The pilon fracture

Abstract

Treatment of the ‘pilon’ fracture provides one of the greatest challenges to orthopaedic surgeons today. The force required to fracture the distal tibia can lead to complex fracture configurations and significant soft tissue compromise that challenge subsequent repair. High complication rates have encouraged extensive research over decades into an operative method that limits the insult to the surrounding soft tissue envelope whilst maintaining the stability of the fixation obtained. Two main techniques of fixation that meet such criteria have evolved more than others namely, open reduction and internal fixation (ORIF — two-staged protocol) and external fixation (ankle sparing hybrid fixation). Advances in these techniques have seen a significant reduction in the rate of catastrophic complications such as amputation, osteomyelitis and arthrodesis. The legacy of the pilon fracture, however, is such that it is hard to decide which treatment method is best and indeed severe fractures (AO classification type C2 or 3 or Reudi and Allgower type III) are better treated with primary arthrodesis and even amputation in some cases. Both methods have their drawbacks. A high prevalence of pin tract infections and possibly inadequate reduction may occur in some cases treated with external fixators. There is considerable variability of outcome with the two-staged protocol depending on the patients treated, the judgement and skill of the surgeon operating and risk of soft tissue compromise. The two-staged protocol seems to have a greater following and seems on the surface to get over many typical complications. No one treatment method is best for all fractures; in fact both are equally good for simpler fractures. It is their outcome in treating severe fractures that will determine which of the two methods is best and which could be adequately tested with a randomised controlled trial.