Pilon Fractures

Matthew Anderson

Stefanos Haddad

Andrew J. Rosenbaum

Sterile Instruments/Equipment

Tourniquet
Implants
- Distal tibia periarticular plating system locking and nonlocking
- Tubular plates
- Small fragment plates and screws
- Mini-fragment plates and screws
- Plan for bone graft—autograft, allograft, DBX, or other substitutes
Large external fixator
Small-caliber Kirschner wires
Wire driver/drill
Large universal distractor
Pointed and serrated bone clamps
Small and large bone picks and hooks
Bone foam or other radiolucent support for injured leg
Bulky Jones splint materials
Intraoperative fluoroscopy

Positioning/Preparation

Preoperative computed tomography (CT) for planning
Discuss pain management with anesthesia; regional nerve block is recommended.
Supine positioning with a towel bump under the hip on operative side to make foot neutral. Lateral positioning may be necessary to access the posterior malleolus.
Use bone foam or padding to elevate surgical leg above contralateral.
Pad bony prominences (eg, contralateral heel).
Place distal thigh tourniquet and secure with silk tape.
Administer prophylactic antibiotics (1-2 g cefazolin or a similar antibiotic).
The operative limb should be prepped in the usual sterile fashion. The external fixator pins are also prepped so that they can be included in the sterile field.
Drape with 1 to 2 U-drapes and an extremity drape, leaving proximal leg to calf on sterile field.

Surgical Approach

The surgical approach for definitive fixation depends on the fracture pattern. The anterior approaches provide access to the plafond for adequate restoration of the articular surface, but the choice is usually determined by the site of comminution.

Direct Anterior Approach

Mark out incision starting 10 cm proximal to the joint and 2 cm lateral to the anterior crest of the tibia, passing between malleoli and ending 5 cm distal to the joint (Figure 24-1).
Stay superficial on initial dissection to avoid injuring superficial peroneal nerve branches. Identify the superficial peroneal nerve, release along its length, and protect.
Incise the deep fascia in line with the skin incision. Identify the plan between the tibialis anterior (TA) and extensor hallucis longus (EHL) proximally.
Identify the neurovascular bundle of the anterior tibial artery and deep peroneal nerve.
The nerve can then be retracted medially with the TA or laterally with the EHL (Figure 24-2).
Incise the joint capsule in line with the skin incision.
Expose the entire width of the ankle joint by subcapsular dissection (Figure 24-3).

Figure 24-1. Anterior approach—a 10-cm longitudinal skin incision is performed lateral to the tibialis anterior tendon. Reprinted with permission from Kristen KH, Trnka HJ, Wien F. Ankle arthrodesis with an anterior approach. Tech Foot Ankle Surg. 2007;6(4):243-248. doi:10.1097/BTF.0b013e31815bc388.

Figure 24-2. The neurovascular bundle is gently mobilized; the tibialis anterior tendon is retracted medially and the extensor digitorum longus tendon laterally. Reprinted with permission from Kristen KH, Trnka HJ, Wien F. Ankle arthrodesis with an anterior approach. Tech Foot Ankle Surg. 2007;6(4):243-248. doi:10.1097/BTF.0b013e31815bc388.

Figure 24-3. Anterior approach and exposure of the ankle joint. Reprinted with permission from Vienne P. Agility total ankle replacement. Tech Foot Ankle Surg. 2005;4(1):62-68. doi:10.1097/01.btf.0000153685.03182.a8.

Modified Anteromedial Approach

The modified anteromedial approach makes a turn at the level of the ankle joint, providing greater access to the joint. It is helpful when significant medial comminution is present.

Mark out an incision starting 1 cm lateral to the anterior crest of the tibia following the course of the TA to the level of the joint, make a 110° turn medially, and end 1 cm distal to the medial malleolus.
Identify the medial aspect of the TA tendon. Ideally, the paratenon should not be violated.
Incise down to bone just medial to the TA, creating full-thickness flaps to minimize risk of subsequent necrosis (Figure 24-4).
Incise the joint capsule in line with the skin incision and subcapsullarly dissect to expose the plafond.

Figure 24-4. Extensile anteromedial approach. A, The skin incision is 1 cm lateral to the tibial crest proximally and then turns at a 110° angle at the ankle joint to end 1 cm distal to the medial malleolus. B, Full-thickness skin flaps are created to reveal the tibialis anterior tendon and extensor retinaculum. The saphenous vein and nerve should be protected. C, The extensor retinaculum is incised longitudinally, preserving the sheath of the tibialis anterior. D, Retraction of tibialis anterior laterally and the full-thickness skin flap medially provides a wide exposure of the anterior plafond from the medial malleolus to the anterolateral edge. Reprinted with permission from Warner SJ, Lorich DG. Surgical approach options for pilon fractures. Tech Foot Ankle Surg. 2016;15(4):169-174. doi:10.1097/BTF.0000000000000124.

Only gold members can continue reading. Log In or Register to continue