Abstract
Precise anatomical restoration of the articular surface is critical in managing tibial pilon fractures to prevent post-traumatic arthritis. We report a case of AO/OTA type 43B3 partial articular pilon fracture successfully treated with arthroscopy-assisted reduction and internal fixation (ARIF). A 21-year-old man presented with a right distal tibial fracture involving significant anterior articular surface depression following a traffic accident. To achieve accurate joint congruity, ARIF was performed after soft-tissue swelling subsided. Under arthroscopic visualization through standard portals, a 2 × 2 cm cortical window was created 3 cm proximal to the joint. The depressed articular fragments were reduced using a bone tamp through this window, and the resulting metaphyseal defect was filled with artificial bone. Final arthroscopic inspection confirmed anatomic reduction without residual step-off. Stable fixation was achieved using a buttress plate. At the 1-year follow-up, radiographs demonstrated solid bone union with maintained articular congruity. The patient regained painless, functional range of motion without complications. ARIF is an effective strategy for managing 43-B3 pilon fractures, allowing for precise restoration of the joint surface while minimizing additional surgical trauma.
Introduction
Tibial pilon fractures are complex intra-articular injuries of the distal tibia and are often associated with substantial soft-tissue compromise. The primary goal of treatment is to restore the congruity of the ankle joint while minimizing surgical trauma to the surrounding soft tissues. Achieving this balance remains challenging, particularly in fractures involving the articular surface.
Partial articular pilon fractures classified as AO/OTA type 43B3 are characterized by depression of the articular surface. In these fracture patterns, accurate reduction of the impacted joint surface is crucial to prevent post-traumatic ankle arthritis. However, precise assessment of the articular congruity can be difficult when relying solely on fluoroscopic imaging.
Conventional open reduction and internal fixation allow direct visualization of fracture fragments but may require extensive exposure, which increases the risk of wound complications, infection, and delayed soft-tissue healing. To reduce these risks, minimally invasive strategies such as percutaneous fixation and staged protocols have been increasingly adopted for selected pilon fractures.
Ankle arthroscopy has emerged as a useful adjunct in the management of intra-articular fractures, providing direct visualization of the joint surface and enabling accurate reduction of depressed articular fragments, which could ultimately improve patient outcomes.
In this report, we present a case of AO/OTA type 43B3 tibial pilon fracture treated with arthroscopy-assisted reduction and internal fixation. We describe the surgical technique and discuss the potential advantages of arthroscopic assistance in achieving accurate articular reduction while minimizing soft-tissue disruption, with reference to the existing literature.
Case presentation
A 21-year-old man with no significant past medical history presented to our emergency department after sustaining an injury to the right ankle following a traffic accident. The patient complained of severe ankle pain and was unable to bear weight on the affected limb.
Physical examination revealed marked swelling and tenderness around the ankle joint without open wounds or neurovascular deficits. Plain radiographs and computed tomography (CT) scans demonstrated a distal tibial fracture involving the ankle joint with anterior articular surface depression ( Figs. 1 , 2 ). Based on these findings, the fracture was classified as an AO/OTA type 43-B3 partial articular pilon fracture.
Plain radiographs of injury film with anteroposterior (A) and lateral (B) view. This is a anterior depression type of pilon fracture over tibial plafond with mild comminution. The fibula is intact and the ankle joint is congruent. The anterior depression fragment is marked with an asterisk. (C).
Computed tomography (CT) scan shows a anterior depression fragment (*) of tibial plafond. There is mild comminution of distal tibial plafond without significant displacement or bone loss. (A) Sagittal cut. (B) 3D CT.
Given the depressed anterior articular surface, arthroscopy-assisted reduction and internal fixation was planned to achieve accurate restoration of the joint surface. Surgery was performed after injury once swelling had subsided.
Under lower limb conduction anesthesia, the patient was placed in the supine position with a thigh tourniquet applied. Standard anteromedial and anterolateral ankle arthroscopy portals were established. Arthroscopic evaluation revealed the depressed anterior articular fragment of the tibial plafond and associated chondral injury ( Fig. 3 ), while the remaining articular surface was relatively preserved.
Arthroscopic imagines of the fracture. The anteromedial portal is the viewing portal. The anterior depressed fragment can be seen with obvious stepping. A fracture depression can be identified just anterior to the depressed fragment as well. The finding correlates with the computed tomography scan. (A)The anteromedial articular surface depression, (B) The anterolateral articular surface depression. The depressed fragment on the CT scan is marked by the white arrow.
Reduction was confirmed directly under arthroscopy and fluoroscopy. Using an anterior ankle approach, a 2 × 2 cm window was created 3 cm proximally and anteriorly from the articular surface, and bone fragments were reduced using bone tamp ( Fig. 4 ). An artificial bone was inserted to fill the void left by impaction and comminution.
