ISSN 0972-978X 

  About COAA








A one-year follow up of Pilon fractures of Tibia treated with Ilizarov   External Fixator without image intensifier guidance.

Faisal Nazeer Hussain*, Irfan Mehboob, Muhammad Naveed

Address for Correspondence

*Assistant Professor,
Department of Orthopedics Surgery,
Post Graduate Medical Institute, Lahore General Hospital,
Lahore 54792, Pakistan.


Introduction: 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.
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.
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.
Key Words: Pilon fractures, Tibial Plafond, Ilizarov Fixator.

J.Orthopaedics 2007;4(1)e16


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.

Statistical Methods:
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 retrospectively. 

Results :

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 fixator.

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 treatment.


Ability to walk on uneven surface

Ability to return to work


8/17 (47.05%)

10/17 (58.82%)


6/17 (35.29%)

3/17 (17.64%)


3/17 (17.64%)

4/17 (23.52%)

Table2: Patients Subjective Evaluation of treatment.


Pain on walking

Weakness of the limb


3/17 (17.64%)

4/17 (23.52%)


5/17 (29.11%)

10/17 (58.82%)


10/17 (58.82%)

3/17 (17.64%)

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 appointment .

Discussion :

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 complications.


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. 

Reference :

  1. B.J. Mockford 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, 104-107.

  2. Pankaj Kumar: Treatment of open fracture of tibial shaft comparison of external fixation versus intramedullary nailing as the primary procedure J.Orthopaedics 2004; 1(3) e3.

  3. Mchale, Kathleen A: The"floating ankle": A pattern of violent injury. Treatment with thin-pin external fixation,. Military Medicine: Jun 2002.

  4. 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.

  5. Hull JB, 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.

  6. Hays SM, 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.

  7. 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; 77(3): 429-34.

  8. Mcdonald MG, 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.

  9. Andrew N. 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).

  10. Patterson MJ, Cole JD: Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma: 1999 Feb; 13(2): 85-91.

  11. K. 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.

  12. David B. 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.

  13. Daniel Weber, 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. p 273-283.

  14. Jong-Keon Oh, 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: 542-546.

  15. Patterson MJ, Cole JD: Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma: 1999 Feb; 13(2): 85-91.

  16. Blauth, M.; 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. 

  17. Swiontkowski, 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.

  18. K. 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.

This is a peer reviewed paper 

Please cite as : Faisal Nazeer Hussain:A one-year follow up of Pilon fractures of Tibia treated with Ilizarov   External Fixator without image intensifier guidance.

J.Orthopaedics 2007;4(1)e16





Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.