FOOT AND ANKLE TRAUMA

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THE TREATMENT OF PILON FRACTURES

Michael Sirkin, MD, and Roy Sanders, MD

Distal tibial fractures represent a significant treatment challenge to most orthopedic surgeons. Pilon fractures represent 1% to 10% of all lower extremity fractures. These fractures can result from low-energy injuries that do not cause significant damage to the soft tissue envelope of the lower leg. Alternatively the advent of high-speed automotive travel has been accompanied by high-energy distal tibial injuries, which can result in severe soft tissue devitalization. Higher energy injuries also can induce significant joint surface cartilage damage, leading to posttraumatic arthritis despite optimal articular surface reduction and fixati~n.~ Initial operative management techniques focused on obtaining anatomic radiographic appearances by reestablishing normal bone anatomy. With the increasing prevalence of high-energy injuries and the accompanying soft tissue damage, the orthopedic community has discovered that reestablishing bone anatomy while ignoring the soft tissues might not lead to optimal postoperative results. Standard open reduction and internal fixation techniques that used large fragment screws with large spoon plates resulted in significant wound complications in high-energy pilon fractures. More recent treatment protocols have focused on maintaining a healthy soft tissue envelope while reducing the articular surface by indirect means using minimally

invasive techniques. Surgeons have combined internal and external fixation to minimize the need for the extensive soft tissue dissection necessitated by large fragment screws and plates. Hybrid external fixators have been used for pilon fractures to allow early ankle range of motion, while reestablishing normal bone anatomy and minimizing the need for extensive internal fixation. Treatment has evolved to a staged protocol that ases external fixation as portable traction for several weeks before performing definitive internal fixation. Many options currently exist for the definitive treatment of pilon fractures for orthopedic surgeons. This article reviews the evolution of treatment as well as the current state-ofthe-art of pilon fracture management.
CLASSIFICATION

For classification systems to be useful tools, any system must determine prognosis as well as guide treatment. By comparing similar fracture patterns, different treatment protocols can be analyzed; this is especially true when evaluating distal tibia fractures. Several published reports discuss the reliability and reproducibility of the most commonly used 18, 27 By using the K classification systems.lO, coefficient, these studies have shown moderate 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, Tampa General Hospital, Tampa, Florida (Rs) ORTHOPEDIC CLINICS OF NORTH AMERICA
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Figure 1. Ruedi and Allgower classification of piton fractures. (FromRuedi TP,Allgower M: Fractures of the lower end of the tibia into the ankle joint: Results 9 years after open reduction and internal fixation, Injury 5130,1973; with permission.)

ferent classification schemes. The K coefficient is an agreement measure used to determine interobserver and intraobserver reliabilit~.'~ These studies show the difficulty in examining scientifically the literature and its impact on treating fractures of the tibia1 pilon. The Ruedi-Allgower classification is the most commonly used scheme for describing

pilon fractures (Fig. 1).Type 1 fractures are cleavage fractures without displacement of the articular surface. In type 2 fractures, there is displacement of the joint surface without comminution. Type 3 fractures have displacement and comminution. The AO/OTA classification provides the most detail but is the most complex classification system (Fig. 2).

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Figure 2. Comprehensive classification of fractures of the long bones for the distal tibia. These are all type 43-XX. (From Muller ME, Schneider R, Allgower M, et al: Manual of Internal Fixation. New York, Springer-Verlag. 1991, pp 146-147, 596; with permission.)

Fractures of the distal tibia have the designation 43. Similar to all articular fractures in the AO/OTA classification, type A fractures are extra-articular, type B fractures are partial articular, and type C fractures are complete articular fractures. Type A fractures are divided further into Al, simple fractures; A2, wedge fractures; and A3, complex fractures. Type B fractures are divided further into B1, pure split fractures; B2, split depression fractures; and type B3, multifragmentary depression fractures. Type C fractures are divided further into C1, fractures that have simple articular and metaphyseal components; C2, fractures that have simple articular and multifragmentary metaphyseal elements; and C3, multifragmentary fractures of the articular surface

and metaphysis. Each group is divided further into subgroups based on location of the fracture and fracture pattern. Multiple studies have shown that distinguishing beyond the fracture type (A, B, C) is meaningless because there is no interobserver or intraobserver reliability.lO, 18, 27 Swiontkowski et a127showed that the best measure one could obtain when using this classification is moderate reliability. As further subdivisions are used and fracture subgroups are used, the reliability drops to fair as determined by the K coefficient.
RADIOGRAPHIC EVALUATION

Plain radiographs are mandatory for evaluation of fractures of the distal tibia fracture.

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Essential radiographs include a film centered on the ankle and one of the entire tibial shaft. Ankle films are used to delineate articular incongruity and fragmentation. Joint impaction is detected frequently on the lateral radiograph. The metaphyseal and diaphyseal extent of injury is appreciated on the fulllength tibial series. These radiographs should be scrutinized for any proximal injuries that can be overlooked easily. Tomograms are no longer useful and have been superseded by CT scans. CT is a useful adjunct to plain radiography. CT scans can allow the surgeon to approximate the degree of three-dimensional anatomic disruption, which may be subtle on plain radiographs. CT scans allow surgical planning of incisions and lag screw placement. These scans can help determine if an acceptable reduction has been obtained by a closed technique or whether open reduction is necessary. CT scans are indispensable for planning thin wire placement when using hybrid fixators. Tometta and GorupZ8noted a 64% change in the operative plan when CT scans were reviewed in addition to plain radiographs. These investigators recommended routine use of CT scans to aid preoperative planning of fixation of pilon fractures.
TREATMENT OPTIONS Nonoperative Treatment

Early results using nonoperative treatment of displaced high-energy, intra-articular fractures of the distal tibia were disappointing.', 8, 21 Nonoperative treatment should be reserved for patients with nondisplaced fractures and for patients who have a poor medical prognosis.
Operative Treatment

Operative treatments include internal fixation and external fixation. Internal fixation can be performed in one stage or two and performed early or late. External fixation includes fixation techniques that cross the joint and techniques that do not. The use of external fixation can be coupled with formal or limited open reduction and percutaneous joint stabilization. As a result of poor outcomes associated with nonoperative treatment of displaced intra-articular distal tibial fractures, Ruedi and A l l g o ~ e r24~investi~,

gated other means of treatment. Their initial report was published in 1969u with a 9-year follow-up reported in 1973.24 Ruedi and Allgower's principles for treatment included (1) reestablishment of fibular length, stabilizing the lateral column; (2) reconstruction of the lower articular surface of the tibia; (3) placement of metaphyseal bone graft; and (4) stabilization of the medial aspect of the tibia using a plate. Using these techniques, Riiedi and Allgower" obtained 73.7% good functional results with 90% of patients returning to their preinjury occupations. This report correlated the adequacy of reduction with a functional end result. The follow-up report showed that posttraumatic arthritis usually manifested itIf~not experienced self within 1 to 2 ~ e a r s . 2 within this period, arthritis rarely developed. Of the 84 fractures, 60 were secondary to lowenergy skiing injuries. Five were related to motor vehicle accidents, and five were classified as open fractures. With these relatively low-energy injuries, these investigators reported a 12% incidence of wound healing problems and a 5% incidence of deep infection. In 1976, Heim and Naser12 reported 90% good-to-excellent results using the techniques described by Ruedi and Allgower. These were mostly lower energy injuries. Kellam and Waddell14reported on a series of 26 patients, dividing them into 2 groups based on fracture pattern. Type A fractures were twisting injuries with little comminution, whereas type B fractures were more severe injuries with a crush component. Overall, 65% of cases had good-to-excellent results. Better results were obtained with type A fractures (84%) than type B injuries (53%). Crucial factors besides fracture type were the length of immobilization and quality of reduction. Prolonged immobilization resulted in poor outcome. This study showed the need for stable fixation to permit early range of motion. Ovadia and Beals2' reported on a large series of patients treated with a variety of different methods. They divided their treatment groups into patients treated with A 0 technique and patients treated with other methods. Ovadia and BealsZ1introduced a new classification scheme based on 5 fracture types, expanding the Ruedi and Allgower scheme. Prognostic variables associated with the final result were fracture type, quality of reduction, and method of treatment. Ovadia and Beals2' classified pilon fractures into 5 types depending on degree of comminution

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an anatomic reconstruction was obtained. and displacement of the articular surface as well as metaphyseal involvement. Type 1 Based on their results, Ovadia and Beals2' recommended open reduction and internal fractures are nondisplaced articular fractures. fixation for all displaced pilon fractures but Type 2 fractures are minimally displaced. cautioned against the use of a limited incision Type 3 fractures are displaced with several large fragments. Type 4 fractures have a large technique. Bourne et a18 reported a 13% incidence of metaphyseal defect. Type 5 fractures have sedeep infection with higher energy injuries. vere comminution. These authors noted better functional results All type 1 fractures, regardless of treatment in Ruedi and Allgower type 1 and 2 fractures modality, had a good-to-excellent result, comand fractures in which stable anatomic fixapared with only 22% of type 5 fractures ( P = tion could be achieved. In 1986, Dillin and 0.01). Fracture type was associated closely with quality of reduction. Ovadia and BealsZ1 Slabaugh9 reported disastrous results when noted that gaps in the articular surface were inadequate and unstable internal fixation was associated with worse outcomes and recomused to treat pilon fractures, including a 36% rate of skin slough and a 55% infection rate. mended closing all fracture gaps whenever Mast et all9 recommended the use of open possible. Clinical results paralleled the quality reduction and internal fixation for displaced of reduction obtained. Of fractures with a pilon fractures. These investigators advocated good reduction, 89% were rated as good to surgery within 8 to 12 hours or delaying surexcellent. Conversely, all patients with a poor gery until soft tissue edema was decreased. reduction had a poor clinical outcome. Patients treated with stable internal fixation did They believed that once swelling had ocbetter than patients treated by other means curred, an operative procedure was unwise because the marginal condition of the soft (74% good-to-excellent results versus 54%; P tissue would make wound closure difficult, 5 0.05). Of patients with stable internal fixaincreasing the risk of skin slough and infection, 69% returned to their preinjury level of tion. Patients with type 1 and 2 fractures employment, compared with 43% of patients could be treated with splinting, but patients in whom stable fixation could not be obtained with type 3 were thought to need calcaneal ( P 5 0.05). Overall, 65% good-to-excellent results were obtained in type 3, 4, and 5 fractraction to prevent tibial shortening, which would lead to a more complicated reconstructures when Ruedi and Allgower's principles tion. were observed as compared with 34% when Trumble et a130 reported on five cases of they were not. This series included injuries full-thickness tissue loss treated with radial of a higher energy pattern than Ruedi and forearm flaps. The average length of delay Allgower's series. Forty-six percent (66 of 145) were related to motor vehicle accidents from injury to surgery in these patients was or significant falls, and 29 were open frac4.6 days (range, 1-6 d). This study highlights the need to avoid surgery during this time of tures. critical soft tissue stabilization. A high-energy injury pattern correlated Helfet et all3 reported on a group of pawith a higher incidence of wound healing tients with higher energy injuries and noted complications. In the closed injury group, 77% and 63% good-to-excellent results in there was a 10% incidence of superficial Ru;auedi and Al1go;auwer type 2 and 3 fracwound infection and 6% incidence of osteomyelitis. In patients with open fractures, there tures. Helfet et all3noted the results of operative treatment depended on the quality of was a 31% incidence of infection, 10% rate reduction, severity of injury, fracture type, of osteomyelitis, and 21% rate of superficial and degree of stability that could be obtained. infection. There was no difference in the comBy obtaining an anatomic reduction with staplication rate for each group regardless of ble internal fixation and early motion, these treatment method. The only exception to this finding was in the group undergoing limited authors achieved acceptable results. To minimize complications, they delayed surgical inincision technique for hardware placement. This group of patients experienced much tervention until the soft tissues were safe. No significant soft tissue complications occurred worse results compared with patients in the in the closed fracture group. other treatment groups. Three patients reLeone et all6decreased the infection rate by quired amputation for chronic osteomyelitis. primarily closing the tibial wound and treatIn this study, 12% of patients required an ing the fibular wound with a delayed closure ankle fusion or joint arthroplasty even when

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or with immediate skin grafting. Using this technique, these investigators reduced the incidence of infection and skin complications to one case. Other surgeons tried to address these complications and problems by changing treatment from internal to external fixation with or without limited internal fixation. It was not always possible to reconstruct comminuted fractures through these limited appro ache^.^ Although there were no infections reported, one case required an amputation, highlighting the seriousness of these injuries. Other authors, using transarticular and nonbridging frames, corroborated these findings.2,6, 4, 7, 25, 29 By using transarticular external fixation with limited internal fixation, Bone et a16 decreased complications to only minor pin tract infections. They delayed open reduction for an average of 5 days and minimized soft tissue dissection and stripping. Although Bone et a16 operated on patients sooner than what the authors currently would recommend, careful attention to the soft tissues and l i m ited surgical incisions minimized the soft tissue complications. A deed infection rate of 0% represented a marked improvement over previous reports. As a result, Bone et a16 recommended this protocol for all significantly comminuted fractures of the tibial plafond. Bonar and Marsh4reported on the use of a hinged transarticular external fixator to treat pilon fractures. Used as portable traction, these transarticular external fixators were placed on the medial side of the lower extremity with one fixation pin placed into the talar neck, 1 pin into the calcaneus, and 2 pins into the tibia. No attempt at open reduction was made in 5 cases with severe intraarticular comminution. In patients who had joints that were deemed salvageable, the fixator was used to obtain and maintain a reduction of the pilon fracture through ligamentotaxis. All patients in this series were Ruedi and Allgower type 2 (n = 9) or type 3 (n = 12); this series included seven open injuries. Before reduction and after external fixator placement, traction radiographs were studied as a guide to major fragment displacement and to help guide placement of subsequent screw fixation. Surgery was delayed an average of 7.5 days because of soft tissue swelling. There was one amputation in the group secondary to the severe nature of the patients injury. Postoperative complications were minimal with no

cases of superficial or deep wound infection or dehiscence. Frequently the calcaneal and talar screws were loose. There were five cases of pin tract infections; two required oral antibiotics, two required intravenous antibiotics, and one required external fixator removal and was associated with a subsequent deformity. There was no late surgery or osteomyelitis related to the talar or calcaneal pin tracts. In the follow-up study,749 fractures were treated under a prospective protocol. Ten patients experienced pin tract problems, eight required antibiotics alone, and one required pin tract debridement for the drainage. There were no cases of late osteomyelitis in the calcaneus or the talus. There was no evidence of avascular necrosis of the talus on any radiograph. There were no wound problems relating to the medial tibial incision, but three patients experienced fibular wound healing problems. One patients incision healed after surgical debridement, hardware removals, and intravenous antibiotics. There were no secondary surgeries related to the tibial incision. All but one (48 of 49) patient experienced complete wound closure eventually. As expected, after the use of limited incision techniques, there were no excellent results with respect to articular reduction. The articular reduction was described as good in 69%, fair in 20%, and poor in 11%. In this study, transarticular external fixation avoided significant soft tissue problems typically experienced in the operative treatment of tibial pilon fractures. Pin tract infections occurred at a rate of 20% but without any long-term sequelae. The main limitation of this technique appears to be the limitations to obtaining an excellent articular reduction. Although unknown, this limitation may have a significant effect on long-term clinical outcome. Using the technique of hybrid external fixation, Tornetta et alZ9accomplished similar results. Without crossing the ankle joint, tensioned 2-mm wires were placed in the distal tibia with half-pins more proximally in the tibia. Surgical incisions were made over the fracture sites after a period of soft tissue stabilization. Patients with Ruedi and Allgower type 2 and 3 fractures were placed in skeletal traction, and surgery was performed when edema resolution had occurred, usually at 5 to 10 days. With this technique, 69% good results were obtained in the higher energy injuries, and major complications were avoided. There was one deep infection, one

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superficial infection, one malunion, and three pin tract infections. Using the same technique, Barbieri et a12 achieved similar results in the higher energy fractures. They had 67% acceptable results without significant complications. There were three cases of osteomyelitis, one skin slough, and five pin tract infections. Three patients had loss of reduction that required frame revision. Overall, limited incisions and use of a hybrid external fixator obtained good results with minimal complications. As experience with hybrid external fixation grows, it appears that its principal advantage lies in its soft tissue management, despite the fact that an anatomic articular reduction may be impossible using these limited techniques. Two questions then arise. First, is open reduction and internal fixation of pilon fractures unwise because of the increased risk of soft tissue complications? Second, are better results obtained with one method as opposed to another? To try to answer these questions, Wyrsch et a133conducted a randomized prospective trial comparing open reduction and internal fixation with external fixation. Group I, the internal fixation group, had a 28% rate of infection, 33% wound dehiscence rate, and 3 (16%) amputations. Group 11, the external fixation group, had a 5% skin slough rate, a 5% infection rate, and no amputations. These authors concluded that limited internal fixation combined with external fixation is an equally effective and significantly safer method of treatment for most fractures of the tibia1 plafond. This conclusion was based on the substantially greater number of complications experienced after open reduction and internal fixation without any differences in long-term clinical outcome. A critical examination of these data reveals that the 2 groups were treated in a different manner. Patients treated with external fixation had surgery performed at presentation (11 of 20)' within hours, or after a delay of 1 week or more (7 of 20). Most (14 of 19) of the patients undergoing open reduction and internal fixation were operated on at 3 to 5 days after injury, when swelling was the greatest. It is no wonder that these latter cases experienced wound complications because the ultimate outcome for each treatment group may have been related to the differences in the period of time between injury and surgery. This study shows that open reduction and internal fixation for pilon frac-

tures 3 to 5 days after injury can lead to a 3o high rate of soft tissue c~mplication.'~, Two studies using a staged protocolz, 26 for the management of soft tissue injury in highenergy pilon fractures have been reported. Stage one consists of the immediate application of a transarticular external fixator accompanied by open reduction and internal fixation of the fibula. Stage 2 occurs after soft tissue stabilization has taken place and formal reconstruction is safe, typically at 10 to 14 days after the injury. By using this technique, major soft tissue complications can be avoided. Minor problems in wound healing do occur but can be treated successfully with local wound care and oral antibiotics. By using this staged protocol, wound healing complications were reduced to 5.3% in all fractures and 2.9%in closed fractures. All wound healing problems occurred in patients who experienced high-energy injuries. There were seven minor wound problems, of which all were treated successfully with local wound care and oral antibiotics; hospitalization was unnecessary. No patient required free tissue transfer for wound management.26Patterson and Cole22 used a similar protocol with equally encouraging results.
TIMING OF TREATMENT

The timing of an operative procedure is determined ultimately by the method of reconstruction. Performing surgery when soft tissue swelling is reduced minimizes complications. Staged procedures frequently are required to reduce complications and to maximize functional results. In a staged protocol, immediate operative intervention (within 12 to 18 hours of injury) is performed by stabilizing the fibula with a plate and using transarticular external fixation to reestablish anatomic bone length and to obtain a preliminary articular reduction by ligamentotaxis. The distraction provided by the external fixator prevents soft tissue contracture, preventing tension of the surgical incisions after definitive placement of fixation. Surgery within the first 72 hours usually is reserved for fractures that are to be treated with limited internal fixation and small wire external fixation. External fixation wires can be placed at the joint or across the fracture. A well-trained and experienced radiology technician is invaluable when performing percutaneous and limited fixation procedures. Per-

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forming these procedures semielectively can only enhance the surgeons performance. Careful planning is necessary for placement of tensioned wires and percutaneous screws if stable fixation is to be achieved. Formal open procedures should be delayed until soft tissue swelling has decreased because the tissues are tenuous and cannot withstand surgical trauma. Wagner and Jakob31showed that when operating on bicondylar tibial plateau fractures, the highest rate of soft tissue problems was encountered when surgery was performed within 7 days from the time of injury. Wyrsch et a133showed an incidence of 28% infection, 33% wound problems, and 16% amputation when open stabilization was performed on the distal tibia within 3 to 5 days after the initial injury. Operating during this period is unwise. When open reduction is contemplated, delaying the procedure for 4 weeks to allow the soft tissue swelling to subside has been quoted by some authors as being ideal?, 13, 16,22 This delay may lead to difficulty in identifying fracture fragments and obtaining perfect articular surface reduction, however.
AUTHORS PREFERRED TECHNIQUE FOR MANAGEMENT OF PILON FRACTURES

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

partment. Patients are immobilized with a well-padded splint with a bulky-type compression dressing. When hemodynamically stable, patients are brought to the operating room for placement of a transarticular external fixator and open reduction and internal fixation of the fibula. The lateral incision is made on the posterolateral aspect of the fibula to allow for the maximum distance from the medial tibial incision that will be used eventually for definitive fixation (Fig. 3 ) . Open fractures undergo irrigation and d6bridement. Patients with isolated or minor injuries are discharged 24 hours after the initial procedure. They are instructed to perform strict elevation of the operative limb on discharge from the hospital. When soft tissue swelling is minimal, a safe open reduction is planned, usually in about 10 to 21 days. If multiple injuries have occurred and the patient remains hospitalized, the extremity is observed, and surgery is planned at the appropriate time. The definitive reconstruction is performed through an anterior-medial incision. An adequate skin bridge is essential to avoid soft tissue complications. The skin incision begins on the the tibial crest medial to the tibialis anterior, 7 cm away from the lateral fibular incision. The incision is carried distally across the ankle joint, staying medial to the tibialis anterior tendon. The extensor retinaculum is

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

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Figure 4. Femoral distractor to help position fragments. (From Muller ME, Schneider R, Allgower M, et al: Manual of Internal Fixation. New York, Springer-Verlag, 1991, pp 146-147, 596; with permission.)

incised. The tibialis anterior tendon and paratenon should be avoided. In the distal extent of the wound, the plane between the tibialis anterior and posterior is exploited. The inci-

sion is carried down to periosteum in an attempt to maintain full-thickness flaps. Periosteal stripping and anterior compartment elevation are performed only where needed. A femoral distractor or the previously placed external fixator can be used for ligamentotaxis and indirect joint surface and fracture reduction (Fig. 4). The joint surface is reconstructed anatomically using the anterolateral tibia1 fragment as a guide. This Chuput fragment maintains its attachment to the fibula. The joint is stabilized provisionally with Kirschner wires. Lag screws are placed into large fragments as needed, and an anteromedial cloverleaf plate is secured to the tibia (Fig. 5). This exposure is extensile and allows concomitant treatment of talar injuries. It also allows for later ankle fusion, if needed. Primary bone grafting is used rarely except for massive defects. Postoperatively, patients are maintained on intravenous antibiotics for 48 hours. The limb is immobilized until the soft tissues are healed and the sutures are removed. Early range of motion is instituted once wounds are healed, with formal physical therapy reserved for patients after the fracture begins to heal. The limb is immobilized for wound drainage or concerns over partial-thickness or full-thickness wound necrosis. Weight bearing typically is instituted at 3 months but

Figure 5. A and 8 , Anteroposterior radiographs of pilon fractures treated with open reduction and 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 be obtained using this protocol (Fig. 6).
EXTERNAL FIXATION ALONE AS DEFINITIVE FIXATION

fixator frame placement, patients follow a similar course as described for open reconstruction.
HYBRID EXTERNAL FIXATION ACCOMPANIED BY PERCUTANEOUS FIXATION

Certain fracture patterns may be amenable to external fixation alone. Patients with highly comminuted articular surfaces may not be candidates for internal fixation. Similarly, ligamentotaxis may allow adequate articular surface reduction or may be appropriate for extra-articular distal tibial fractures. Preoperative evaluation and immobilization are similar to the authors preferred treatment method. The patients fracture pattern determines whether a definitive hybrid frame is placed or whether a temporizing transarticular fixator is needed. After initial external

Figure 6. Range of motion of ankle joint with formal open reconstruction. A, Plantar flexion. 6, Dorsiflexion.

When the articular surface is nondisplaced, definitive fixation can be performed primarily. If the articular surface is displaced minimally, percutaneous screw fixation may be performed before external fixator placement. The remainder of the extra-articular fracture components can be reduced and stabilized by a hybrid external fixator. Olive wires are placed in the distal segment, with proximal half-pins being placed second. The first thin wire is placed from posterolateral, through the fibula, to anteromedial. The second wire placed is from posteromedial, anterior to the posterior tibial tendon, to anterolateral (Fig. 7). This placement follows the safe zones as described by Behrens and S e a r l ~The . ~ authors attempt to maximize the angle between these wires whenever possible. These wires are then connected to a 5/s ring and tensioned. Next, 2 Schantz screws are placed into the diaphysis proximally. These half-pins are connected to the distal ring with radiolucent bars. Axial traction is applied, and length and alignment are restored. The frame is tightened, and the carm is used to check the reduction. Finally, a third tensioned wire is placed in the distal segment to increase stability of the distal segment. As a final check, all nuts and bolts are tightened. Final radiographs are obtained while the patient is still under anesthesia. Radiographs taken on full-size 14 X 17 sheets allow the surgeon to determine whether the final alignment is acceptable. Postoperatively, patients are encouraged to move their ankles within pain tolerance. If they are unable to cooperate with this, a footplate is placed to keep the ankle in dorsiflexion. As an alternative, a metatarsal pin can be placed to keep the foot in neutral. If placed, this pin is removed at about 4 weeks postoperatively when the soft tissues and the patients pain level allow ankle motion. Typically, 30 lb of weight bearing is allowed immediately with full weight bearing at 6 to 8 weeks. Dynamization is performed as a means to test 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 and external fixation. J Orthop Trauma 7:489496, 1993; with permission.)

process. The frame is left in place until fracture healing is complete. Early removal may result in subsequent deformity. Frame removal may be performed in the office when no serious pin tract infections have occurred and the surgeon is convinced that the fracture is healed completely. If a significant pin tract infection has occurred, the bone should be overdrilled and the soft tissue debrided. When unsure about fracture healing, a fluoroscopic examination is invaluable. The frame is loosened, and the fracture stability is tested.

SUMMARY

formed with plates and screws when operative intervention is safe. These methods appear to be equally effective in reducing major soft tissue complications. Surgeons should treat these complex fractures with the method with which they are most comfortable. Surgeons who feel comfortable with techniques of internal fixation are best qualified to perform open reductions. Surgeons who have experience with percutaneous fixation and hybrid external fixator application should use this method. Surgeons with limited or minimal experience with pilon fractures should consider fibula fixation and transarticular external fixation followed by transfer to an orthopedic trauma surgeon for definitive management.
References
1. Ayeni JP: Pilon fractures of the tibia: A study based on 19 cases. Injury 19:109-114,1988 2. Barbieri R, Schenk R, Koval K, et a1 Hybrid external fixation in the treatment of tibial plafond fractures. Clin M o p 332:16-22,1996 3. Behrens F, Searls K External fixation of the tibia: Basic concepts and prospective evaluation. J Bone Joint Surg Br 68:246,1986 4. Bonar SK, Marsh JL: Unilateral external fixation for severe pilon fractures. Foot Ankle Int 14:57-64,1993 5. Bone L, Sucato D, Stegemann PM, et al: Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. J Bone Joint Surg Am 79:1336--1341,1997 6. Bone LB, Stegemann P, McNamara K, et a1 External

Soft tissue complications, skin slough, and superficial infection lead to deeper infection and amputation. By avoiding these complications, it is expected that better results can be obtained. Two techniques are available to do this. The first is to limit incisions and use external fixation to obtain stability. Even in these cases, care must be taken with the soft tissues. The second is a staged reconstruction, whereby stage one allows soft tissue stabilization. To this end, the fibula is plated, and transarticular external fixation is performed; this maintains anatomic length, preventing soft tissue contraction and permitting edema resolution. The second stage, formal tibial open reduction and internal fixation, is per-

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20. Muller ME, Schneider R, Allgower M, et al: Manual of Internal Fixation. New York, Springer-Verlag, 1991 21. Ovadia DN, Beals RK: Fractures of the tibial plafond. J Bone Joint Surg Am 68: 543-551,1986 22. Patterson M, Cole J D Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma 13235-91, 1999 ' I T Allgower M Fractures of the lower end of 23. Ruedi , the tibia into the ankle joint. Injury 1:92-99, 1969 ' l T Allgower M Fractures of the lower end of 24. Riiedi , the tibia into the ankle joint: Results 9 years after open reduction and internal fixation. Injury 5:130, 1973 25. Saleh M, Shanahan MD, Fern E D Intra-articular fractures of the distal tibia: Surgical management by limited internal fixation and articulated distraction. Injury 24:37-40,1993 26. Sirkin M, Sanders R, DiPasquale T, et a1 Results of a staged protocol for wound management in complex pilon fractures. J Orthop Trauma 13:78-84, 1999 27. Swiontkowski MF, Sands AK, Age1 J, et al: Interobserver variation in AO/OTA fracture classification system for pilon fractures: Is there a problem? J Orthop Trauma 11467-476, 1997 28. Tometta PI, Gorup J: Axial computed tomography of pilon fractures. Clin Orthop 323:276, 1996 29. Tometta PI, Weiner L, Bergman M, et al: Pilon fractures: Treatment with combined internal and external fixation. J Orthop Trauma 7489496,1993 30. Trumble TE, Benirschke SK, Vedder N B Use of radial forearm flaps to treat complications of closed pilon fractures. J Orthop Trauma 6358-365, 1992 31. Wagner HE, Jakob Rp: Zur problematik der plattenosteosynthese bei den bikondylaren tibiakopffrakturen. Unfallchinug 89304-311, 1986 32. Whittle AP, Crates J: Distal fourth tibial fractures treated with locked intramedullaq nailing [abstr]. Orthopaedic Trauma Association, Annual Meeting, Louisville, KY, 1997 33. Wyrsch B, McFerran MA, McAndrews M, et al: Operative treatment of fractures of the tibia plafond: A randomized, prospective study. J Bone Joint Surg Am 78: 1646-1657, 1996

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Address reprint requests to Michael Sirkin, MD Department of Orthopaedics New Jersey Medical school 90 Bergen Street, DOC 5200 Newark, NJ 07103