1. Pilon Fracture Fixation:
Introduce the Topic
Pilon Fracture Fixation:
Joseph Borrelli, Jr. MD
Professor and Chair
Department of Orthopaedic Surgery
University of Texas – Southwestern Medical Center
Dallas, TX

2. Objectives:
1- Briefly review radiographic and clinical findings of high energy pilon fractures,
2- Describe the ‘Two-Stage Approach’ for the treatment of high energy pilon fractures,
3- Review surgical options and approaches for these fractures,

3. Rotational Type: Characteristics: spiral distal tibia fracture,
little metaphyseal comminution,
few articular fragments,
mild/moderate displacement,
w/wo fibula fracture,
mild to moderate soft tissue injury,
spiral distal tibia fracture in which the fracture extends into the articular surface,
associated with little metaphyseal comminution,
few articular fragments,
mild/moderate displacement,
with or without associated fibula fracture,
mild to moderate soft tissue injury,

4. Axial Compression Type:
Characteristics
articular impaction,
metaphyseal and articular comminution,
moderate to major displacement,
severe soft tissue injury/open
associated with fibula fracture (85%),
intra-articular distal tibia fracture,
generally with considerable metaphyseal comminution,
many articular fragments,
moderate/major displacement
85% with associated fibula fracture,
severe soft tissue injury/open,

5. Recognize the Difference !
Timing of treatment,
earlier vs delayed,
Type of treatment,
approach,
ORIF vs limited IF and EF,
Complications,
Outcome,

6. Radiographic Evaluation:
Plain radiographs: AP
Mortice
Lateral

7. Radiographic Evaluation:
Axial CT scans,
identifying fracture planes,
intra-articular fracture fragments,
pre-operative planning,
prognosis, *

8. Radiographic Evaluation:
CT scans: Coronal reconstructions,

9. Radiographic Evaluation:
CT scans: Sagittal reconstructions,

10. Goals of Treatment Biological exposure
Articular surface restoration (1)
Bone graft metaphyseal defect (2)
Buttress plate fixation (3)
Atraumatic closure
Early active ROM (4)
Protected weightbearing
RÜEDI - ALLGÖWER

11. ‘Two Stage Protocol’ 1st Stage: Ankle Spanning External Fixator,
ORIF of the fibula,
as soon as possible after presentation,
maximize “ligamentotaxis”,
stabilize the fracture while soft tissues are recovery,
1st Stage: Temporary Fixation
applicatin of temporary spanning external fixator and ORIF of the fibula,
as soon after presentation as possible,
stabilize the fracture while allowing the soft tissue swelling to resolve,

12. ‘Two Stage Protocol’ Interim: ice, elevation, pre-operative plan,
physical therapy,
TIME to allow swelling to resolve,

13. Surgical Timing Patience Timing critical Avoid 1-6 days
Await soft tissue envelope (10-21 days)

14. Fibular Alignment Controls Talus

15. Fibular Alignment Controls Talus

16. “traveling traction”

17. Frame Configuration

18. “Traveling Traction”
Half Pins
Transfixation
Pin

19. Posterolateral fibular approach

20. Interim: Pre-operative Plan !!!
Patient
Ice, elevation,
CT scan,
Crutch training,
Surgeon
Pre-operative plan,
TIME to allow swelling to resolve,

21. Definitive Fixation: Plates/Screws
2nd Stage: Definitive Fixation
ORIF tibia and fibula,
removal of external fixator,
ORIF Fibula,
posterolateral approach,
maximize skin bridge,

22. Definitive Fixation: Plates/Screws
Anteromedial Approach: Indications
Anterior and medial comminution
Planning a ant and/or medial plate
Approach
½ finger breath lateral to tibial crest,
maintain 7 cm skin bridge,
parallel to Anterior Tibialis tendon,
towards the talonavicular joint,
Anteromedial Approach:
begin ½ finger breath lateral to crest over the anterior compartment,
minimum 7 cm skin bridge,
continue parallel to Anterior Tibialis tendon,
towards the talonavicular joint,

23. Definitive Fixation: Plates/Screws
Anteromedial Approach:
talonavicular joint
medial
Anteromedial Approach:
begin ½ finger breath lateral to crest over the anterior compartment,
minimum 7 cm skin bridge,
continue parallel to Anterior Tibialis tendon,
towards the talonavicular joint,

24. Definitive Fixation: Plates/Screws
Articular Reduction:
largest, least displaced fragments first,
posterior fragment,
reduce fragments and hold,
K-wires (1.6 mm),
pointed reduction forceps,
definitive fixation,
lag screws, cannulated screws,
reduce articular bloc to shaft,
Articular Reduction:
start with largest, least displaced articular fragments first,
reduced fragments and hold with:
K-wires (1.6 or 2 mm),
pointed reduction forceps,
definitive fixation,
lag screws,
reduce articular bloc to shaft,
plate(s),

25. Definitive Fixation: Plates/Screws
DON’T make medial a incision !!!
incision is directly over the bone/plate,
difficult to close,
increased wound complications,
deep infection,
soft tissue loss,
free flap only bailout,
burns bridges for later reconstruction,
DON’T make medial a incision !!!
the incision ends up directly over the plate,
difficult to close,
increased wound complications,
deep infection,
soft tissue loss,
free flap only bailout,
burns bridges for later reconstruction,
NO !!

26. Definitive Fixation: Plates/Screws
Anterolateral Approach (Bohler):
Indications:
open medial wound,
displaced Chaput fragment,
lateral articular comminution,
Advantage:
good soft tissue coverage,
uninjured skin,
single incision for ORIF of the tibia and fibula,
Wolinsky, P, & Lee, M J Ortho Trauma 2008

27. Anterolateral Approach
Deep Dissection:
through superior and inferior retinaculae,
interval between toe extensors and fibula,
elevate muscles off interosseous membrane,
Caution:
superficial peroneal nerve,
8 cm proximal to joint,

28. Anterolateral Approach
Wolinsky, P, & Lee, M J Ortho Trauma 2008

29. Definitive Fixation: Plates/Screws
Implants: Small Fragment Plates
small fragment plates,
3.5 LC-DCP,
precontoured medial LCP,
anterolateral plates LCP,
Screws
3.5 cortical/4.0 cancellous,
cannulated: 4.0/4.5

30. Definitive Fixation: Plates/Screws
Implants: Small Fragment Plates
small fragment plates,
3.5 LC-DCP,
precontoured medial LCP,
anterolateral plates LCP,
Screws
3.5 cortical/4.0 cancellous,
cannulated: 4.0/4.5

31. Definitive Fixation: Plates/Screws
Bone Graft: Theory
support articular fragments,
augment healing,
fill cancellous defects,
ICBG,
Allograft,
Synthetic
Calcium putties,

32. Definitive Fixation: Plates/Screws
Meticulous Wound Closure
Deep closure,
1-0 vicryl for capsule,
2-0 vicryl for subcutaneous
tissue,
Skin closure
3-0 nylon,
AllgÖwer’s modification of the Donati stitch,

33. PL 45 y/o MVC

34. “Two Stage Protocol”
“Traveling Traction”

35. “Two Stage Protocol”

36. “Two Stage Protocol”

37. “Two Stage Protocol”

38. Ligamentotaxis

39. Definitive fixation

40. Summary Represent both a bony and soft tissue injury,
Tibial Plafond Fractures are challenging injuries,
Represent both a bony and soft tissue injury,
AO principles have remained the same:
articular reduction,
stable fixation,
early mobilization of the patient and ankle,
meticulous soft tissue handling,

41. Summary “Two Stage Protocol”, Approaches, Implants,
spanning external fixation and +/- ORIF fibula,
definitive management of the tibia,
Approaches,
Anteromedial approach,
Anterolateral approach,
Implants,
Small fragment plates and screws,
Pre-contoured plates (LCP),

42. Thank You