Distal Tibial fractures involving the Plafond have been treated
in the past in various ways resulting in an array of
complications with each. There has been a recent trend to treat
them with external fixators. Circular fixators have a special
appeal in Pilon Fractures.
Study Design: Retrospective, Observational, nonrandomized,
without control group.
Material and Methods: Seventeen cases of
closed or Gustilo Type I/II open
fractures which had been treated with Illizarov Fixators with or
without the use of a U ring attachment or fibular plate
fixation. All had been allowed to bear full weight on the limb
in the early postoperative period. A follow up review was done
at the completion of one year.
Statistical Methods: None applicable because of the study
being retrospective & observational in nature.
Results: All cases healed with minimal displacement, a low
complication rate and high patient satisfaction rates regardless
of radiological misalignment of the bones. The time of fracture
healing was short and a good range of motion was achieved in
most at the end of one year.
Conclusion: Ilizarov fixators can be used with safety and
confidence in the treatment of Pilon fractures with low
morbidity of the procedure and satisfactory outcome where
facilities of image intensifier are not available.
Pilon fractures, Tibial Plafond, Ilizarov Fixator.
Fractures involving a major part of the
articular surface of the distal tibia are difficult to manage.
The French radiologist Destot first described the term ‘tibial
pilon’ in 1911 when he likened the shape of the distal tibia to
a pestle and compared the explosive impact of the talus against
the tibia to that of a hammer striking a nail1. High velocity
trauma is the cause of maximum number of morbidity in the
younger age group worldwide. Open fractures of the leg remain
the injuries with a higher complication rate. Bone and soft
tissue injuries need aggressive yet careful treatment to avoid
further damage that results in uncomplicated healing. Due to its
location, structural anatomy and sparse anterior soft tissue
coverage the tibia is particularly prone to exposure and
ischaemia due to injury2. Pilon fractures are high-energy
injuries and the primary component of force is vertically
directed through the talus into the distal tibia.
Characteristically, pilon fractures show varying degrees of
impact of the supraarticular metaphysic, comminution of the
tibial plafond and primary articular cartilage damage1,9. There
is usually associated major disruption of the soft tissue
envelope directly proportional to the amount of energy involved
in the traumatic event. Mal-position of distal fragments, loss
of leg length and later joint stiffness remain the main
concern3,4,9,10. Reduction and restoration of length can be
achieved through ligamentotaxis by various methods but calcaneal
traction or bridging external fixation is commonly employed12.
The use of the Ilizarov method of external fixation with
ligamentotaxis along with prudent internal fixation has proven
to be a successful regimen for the treatment of pilon
fractures10,11. This fixator has also been shown to be an
exceptionally fine tool for the reconstruction of complex
injuries around the ankle used as a definitive or temporary
fixation3,10,11. Re-absorbable implants have also shown
promise but the results in complex fracture patterns have been
unsatisfactory18. Operative treatment after high-energy pilon
fractures takes around 4 months on an average to heal where 75%
of patients who do not develop wound complications may expect a
good result4,10,11,15,16. However a very high rate of subsequent
arthrodesis rate like 10% has been reported in some
series4,10,11,15,16. Many studies have used a two stage method
to address the soft tissue injury with an external fixator first
and then they have fixed the fracture using minimal fixation
with or without a medially placed external fixator15,16,17 .We
have been experiencing some of the similar problems in our
practice and had started using the circular fixator in
epiphyseal-diaphyseal mode for the treatment of Pilon fractures.
Some of these cases had been treated without the use of image
intensifier due to its non availability for some time. Our aim
was to study a series of such cases retrospectively.
Material and Methods :
The study was conducted retrospectively and
27 patients were included from the records of the department who
had presented to the emergency after trauma or road traffic
injuries. All patients with Pilon fractures of the distal tibia
were included closed, Gustilo type I, and II which had been
treated with Ilizarov External fixator. Only those with Gustilo
Type III B or C injuries were excluded where a local flap
rotation or plastic surgery was required and the circular
fixator was expected to interfere with soft tissue
reconstruction procedures. A single observer evaluated each
patient clinically, classified the fractures radiologically
using Ruedi-Allgower method9 and the records were maintained by
the same to avoid any interobserver bias17. However various
different surgeons operated had upon the patients. The local
wounds had been looked after till they were expected to heal
without further operative effort (some were closed at the time
of second look debridement if possible). All were operated
electively within 5-12 days of injury without image intensifier
guidance and a 3/4-ring circular construct was used in a
bridging manner with or without a U-ring for the foot. The Image
Intensifier was not used because of its non-availability in the
unit at that time however intra-operative X-rays were acquired
at the end of the procedure where desirable. In some cases the
fibula was fixed using an AO 3.5mm Dynamic Compression Plate.
All cases were operated for fracture fixation
after closed reduction without image intensifier guidance. An
assistant applied traction to the foot while the other
maintained counter traction to the limb. After manipulation the
surgeon applied the three/four ring pre assembled Illizarov
construct holding the distal fragment with one or two rings with
tensioned cross wires and two proximal rings placed with two
tensioned cross wires applied around 2-3 centimeters from the
joint or fracture. Olive wires were used if fracture geometry
required so. On table X-rays were obtained in some to confirm
adequacy of reduction and placement of wires.
Post operatively the patients were allowed to
bear partial or full weight over the limb if other injuries
allowed and the fracture configuration/stability permitted. The
minor adjustments in alignments of the fractures were under
intravenous sedation in the ward if needed using the threaded
rods attached to the rings. The follow up in out patients clinic
had continued at monthly intervals till the fractures healed
radiologically when the fixator was removed on out patient’s
basis. However a protective below knee cast was applied if
needed. Bone graft was added to the fracture site in the follow
up period if there was a gap in the bone that was not expected
to bridge by itself. The patients were followed up for one year
afterwards at monthly intervals in the beginning and after each
three months. At the end of one year each was asked to come for
an evaluation which included fresh biplane X-rays, measurement
of ankle range of motion, questionnaire regarding ability to
walk on uneven surfaces, status about return to work, pain on
walking and weakness of the limb. The patients were asked to
grade them as Good/Fair/Poor based on their own observation.
Owing to small number of patients and possibility of type 2
errors no statistical analysis was performed. However a single
observer collected the data and the same person did the
radiological classification of the cases. Data was collected
All cases were followed up in the out patients at monthly
intervals when a note was taken of the wound condition, range of
motion of the knee/ankle, pin tracts and serial radiographs were
taken. Ten patients were excluded due to having segmental tibial
fractures in the same segment of the limb, ipsilateral
knee/lower femoral injuries/ or where a segmental loss in the
bone necessitated a distraction osteogenesis with the same
Seventeen patients fulfilling the criteria
were included in the final results. All were evaluated at the
end of one-year post operatively when they were reviewed for
limb length loss, deformity, asked to evaluate the treatment for
ability to use the limb/return to work/subtalar stiffness and
the ability to walk on uneven surfaces or about pain on walking.
A note was taken of the cases that had to be operated for bone
grafting. A total of seventeen patients were available for
evaluation out of which 5 were females. The average age was
41.35years (range 20-67 years). One patient had been injured
while playing football, 5 were injured after falls from height
and the rest were brought after road traffic injuries. Two
patients had bilateral injuries to the plafond region and both
had fallen from height. Right side was injured in 9 out of a
total of 17 patients while 2 had both limb fractures. Four limbs
had Type I injuries, 8/19 had Type II injuries and 7/19 had Type
III Pilon fractures classified as per Ruedi-Allgower9. The
patients were operated 6.65 days (range 3-12days) after injury.
The average operating time for each patient was 75.9 minutes
(range 50-200 min.). Five Fixators were applied with additional
U rings to hold the feet plantigrade. In 5 cases fibula was
fixed with a narrow 3.5 mm dynamic compression AO plate before
application of the external fixator. The average time to heal
was 17.05 weeks (range 14-28weeks).
Table1: Patients Subjective Evaluation of
Ability to walk on uneven surface
Ability to return to work
Table2: Patients Subjective Evaluation of
Pain on walking
Weakness of the limb
Ankle range of motion was
measured using a hand held goniometer at the time of last
evaluation. Average range of ankle motion was 40.260
(range 30-600). Nine patients (52.93%) complained of difficulty
in walking over uneven surfaces. Ten patients had returned to
work (58.82%). Three patients were experiencing feeling of
instability of the ankle joint (Table2) and had severe pain on
walking (Table:1). Stress view X-rays of the ankle were obtained
and one patient showed varus stress opening of the ankle but was
put on active physiotherapy to continue the follow up. Other two
may have to under go an ankle arthrodesis Only three patients
were happy with limb having regained the same strength as pre
injury status, whereas all the others rated the limb weaker than
before which could not be documented on clinical examinations
(Table:2). The muscle strength on MRC scale was found to be
normal and on peripheral nerve examination they had no deficit.
Complications were few including two cases of pin tract
infection/loosening, one had a wire breakage needing
replacement, two had more than 5 degrees of varus and one showed
varus malunion of the fracture more than 15 degrees. This
patient did not report for his follow up visits in time and had
a near union of the ankle fracture by that time when it was
decided to continue with the same treatment and consider other
options at a later stage. One patient developed Common Peroneal
Nerve injury immediately after surgery that recovered fully
after the injuring wire was replaced. At the end of one year the
number of follow up commitments complied with by the patient
were recorded against the expected number and only 60.05% of
times the patients turned up for their out patient clinic
Due to its location, structural anatomy and
sparse anterior soft tissue coverage the tibia is particularly
prone to exposure and ischaemia due to injury. The optimum
treatment for open fractures of the distal tibia remains
controversial. Treatment options include wound debridement,
reduction and immobilization with cast, open reduction and plate
fixation, external fixation and intramedullary nailing8. The
absorbable implants seem to provide a secure fixation in the
majority of ankle fractures but the use of these implants showed
unsatisfactory results in unstable and comminuted fractures11.
Our results have proven yet again the utility of Ilizarov
technique that provides near anatomic reduction and decreases
complications such as infection, malunion, nonunion and talar
avascular necrosis (AVN) by minimizing soft tissue disruption.
The third generation monolateral external Fixators such as the
dynamic axial fixator have led to improve patient care and a
resurgence of interest in external fixation techniques 5,6,7 of
particular merit is the 6mm tapered screw design and bimodal
characteristics of the fixator body, which may be converted from
rigid to dynamic support. Over a number of years of clinical
trials, the 6mm cortical tapered screws have provided strong,
durable fixation in diaphyseal bone. Osteolysis and infection
are rare events, provided that good surgical technique is
adhered to and the screws are inserted in the center of the
bone. By contrast, metaphyseal fixation has been less
satisfactory with loosening occurring more frequently. The
probable reasons for reduced performance relate to the open
"cell like" structure of trabecular bone and cantilever loading.
The Ilizarov technique offers many advantages over open
reduction and internal fixation (ORIF) for severe, intra-articular
fractures of the tibia by preservation of blood supply allowing
better healing and an earlier range of motion (ROM) is achieved
at three to four weeks. The patients in this small series have
also shown good recovery of ankle range of motion. However owing
to a closed application of the external fixator without the use
of image intensifier being not available at that time we have
faced a few mal-unions and had to add bone grafts at subsequent
surgeries. The results have been quite acceptable when compared
with other published series11. The Fibula had malunited close to
the ankle in some with some displacement and did not need to be
re-fixed as done by Daniel Weber et al in 200113. Monolateral
external Fixators support the bone by cantilever loading and
this leads to concentrated high stresses on the near cortex.
Repeated cyclical loading during gait is probably the
explanation for the loosening, which occurs. Our series has a
very low incidence of wire loosening and breakage probably due
to the multiplanar multilaterality of the ring fixator used.
Recent studies into have shown that the adequate strength of the
construct can be achieved with the usage of hybrid external
fixators and the addition of a medial half pin adds
significantly to it14. These findings may prove to be of value
in the cases where Tibialis anterior and posterior tendon
impalement is a problem in using two-pin fixation of the lower
ring14. In this study the range of motion achieved for the ankle
is lower than the average achieved by the other studies using
two stage fixation methods13,15,16.
The process of external fixation has many
complications as pin tract infection, aseptic non-union,
re-fracture and may need bone grafting but is said to have the
advantage of low infection rate. We did have a case where a wire
in the proximal ring had to be replaced due to dysfunction of
the common peroneal nerve. The operating time has been
relatively short due to prior assembly of the fixator and a
relatively simple technique without the help of the image
intensifier. However this management technique should be used in
relatively fresh cases where ligamentotaxis is expected to
reduce the fracture fragments more easily in the cancellous
area. Despite of our observations we do not recommend routine
usage of Illizarov Fixator to treat Pilon fractures without
image control. However where ever the facility is not available
there is place for its guarded usage with low expectancy of
Distal tibial fractures have shown a high
rate of wound dehiscence and infection following open reduction
and internal fixation using conventional hardware. Many
operative methods have been used in the past but the use of
Illizarov external fixators may become the gold standard if
applied with a meticulous technique. However the use of on table
X-ray image should be used and Closed/Grade I open fractures can
be treated in a single stage with adequate results.
L. Ogonda D. Warnock R.J. Barr C. Andrews: The early
management of severe tibial pilon fractures using a temporary
ring fixator Surg J R Coll Surg Edinb Irel. 1 April 2003,
Treatment of open fracture of tibial shaft comparison of
external fixation versus intramedullary nailing as the primary
J.Orthopaedics 2004; 1(3) e3.
Kathleen A: The"floating ankle": A pattern of
violent injury. Treatment with thin-pin external fixation,.
Military Medicine: Jun 2002.
L Dillin and P
Slabaugh. Delayed wound healing, infection, and nonunion
following open reduction and internal fixation of the tibial
plafond fractures.J. Trauma. Vol 26. 1986. p 1116-1119.
Sanderson PL, Rickman M, Bell MJ, Saleh M, External fixation
of children's fractures: Use of the Orthofix Dynamic Axial
fixator. J Paed Orthop part B, 6:203-206, 1997.
Rickman M, Saleh M. Fracture of the tibial diaphysis treated
by external fixation and the axial alignment grid. A single
surgeons experience. Injury Vol 28, No 7, 437-443, 1997.
Saleh M Rees
A. Bifocal surgery for deformity and bone loss after
lower-limb fractures. Comparison of bone transport and
compression distraction methods. J Bone Joint Surg (Br) 1995;
Burgess RC, Balono LE, Nicolls PJ: Ruedi T, Allgower M: The
operative treatment of intra-articular fractures of the lower
end of tibia, Clin Orthop 138:105,1979.
Pollak, MD, Melissa L. McCarthy, MSScD, R. Shay Bess, MD,
Julie Agel, ATC and Marc F. Swiontkowski, MD: Outcomes After
Treatment of High-Energy Tibial Plafond Fractures: The Journal
of Bone and Joint Surgery (American) 85:1893-1900 (2003).
Cole JD: Two-staged delayed open reduction and internal
fixation of severe pilon fractures. J Orthop Trauma: 1999 Feb;
Pelto-Vasenius, E. Hirvensalo, J. Vasenius, E. K. Partio, O.
Böstman, P. Rokkanen: Archives of Orthopedic and Trauma
Surgery:Vol.117,No;7: Feb. 1998. p152-62.
Thordarson: Complications After Treatment of Tibial Pilon
Fractures: Prevention and Management Strategies. J Am Acad
Orthop Surg, Vol 8, No 4, July/August 2000, 253-265.
Daniel Fritschy, Niklaus F. Friederich, Werner Müller:
Osteotomy of the Distal Fibula for Correction of Posttraumatic
Malunion. Orthopedics and Traumatology. Vol9, No: 4.Dec 2001.
Jeon-Joon Lee, Duk-Young Jung, Bong-Ju Kim, Chang-Wug Oh:
Hybrid external fixation of distal tibial fractures: new
strategy to place pins and wires without penetrating the
anterior compartment. Ach Orthop Trauma surg (2004) 124:
Cole JD: Two-staged delayed open reduction and internal
fixation of severe pilon fractures. J Orthop Trauma: 1999 Feb;
Bastian, L.; Krettek, C.; Knop, C.; Evans, S.: Surgical
Options for the Treatment of Severe Tibial Pilon Fractures: A
Study of Three Techniques. Journal of Orthopaedic Trauma.
15(3): 153-160, March/April 2001.
M. F.; Sands, A. K.; Agel, J.; Diab, M.; Schwappach, J. R.;
Kreder, H. J. Interobserver Variation in the AO/OTA Fracture
Classification System for Pilon Fractures: Is There a Problem?
Journal of Orthopaedic Trauma. 11(7): 467-470, October 1997.
Pelto-Vasenius, E. Hirvensalo , J. Vasenius , E. K. Partio ,
O. Böstman, P. Rokkanen: Redisplacement after ankle
osteosynthesis with absorbable implants.: Archives of
Orthopedic and Trauma Surgery: Vol 117, no:3, :February 1998
Pages: 159 – 162.