented to allow access to asuture line, a traumatic wound, or amuscle flap.

Delicate, meticulous management

in the postoperative period followingring fixation is crucial to a successfuloutcome. Compressive dressings areapplied, and the patient is kept on bedrest for 48 hours, with strict elevationof the extremity. Intravenous antibiot-ics should continue for 24 hours post-operatively, and appropriate thrombo-embolic prophylaxis should be used.On postoperative day 2, pin careshould begin. Daily showering of theexternal fixator with soap and waterfollowed by scrubbing the pin siteswith povidone iodine or chlorhexidineis safe and effective. Hydrogen perox-ide is not recommended for pin care.Weight bearing in the frame shouldtake place only after there is radio-graphic evidence of union of the artic-ular fracture, which can occur as earlyas 8 weeks. Close follow-up in the first6 to 12 weeks is necessary to preventpin tract infections and noncompli-ance with frame maintenance.

Initially, radiographs should bemade every 2 to 4 weeks to ensure thatthere is no loss of reduction or migra-tion of wires through comminuted

bone. To prevent loss of a pin or a wire,pin tract infections should be treatedwith oral antibiotics, with coverage forstaphylococcus, and monitored closely.In infections that are recalcitrant tooral antibiotics, pins and wires shouldbe removed to prevent the develop-ment of osteomyelitis. If a frame isneeded for more than 3 months, atleast one pin or wire should be re-moved during the course of treatment.Despite the scarcity of data, with me-ticulous care and proper management,external ring fixation can provide a via-ble treatment option in the setting ofsalvage, a pilon fracture with severesoft-tissue injury, or in the late orfailed stages of definitive fracture man-agement.

Decision Making forManaging ComplicationsThere are many potential complica-tions resulting from the surgical treat-ment of tibial pilon fractures.45,85

Early complications of the definitivemanagement of pilon fractures includesurgical wound dehiscence, postopera-

Figure 9 A, Olive wires can be tensioned from one side using a tensioner(shown as box) to create a vector to assist in bone compression. B, The boneafter compression.



tive infection, malreduction, and lossof fixation.45 Late complications in-clude chronic infection, nonunion,malunion, and posttraumatic arthri-tis.45 Infection is potentially the mostdevastating complication.86

In the early postoperative period,the most common wound complica-tion is superficial surgical wound ne-crosis without dehiscence.45,87 Thiscondition can be treated with standardlocal wound care and soft-tissue restwith temporary splint or cast immobi-lization. If associated with wound ery-thema, there may be a role for systemicoral antibiotics. Wound culture of thepartial thickness skin slough is notgenerally indicated and will likely re-sult in only normal skin flora beingisolated. Close observation of thewound is required to expeditiouslyidentify a deep wound infection.86

If a surgical wound dehiscence isidentified, the patient should betreated with urgent surgical débride-ment.86 The tenuous soft-tissue enve-lope surrounding the distal tibia oftenmakes reclosure of the surgical woundunlikely. The wound should becleansed, deep cultures taken, and thestability of the fracture implants as-sessed. Although grossly loose and in-competent implants should be re-moved, bone stability is critical tocontrolling the integrity of the soft tis-sues, and competent hardware shouldbe retained. There may be a role fornegative-pressure wound managementif the surgical wound cannot be fullyapproximated.45

Deep wound infection also requiressurgical treatment, frequently with se-rial irrigation and débridement proce-dures performed every 48 to 72 hoursuntil no further purulence is identifiedand no devitalized or necrotic tissue ispresent.45,87 Negative-pressure woundmanagement or local antibiotic ther-apy with impregnated polymethylmethacrylate beads is used in combi-

nation with systemic antibiotic ther-apy based on the findings from thewound cultures. Typically, systemicantibiotics are given for 6 weeks, fol-lowed by serial erythrocyte sedimenta-tion rate and C-reactive protein analy-ses to guide the appropriate durationof the therapy. Definitive soft-tissuemanagement with rotational or free-tissue transfer may be needed; a sur-geon familiar with such proceduresshould be consulted early in the treat-ment process to appropriately coordi-nate the reconstruction.88

Late or chronic infections after pi-lon fracture surgery are generally asso-ciated with osteomyelitis and contami-nated surgical implants.45 Theimplants usually cannot be retained ifsuccessful sterilization of the bone is tobe achieved. All devitalized and ne-crotic bone should be removed. Corti-cal saucerization with a high-speedburr should be performed, and a thor-ough bony débridement may requirereaming of the intramedullary canal.Large bony defects may be filled withan antibiotic-impregnated cementspacer.45,87 In rare instances of grossosseous instability, hardware may beexchanged or retained; removal of thehardware with spanning external fixa-tion also can be considered until theinfection has subsided and definitiveinternal fixation can be reapplied.

Malunions or nonunions after pi-lon fracture surgery may pose complexreconstructive problems.86,89 The de-formity must be characterized and un-derstood. Is the deformity extra-articular or intra-articular? What is thesagittal and coronal alignment? Is therea rotational malalignment? What is therelationship of the tibial articular sur-face to that of the distal fibula? What isthe degree of axial shortening? It is alsoimportant to evaluate the soft-tissuestatus around the distal tibia, and it iscritical to assess the viability (salvage-ability) of the joint. Often, the articu-

lar surface of the pilon fracture hasunited, and the nonunion or malunionis largely extra-articular. If the articularsurface is reasonably well aligned, anextra-articular correction of the defor-mity or nonunion may be performed.The choice of correcting such a defor-mity in a single stage or by gradual cor-rection will be determined by the in-tegrity of the soft tissues and theirtolerance to surgical intervention. Theselection of nail fixation, plate fixation,or external fixation should be madewith consideration of the distance ofthe deformity from the articular sur-face, the viability of the bone at thenonunion/malunion site, the patencyof the medullary canal, and the effecton the bone of prior implants and sur-geries. Resultant bone defects after thecorrection of the deformity may re-quire treatment with morcellized orstructural bone grafts. Large complexdeformities, particularly in compro-mised soft tissues, may be best treatedwith gradual correction and distrac-tion osteogenesis.

The treatment of intra-articularmalunion or nonunion requires a care-ful assessment of the viability of theankle joint. Well-positioned radio-graphs and CT are used to assess thecongruence of the joint surfaces andthe degree of union between fracturefragments. MRI may be used to assessthe degree of articular damage andchondral injury but is less useful whenthere is retained hardware from a priorfracture or nonunion surgery. Stagingarthroscopy may be used to evaluatethe chondral surface in circumstanceswhere other diagnostic imaging studieshave failed to provide sufficient infor-mation for surgical planning and deci-sion making. Joint mobility and thedegree of soft-tissue contracturearound the ankle must be carefully as-sessed. Correction of bony deformitywithout soft-tissue balancing is likelyto lead to a poor outcome. Achilles

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tendon lengthening and the release ofjoint contractures may be done eitheras part of the surgical approach or as aseparate part of the procedure. In diffi-cult situations, bony union may haveto be achieved first and a secondarysubsequent soft-tissue surgery per-formed later; however, the treatmentof both components simultaneously isgenerally preferred.45,90

In general, the treatment of intra-articular nonunion or malunions afterpilon fracture is generally reserved forpartial articular fractures76 (Fig-ure 10). The correction of a completearticular nonunion, while possible, isgenerally exceedingly difficult becausethe vascularity of each articular frag-ment must be maintained during theosteotomy, realignment, and fixation.Partial articular nonunions ormalunions require osteotomy and mo-bilization of the displaced articularfragment and reduction of the articularsurface (Figure 11, A). There may beresultant gaps in the articular recon-struction, but the goal is to provide acongruent joint surface with as mini-mal a residual irregularity as possible(Figure 11, B and C). Stable interfrag-mentary compressive fixation is re-quired and is often supplemented bybuttress plate fixation (Figure 12). In-tercalary allograft or tricortical au-tograft may be necessary if stable

fixation cannot be achieved by com-pression alone.

The most common long-term com-plication after a tibial pilon fracture isposttraumatic arthritis.45,85 Radio-graphic findings of posttraumatic ar-thritis may not always correlate withthe patient’s symptoms or reported dis-ability. The initial management of the

symptomatic patient should includenonsteroidal anti-inflammatory drugs,shoe wear modification, or activitymodification. A heel lift may providesome initial relief to the patient withlimited dorsiflexion caused by anteriortibiotalar osteophyte formation. Arocker-bottom sole or an Arizonabrace may provide symptomatic relief

Figure 10 AP (A) and lateral (B) radiographs of a pilon fracture malunion7 months after the initial injury.

Figure 11 A, Intraoperative fluoroscopic view of the restoration of alignment and the articular joint surface. AP (B)and lateral (C) intraoperative views of definitive ORIF.



for the relatively stiff, painful ankle.Intra-articular steroid injections mayprovide temporary symptomatic reliefbut are typically used sparingly. Ar-throscopy generally plays a role only inthe patient with symptomatic im-pingement; the resection of anteriorosteophytes may temporarily relievesymptoms and improve ambulation.45

The long-term results are uncertain.Although distraction arthroplasty withor without fascial interposition hasbeen advocated, there are no large se-ries reporting long-term relief of symp-toms with this technique.45

The most reliable treatment of end-stage posttraumatic ankle arthritis isarthrodesis35,36,38,39,91 (Figure 13).This is generally performed as an open

procedure because of the presence ofpreviously placed fracture hardware.Retained implants are generally re-moved, erosions or subchondral cystsare grafted, and the deformity is cor-rected to establish proper position forfoot placement. Generally, the recom-mended position for arthrodesis iswith a plantigrade foot, slight hindfootvalgus, external rotation equivalent tothe patient’s contralateral limb, and atranslation of the talus posteriorly un-der the plafond to improve gait me-chanics. Motion in the subtalar jointand midtarsal joints should be pre-served if possible, and a careful assess-ment of arthritic changes, particularlyin the subtalar joint, should be per-formed. Selective injection of the sub-

talar joint as a diagnostic proceduremay help the surgeon determinewhether radiographic changes in thesubtalar joint are sufficiently symp-tomatic to warrant treatment at thetime of ankle arthrodesis. In posttrau-matic situations, the surgical approachand the technique for arthrodesis isgenerally determined on the basis ofprior incisions, the compromise ofsoft-tissue flaps, the location of previ-ously placed implants, and any residu-al deformity.39 The presence of infec-tion and osteonecrotic bone maynecessitate a staged procedure with re-moval of the implants, débridement,and placement of an antibiotic spacerfollowed by second-stage definitive ar-throdesis.35 Arthrodesis in the pres-ence of significant deformity may re-quire acute shortening to avoid soft-tissue coverage. Subsequent limblengthening may be performed if theresultant limb-length inequality is un-

Figure 12 AP (A) and lateral (B) radiographs of a pilon fracture at 3-monthfollow-up with corrected and articular alignment.

Figure 13 AP radiograph followingankle arthrodesis for posttraumaticarthritis 2 years after definitive ORIFfor a pilon fracture.

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acceptable to the patient. Alternatively,gradual deformity correction may becombined with the arthrodesis andlimb lengthening with of the use ofmultiplanar external fixation and dis-traction osteogenesis.92,93

Short- and intermediate-term out-comes are generally good after arthro-desis, with patients reporting a sig-nificant reduction in pain andimprovement in gait; however, the de-velopment of symptomatic degenera-tive arthritis in the subtalar, transversetarsal, and midtarsal joints may be re-ported with long-term follow-up.36,39

Patients almost universally reportfunctional limitations secondary topain.35,36,39,91

Ankle arthroplasty is another op-tion for the treatment of symptomaticposttraumatic ankle arthritis.37,43,44 Itis generally reserved for patients withminimal deformity, a healthy soft-tissue envelope, and no history of priorinfection.94 Vascularized bone, ahealed fracture, and minimal residualimplant defects are considered prereq-uisites for this procedure.94 Many sur-geons recommend a staged treatmentprotocol for these injuries, with initialremoval of the hardware, a biopsy torule out infection, and an assessmentof bone viability followed by a second-stage definitive arthroplasty. The re-sults of total ankle arthroplasty forposttraumatic arthritis are generally in-ferior to those of arthrodesis.44 In moststudies, an increased incidence of ma-jor complications is generally reportedafter arthroplasty, and satisfaction isequivalent to that after arthrodesis.43

The major reoperation rate for compli-cations after the procedures is substan-tially higher after arthroplasty, al-though the need for subtalararthrodesis has been reported to belower.44 At the present time, most au-thors generally do not recommend to-tal ankle arthroplasty over arthrodesisfor posttraumatic ankle arthritis after a

pilon fracture. It is hoped that contin-ued improvements in implant designand longevity will lead to improvedoutcomes and expanded indicationsfor the procedure.

Ankle arthrodesis remains themainstay of treatment of the failed pi-lon fracture. Osteotomy and joint sal-vage of the nonunited or malunitedfracture is an uncommon situation andis generally reserved for partial articu-lar injuries or those in which the artic-ular surface has united in a reasonableposition. The role of arthroplasty isuncertain and remains investigational,with longer term follow-up required toarrive at a definitive, efficacious con-clusion.

SummaryEven though staged protocols and ad-vancements in technique and technol-ogy have evolved, the original prin-ciples regarding pilon fracturemanagement remain unchanged. Res-toration of length with fibular fixation,reconstruction of the articular surface,bone grafting, and buttressing of themetadiaphyseal reconstruction remainthe foundation of optimal manage-ment. Treatment modifications in-clude a better understanding of theimportance of soft-tissue manage-ment, with particular focus on soft-tissue edema and blister resolution.Strategic preoperative planning withthe use of CT and selection of appro-priately bridged surgical incisions mayfacilitate an easier perioperative periodand desired postoperative outcome. Tostage the subsequent incision, the sur-geon who provides definitive treat-ment should initiate the first “work-horse” incision. Knowing the pros andcons of each surgical approach will im-prove the chances of achieving the de-sired clinical results. Future protocolchanges, implant technologies, and therole of IMN in the management of pi-lon fractures may be the subjects of

further research, but the principles ofpilon restoration will most likely re-main the same. External ring fixatorsare complicated but are viable optionsfor treating unsalvageable, severely in-jured pilon fractures and are a usefultool for fracture management in thelate and failed stages of treatment.Treating complications requires carefulattention to wound management toavoid infection, malunion, and non-union. If complications arise, arthro-desis remains the mainstay of man-agement. The efficacy of anklearthroplasty awaits improved clinicaland longer term survival data.

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