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Distal tibial fractures represent a significanttreatment challenge to most orthopedic sur-geons. Pilon fractures represent 1 to 10% ofall lower extremity fractures. These fracturescan result from low-energy injuries that donot cause significant damage to the soft tissueenvelope of the lower leg. Alternatively theadvent of high-speed automotive travel hasbeen accompanied by high-energy distal tibialinjuries, which can result in severe soft tissuedevitalization. Higher energy injuries also caninduce significant joint surface cartilage dam-age, leading to posttraumatic arthritis despiteoptimal articular surface reduction and fixa-t i ~ n . ~Initial operative management techniquesfocused on obtaining anatomic radiographicappearances by reestablishing normal boneanatomy. With the increasing prevalence ofhigh-energy injuries and the accompanyingsoft tissue damage, the orthopedic commu-nity has discovered that reestablishing boneanatomy while ignoring the soft tissues mightnot lead to optimal postoperative results.Standard open reduction and internal fixationtechniques that used large fragment screwswith large spoon plates resulted in significantwound complications in high-energy pilonfractures. More recent treatment protocolshave focused on maintaining a healthy softtissue envelope while reducing the articularsurface by indirect means using minimally

THE TREATMENT OFPILON FRACTURES

Michael Sirkin, MD, and Roy Sanders, M D

invasive techniques. Surgeons have combinedinternal and external fixation to minimize theneed for the extensive soft tissue dissectionnecessitated by large fragment screws andplates. Hybrid external fixators have beenused for pilon fractures to allow early anklerange of motion, while reestablishing normalbone anatomy and minimizing the need forextensive internal fixation. Treatment hasevolved to a staged protocol that ases externalfixation as portable traction for several weeksbefore performing definitive internal fixation.Many options currently exist for the definitivetreatment of pilon fractures for orthopedicsurgeons. This article reviews the evolutionof treatment as well as the current state-of-the-art of pilon fracture management.

CLASSIFICATIONFor classification systems to be useful tools,any system must determine prognosis as wellas guide treatment. By comparing similar

fracture patterns, different treatment proto-cols can be analyzed; this is especially truewhen evaluating distal tibia fractures. Severalpublished reports discuss the reliability andreproducibility of the most commonly usedclassification systems.lO,8 7 By using the Kcoefficient, these studies have shown moder-ate to poor agreement when using these dif-

From the Orthopaedic Trauma Service, Department of Orthopaedics, New Jersey Medical School, Newark, New Jersey(MS); the Division of Orthopaedic Surgery, University of South Florida and the Department of Orthopaedics, TampaGeneral Hospital, Tampa, Florida Rs)

ORTHOPEDIC CLINICS OF NORTH AMERICAVOLUME 32 NUMBER 1 JANUARY 2001 91


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I1

IIIFigure 1. Ruedi an d A llgower classif ication of piton fractures. FromRuedi TP, l lgower M: Fracturesof the lower end of the tibia into the ankle joint: Results 9 years after open reduction and internalfixation, Injury 5130, 973; with permission.)

ferent classification schemes. The K coefficientis an agreement measure used to determineinterobserver and intraobserver reliabilit~.'~These studies show the difficulty in examin-ing scientifically the literature and its impacton treating fractures of the tibia1 pilon.The Ruedi-Allgower classification is themost commonly used scheme for describing

pilon fractures (Fig. 1).Type 1 fractures arecleavage fractures without displacement ofthe articular surface. In type 2 fractures, thereis displacement of the joint surface withoutcomminution. Type 3 fractures have displace-ment and comminution. The AO/OTA classi-fication provides the most detail but is themost complex classification system (Fig. 2).


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THE TREATMENT OF PILON FRACTURES 93A B C

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2

3

Figure 2. Comp rehensive classification of fractures of the long bones for the distaltibia. These are all type 43-XX. From Muller ME, Schneider R, Allgower M, et al:Manu al of Intern al Fixation . New York, Spring er-Verlag. 1991 pp 146-147 596; withpermission.)

Fractures of the distal tibia have the designa-tion 43. Similar to all articular fractures in theAO/OTA classification, type A fractures areextra-articular, type B fractures are partial ar-ticular, and type C fractures are complete ar-ticular fractures. Type A fractures are dividedfurther into Al , simple fractures; A2,wedgefractures; and A3, complex fractures. Type Bfractures are divided further into B1, puresplit fractures; B2, split depression fractures;and type B3, multifragmentary depressionfractures. TypeC fractures are divided furtherinto C1, fractures that have simple articularand metaphyseal components; C2, fracturesthat have simple articular and multifragmen-tary metaphyseal elements; and C3, multi-fragmentary fractures of the articular surface

and metaphysis. Each group is divided fur-ther into subgroups based on location of thefracture and fracture pattern. Multiple studieshave shown that distinguishing beyond thefracture type (A, B, C) is meaningless becausethere is no interobserver or intraobserver re-liability.lO,18, 27 Swiontkowski et a127 showedthat the best measure one could obtain whenusing this classificationis moderate reliability.As further subdivisions are used and fracturesubgroups are used, the reliability drops tofair as determined by the K coefficient.RADIOGRAPHIC EVALUATION

Plain radiographs are mandatory for evalu-ation of fractures of the distal tibia fracture.


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Essential radiographs include a film centeredon the ankle and one of the entire tibial shaft.Ankle films are used to delineate articularincongruity and fragmentation. Joint im-paction is detected frequently on the lateralradiograph. The metaphyseal and diaphysealextent of injury is appreciated on the full-length tibial series. These radiographs shouldbe scrutinized for any proximal injuries thatcan be overlooked easily. Tomograms are nolonger useful and have been superseded byCT scans. CT is a useful adjunct to plainradiography. CT scans can allow the surgeonto approximate the degree of three-dimen-sional anatomic disruption, which may besubtle on plain radiographs. CT scans allowsurgical planning of incisions and lag screwplacement. These scans can help determine ifan acceptable reduction has been obtained bya closed technique or whether open reductionis necessary. CT scans are indispensable forplanning thin wire placement when using hy-brid fixators. Tometta and GorupZ8noted a64 change in the operative plan when CTscans were reviewed in addition to plain ra-diographs. These investigators recommendedroutine use of CT scans to aid preoperativeplanning of fixation of pilon fractures.

TREATMENT OPTIONSNonoperative Treatment

Early results using nonoperative treatmentof displaced high-energy, intra-articular frac-tures of the distal tibia were disappointing.',8 21 Nonoperative treatment should be re-served for patients with nondisplaced frac-tures and for patients who have a poor medi-cal prognosis.

Operative TreatmentOperative treatments include internal fixa-tion and external fixation. Internal fixationcan be performed in one stage or two andperformed early or late. External fixation in-cludes fixation techniques that cross the jointand techniques that do not. The use of exter-nal fixation can be coupled with formal or

limited open reduction and percutaneousjoint stabilization. As a result of poor out-comes associated with nonoperative treat-ment of displaced intra-articular distal tibialfractures, Ruedi and A l l g o ~ e r ~ ~ ,4 investi-

gated other means of treatment. Their initialreport was published in 1969u with a 9-yearfollow-up reported in 1973.24Ruedi and All-gower's principles for treatment included 1)reestablishment of fibular length, stabilizingthe lateral column; (2) reconstruction of thelower articular surface of the tibia; (3) place-ment of metaphyseal bone graft; and (4) stabi-lization of the medial aspect of the tibia usinga plate. Using these techniques, Riiedi andAllgower obtained 73.7% good functionalresults with 90% of patients returning to theirpreinjury occupations. This report correlatedthe adequacy of reduction with a functionalend result. The follow-up report showed thatposttraumatic arthritis usually manifested it-self within 1 to 2 ~ e a r s . 2 ~f not experiencedwithin this period, arthritis rarely developed.Of the 84 fractures, 60 were secondary to low-energy skiing injuries. Five were related tomotor vehicle accidents, and five were classi-fied as open fractures. With these relativelylow-energy injuries, these investigators re-ported a 12% incidence of wound healingproblems and a 5% incidence of deep infec-tion.In 1976, Heim and Naser12 reported 90%good-to-excellent results using the techniquesdescribed by Ruedi and Allgower. These weremostly lower energy injuries. Kellam andWaddell14 reported on a series of 26 patients,dividing them into 2 groups based on fracturepattern. Type A fractures were twisting injur-ies with little comminution, whereas type Bfractures were more severe injuries with acrush component. Overall, 65% of cases hadgood-to-excellent results. Better results wereobtained with type A fractures (84 ) thantype B injuries (53%). Crucial factors besidesfracture type were the length of immobiliza-tion and quality of reduction. Prolonged im-mobilization resulted in poor outcome. Thisstudy showed the need for stable fixation topermit early range of motion.Ovadia and Beals2' reported on a large se-ries of patients treated with a variety of differ-ent methods. They divided their treatmentgroups into patients treated with A 0 tech-nique and patients treated with other meth-ods. Ovadia and BealsZ1 introduced a newclassification scheme based on 5 fracturetypes, expanding the Ruedi and Allgowerscheme. Prognostic variables associated withthe final result were fracture type, quality ofreduction, and method of treatment. Ovadiaand Beals2' classified pilon fractures into 5types depending on degree of comminution


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THE TREATMENT OF PILON FRACTURES 95

and displacement of the articular surface aswell as metaphyseal involvement. Type 1fractures are nondisplaced articular fractures.Type 2 fractures are minimally displaced.Type 3 fractures are displaced with severallarge fragments. Type 4 fractures have a largemetaphyseal defect. Type 5 fractures have se-vere comminution.All type 1 fractures, regardless of treatmentmodality, had a good-to-excellent result, com-pared with only 22% of type 5 fractures P =0.01). Fracture type was associated closelywith quality of reduction. Ovadia and BealsZ1noted that gaps in the articular surface wereassociated with worse outcomes and recom-mended closing all fracture gaps wheneverpossible. Clinical results paralleled the qualityof reduction obtained. Of fractures with agood reduction, 89 were rated as good toexcellent. Conversely, all patients with a poorreduction had a poor clinical outcome. Pa-tients treated with stable internal fixation didbetter than patients treated by other means(74 good-to-excellent results versus 54 ;P0.05). Of patients with stable internal fixa-tion, 69 returned to their preinjury level ofemployment, compared with 43 of patientsin whom stable fixation could not be obtained( P 0.05). Overall, 65 good-to-excellent re-sults were obtained in type 3, 4, and 5 frac-tures when Ruedi and Allgower's principleswere observed as compared with 34 whenthey were not. This series included injuriesof a higher energy pattern than Ruedi andAllgower's series. Forty-six percent (66 of145) were related to motor vehicle accidentsor significant falls, and 29 were open frac-tures.A high-energy injury pattern correlatedwith a higher incidence of wound healingcomplications. In the closed injury group,there was a 10% incidence of superficialwound infection and 6 incidence of osteo-myelitis. In patients with open fractures, therewas a 31 incidence of infection, 10% rateof osteomyelitis, and 21% rate of superficialinfection. There was no difference in the com-plication rate for each group regardless oftreatment method. The only exception to thisfinding was in the group undergoing limitedincision technique for hardware placement.This group of patients experienced muchworse results compared with patients in theother treatment groups. Three patients re-quired amputation for chronic osteomyelitis.In this study, 12% of patients required anankle fusion or joint arthroplasty even when

an anatomic reconstruction was obtained.Based on their results, Ovadia and Beals2'recommended open reduction and internalfixation for all displaced pilon fractures butcautioned against the use of a limited incisiontechnique.Bourne et a18 reported a 13 incidence ofdeep infection with higher energy injuries.These authors noted better functional resultsin Ruedi and Allgower type 1 and 2 fracturesand fractures in which stable anatomic fixa-tion could be achieved. In 1986, Dillin andSlabaugh9 reported disastrous results wheninadequate and unstable internal fixation wasused to treat pilon fractures, including a 36rate of skin slough and a 55% infection rate.Mast et all9 recommended the use of openreduction and internal fixation for displacedpilon fractures. These investigators advocatedsurgery within 8 to 12 hours or delaying sur-gery until soft tissue edema was decreased.They believed that once swelling had oc-curred, an operative procedure was unwisebecause the marginal condition of the softtissue would make wound closure difficult,increasing the risk of skin slough and infec-tion. Patients with type 1 and 2 fracturescould be treated with splinting, but patientswith type 3 were thought to need calcaneal

traction to prevent tibial shortening, whichwould lead to a more complicated reconstruc-tion.Trumble et a130 reported on five cases offull-thickness tissue loss treated with radialforearm flaps. The average length of delayfrom injury to surgery in these patients was4.6 days (range, 1-6 d). This study highlightsthe need to avoid surgery during this time ofcritical soft tissue stabilization.Helfet et all3 reported on a group of pa-tients with higher energy injuries and noted77 and 63 good-to-excellent results inRu;auedi and Al1go;auwer type 2 and 3 frac-tures. Helfet et all3 noted the results of opera-tive treatment depended on the quality ofreduction, severity of injury, fracture type,and degree of stability that could be obtained.By obtaining an anatomic reduction with sta-ble internal fixation and early motion, theseauthors achieved acceptable results. To mini-mize complications, they delayed surgical in-tervention until the soft tissues were safe Nosignificant soft tissue complications occurredin the closed fracture group.Leone et all6 decreased the infection rate byprimarily closing the tibial wound and treat-ing the fibular wound with a delayed closure


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superficial infection, one malunion, and threepin tract infections.Using the same technique, Barbieri et a12achieved similar results in the higher energyfractures. They had 67 acceptable resultswithout significant complications. There werethree cases of osteomyelitis, one skin slough,and five pin tract infections. Three patientshad loss of reduction that required frame re-vision. Overall, limited incisions and use of ahybrid external fixator obtained good resultswith minimal complications.As experience with hybrid external fixationgrows, it appears that its principal advantagelies in its soft tissue management, despite thefact that an anatomic articular reduction maybe impossible using these limited techniques.Two questions then arise. First, is open reduc-tion and internal fixation of pilon fracturesunwise because of the increased risk of softtissue complications? Second, are better re-sults obtained with one method as opposedto another?To try to answer these questions, Wyrsch eta133conducted a randomized prospective trialcomparing open reduction and internal fixa-tion with external fixation. Group I, the inter-nal fixation group, had a 28% rate of infection,33 wound dehiscence rate, and 3 (16%) am-putations. Group 11, the external fixationgroup, had a 5 skin slough rate, a 5 infec-tion rate, and no amputations. These authorsconcluded that limited internal fixation com-bined with external fixation is an equally ef-fective and significantly safer method of treat-ment for most fractures of the tibia1 plafond.This conclusion was based on the substan-tially greater number of complications experi-enced after open reduction and internal fixa-tion without any differences in long-termclinical outcome.A critical examination of these data revealsthat the 2 groups were treated in a differentmanner. Patients treated with external fixa-tion had surgery performed at presentation(11 of 20)' within hours, or after a delay of 1week or more (7 of 20 . Most (14 of 19) ofthe patients undergoing open reduction andinternal fixation were operated on at 3 to5 days after injury, when swelling was thegreatest. It is no wonder that these latter casesexperienced wound complications becausethe ultimate outcome for each treatmentgroup may have been related to the differ-ences in the period of time between injuryand surgery. This study shows that open re-duction and internal fixation for pilon frac-

tures 3 to 5 days after injury can lead to ahigh rate of soft tissue c~mplication.'~,oTwo studies using a staged protocolz, 6 forthe management of soft tissue injury in high-energy pilon fractures have been reported.Stage one consists of the immediate applica-tion of a transarticular external fixator accom-panied by open reduction and internal fixa-tion of the fibula. Stage 2 occurs after softtissue stabilization has taken place and formalreconstruction is safe, typically at 10 to 14days after the injury. By using this technique,major soft tissue complications can beavoided. Minor problems in wound healingdo occur but can be treated successfully withlocal wound care and oral antibiotics. By us-ing this staged protocol, wound healing com-plications were reduced to 5.3 in all frac-tures and 2.9 n closed fractures. All woundhealing problems occurred in patients whoexperienced high-energy injuries. There wereseven minor wound problems, of which allwere treated successfully with local woundcare and oral antibiotics; hospitalization wasunnecessary. No patient required free tissuetransfer for wound management.26Pattersonand Cole22 used a similar protocol withequally encouraging results.

TIMING OF TREATMENTThe timing of an operative procedure isdetermined ultimately by the method of re-construction. Performing surgery when softtissue swelling is reduced minimizes compli-cations. Staged procedures frequently are re-quired to reduce complications and to max-imize functional results. In a staged protocol,immediate operative intervention (within 12to 18hours of injury) is performed by stabiliz-ing the fibula with a plate and using transar-ticular external fixation to reestablish ana-tomic bone length and to obtain a preliminaryarticular reduction by ligamentotaxis. Thedistraction provided by the external fixatorprevents soft tissue contracture, preventingtension of the surgical incisions after defini-tive placement of fixation.Surgery within the first 72 hours usually isreserved for fractures that are to be treatedwith limited internal fixation and small wire

external fixation. External fixation wires canbe placed at the joint or across the fracture. Awell-trained and experienced radiology tech-nician is invaluable when performing percu-taneous and limited fixation procedures. Per-


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98 SIRKIN SANDERSforming these procedures semielectively canonly enhance the surgeons performance.Careful planning is necessary for placementof tensioned wires and percutaneous screwsif stable fixation is to be achieved.Formal open procedures should be delayeduntil soft tissue swelling has decreased be-cause the tissues are tenuous and cannotwithstand surgical trauma. Wagner and Ja-kob31 showed that when operating on bicon-dylar tibial plateau fractures, the highest rateof soft tissue problems was encounteredwhen surgery was performed within 7 daysfrom the time of injury. Wyrsch et a133showedan incidence of 28% infection, 33 woundproblems, and 16 amputation when openstabilization was performed on the distal tibiawithin 3 to 5 days after the initial injury.Operating during this period is unwise.When open reduction is contemplated, de-laying the procedure for 4 weeks to allow thesoft tissue swelling to subside has beenquoted by some authors as being ideal?,13, 16,22This delay may lead to difficulty in identi-fying fracture fragments and obtaining per-fect articular surface reduction, however.AUTHORS PREFERRED TECHNIQUEFOR MANA GEMENT OF PILONFRACTURES

Patients with complex fractures of the dis-tal tibia are evaluated in the emergency de-

partment. Patients are immobilized with awell-padded splint with a bulky-type com-pression dressing. When hemodynamicallystable, patients are brought to the operatingroom for placement of a transarticular exter-nal fixator and open reduction and internalfixation of the fibula. The lateral incision ismade on the posterolateral aspect of the fib-ula to allow for the maximum distance fromthe medial tibial incision that will be usedeventually for definitive fixation (Fig. 3 ) .Open fractures undergo irrigation and d6-bridement.Patients with isolated or minor injuries aredischarged 24 hours after the initial proce-dure. They are instructed to perform strictelevation of the operative limb on dischargefrom the hospital. When soft tissue swellingis minimal, a safe open reduction is planned,usually in about 10 to 21 days. If multipleinjuries have occurred and the patient re-mains hospitalized, the extremity is observed,and surgery is planned at the appropriatetime.The definitive reconstruction is performedthrough an anterior-medial incision. An ade-quate skin bridge is essential to avoid softtissue complications. The skin incision beginson the the tibial crest medial to the tibialisanterior, 7 cm away from the lateral fibularincision. The incision is carried distally acrossthe ankle joint, staying medial to the tibialisanterior tendon. The extensor retinaculum is

Figure 3.A Position of incision for open reduction of tibial plafond. B, Fibulaincision after plating and a large skin bridge remains.


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Figure 4 Femoral distractor to help position fragments.FromMuller ME, SchneiderR, Allgower M, et al: Manualof Internal Fixation. New York, Springer-Verlag, 1991, pp146-147, 596; with permission.)

incised. The tibialis anterior tendon and para-tenon should be avoided. In the distal extentof the wound, the plane between the tibialisanterior and posterior is exploited. The inci-

sion is carried down to periosteum in an at-tempt to maintain full-thickness flaps. Perios-teal stripping and anterior compartmentelevation are performed only where needed.A femoral distractor or the previouslyplaced external fixator can be used for liga-mentotaxis and indirect joint surface and frac-ture reduction (Fig. 4). The joint surface isreconstructed anatomically using the antero-lateral tibia1 fragment as a guide. This Chuputfragment maintains its attachment to the fib-ula. The joint is stabilized provisionally withKirschner wires. Lag screws are placed intolarge fragments as needed, and an ante-romedial cloverleaf plate is secured to thetibia (Fig. 5). This exposure is extensile andallows concomitant treatment of talar injuries.It also allows for later ankle fusion, if needed.Primary bone grafting is used rarely exceptfor massive defects.Postoperatively, patients are maintained onintravenous antibiotics for 48 hours. The limbis immobilized until the soft tissues arehealed and the sutures are removed. Earlyrange of motion is instituted once woundsare healed, with formal physical therapy re-served for patients after the fracture beginsto heal. The limb is immobilized for wounddrainage or concerns over partial-thickness orfull-thickness wound necrosis. Weight bear-ing typically is instituted at 3 months but

Figure 5. A and 8 Anteroposterior radiographs of pilon fractures treated with open reductionand internal fixation. Excellent stability has been achieved allowing early motion.


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depends on satisfactory fracture healing.Functional range of motion frequently can beobtained using this protocol (Fig. 6 ) .

EXTERNAL FIXATION AL ONE A SDEFINITIVE FIXATION

Certain fracture patterns may be amenableto external fixation alone. Patients with highlycomminuted articular surfaces may not becandidates for internal fixation. Similarly, lig-amentotaxis may allow adequate articularsurface reduction or may be appropriate forextra-articular distal tibial fractures. Preoper-ative evaluation and immobilization are simi-lar to the authors preferred treatmentmethod. The patients fracture pattern deter-mines whether a definitive hybrid frame isplaced or whether a temporizing transarticu-lar fixator is needed. After initial external

Figure 6. Range of motion of ankle joint with formal openreconstruction. A, Plantar flexion. 6 orsiflexion.

fixator frame placement, patients follow asimilar course as described for open recon-struction.

HYBRID EXTERNAL FIXATIONACCOMPA NIED BY PERCUTANEOUSFIXATION

When the articular surface is nondisplaced,definitive fixation can be performed primar-ily. If the articular surface is displaced mini-mally, percutaneous screw fixation may beperformed before external fixator placement.The remainder of the extra-articular fracturecomponents can be reduced and stabilized bya hybrid external fixator.Olive wires are placed in the distal seg-ment, with proximal half-pins being placedsecond. The first thin wire is placed fromposterolateral, through the fibula, to ante-romedial. The second wire placed is from pos-teromedial, anterior to the posterior tibial ten-don, to anterolateral (Fig. 7). This placementfollows the safe zones as described by Beh-rens and Sea rl ~. ~he authors attempt to max-imize the angle between these wires when-ever possible. These wires are then connectedto a 5/s ring and tensioned. Next, 2 Schantzscrews are placed into the diaphysis proxi-mally. These half-pins are connected to thedistal ring with radiolucent bars. Axial trac-tion is applied, and length and alignment arerestored. The frame is tightened, and the c-arm is used to check the reduction. Finally, athird tensioned wire is placed in the distalsegment to increase stability of the distal seg-ment. As a final check, all nuts and boltsare tightened. Final radiographs are obtainedwhile the patient is still under anesthesia.Radiographs taken on full-size 14 X 17sheetsallow the surgeon to determine whether thefinal alignment is acceptable.Postoperatively, patients are encouraged tomove their ankles within pain tolerance. Ifthey are unable to cooperate with this, a foot-plate is placed to keep the ankle in dorsiflex-ion. As an alternative, a metatarsal pin can beplaced to keep the foot in neutral. If placed,this pin is removed at about 4 weeks postop-eratively when the soft tissues and the pa-tients pain level allow ankle motion. Typi-cally, 30 lb of weight bearing is allowedimmediately with full weight bearing at 6 to8 weeks.Dynamization is performed as a means totest healing as well as to speed the healing


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Figure 7. Wire position in the distal tibia. (From Tornetta PI, Weiner L,Bergman M, et al: Pilon fractures: Treatment with combined internal andexternal fixation. J Orthop Trauma 7:489496, 1993; with permission.)

process. The frame is left in place until frac-ture healing is complete. Early removal mayresult in subsequent deformity. Frame re-moval may be performed in the office whenno serious pin tract infections have occurredand the surgeon is convinced that the fractureis healed completely.If a significant pin tract infection has oc-curred, the bone should be overdrilled andthe soft tissue debrided. When unsure aboutfracture healing, a fluoroscopic examinationis invaluable. The frame is loosened, and thefracture stability is tested.

SUMMARYSoft tissue complications, skin slough, andsuperficial infection lead to deeper infectionand amputation. By avoiding these complica-tions, it is expected that better results can beobtained. Two techniques are available to dothis. The first is to limit incisions and useexternal fixation to obtain stability. Even inthese cases, care must be taken with the softtissues. The second is a staged reconstruction,whereby stage one allows soft tissue stabiliza-tion. To this end, the fibula is plated, and

transarticular external fixation is performed;this maintains anatomic length, preventingsoft tissue contraction and permitting edemaresolution. The second stage, formal tibialopen reduction and internal fixation, is per-

formed with plates and screws when opera-tive intervention is safe.These methods appear to be equally effec-tive in reducing major soft tissue complica-tions. Surgeons should treat these complexfractures with the method with which theyare most comfortable. Surgeons who feelcomfortable with techniques of internal fixa-tion are best qualified to perform open reduc-tions. Surgeons who have experience withpercutaneous fixation and hybrid externalfixator application should use this method.Surgeons with limited or minimal experiencewith pilon fractures should consider fibulafixation and transarticular external fixationfollowed by transfer to an orthopedic traumasurgeon for definitive management.

References1.2.

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4.5.

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Ayeni JP: Pilon fractures of the tibia: A study basedon 19 cases. Injury 19:109-114,1988Barbieri R Schenk R KovalK, et a1 Hybrid externalfixation in the treatment of tibial plafond fractures.Clin M o p 32:16-22,1996Behrens F, Searls K External fixation of the tibia:Basic concepts and prospective evaluation. J BoneJoint Surg Br 68:246,1986Bonar SK, Marsh JL: Unilateral external fixation forsevere pilon fractures. Foot Ankle Int 14:57-64,1993Bone L, Sucato D Stegemann PM, et al: Displacedisolated fractures of the tibial shaft treated with eithera cast or intramedullary nailing. J Bone Joint SurgAm 79:1336--1341,1997Bone LB, Stegemann P, McNamara K et a1 External


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