Tibial Pilon Fractures

Distal tibia fractures with joint involvement are rare (less than 1% of lower extremity fractures), but they are one of the most difficult injuries to treat for traumatologists seeking to achieve good results [1]. It was initially called “tibial pilon” by Destot in 1911, later, Bonin coined the term “tibial pylon fracture” in 1950 to describe the alteration of the roof of the ankle joint [2].

The mechanism of injury described presents two significant variants: a relatively low-energy torsional mechanism, associated with falls in sports activities, and another high-energy mechanism, in which the talus impacts axially on the distal tibia, producing fractures with comminution at different levels, generally associated with falls from height and car accidents [2]. The fracture pattern is determined by the position of the foot and, therefore, of the talus at the time of the injury.

The long-term outcome is often poor and correct initial management is crucial. In the early years of this century, treatment has evolved into a two-stage protocol, which today is the gold standard of care. Additional methods to treat soft tissue envelope are currently being investigated and have shown promising results for the future [3].

The aim of this review is to summarize strategies for the management of these difficult fractures, review the literature on recent developments, and thereby provide surgeons with a better understanding and ability to manage tibial pilon fractures.

Search strategy and selection criteria

The references were identified by searching PubMed, Google Scholar and Elsevier for publications between 2013-2025 in English with the terms: “treatment of tibial pylon fractures”, “management of fractures of the distal end of the tibia” and “metaphyso-articular fractures of the distal tibia”. Articles accessible freely or through the Clinical key and Hinari services were also reviewed.

A number of articles were selected that met the necessary requirements to support this review. Articles were added that are more than ten years old, but that are key to the topic. We excluded papers because they were duplicates or the source data was insufficient. Power Point presentations were discarded.

Development

There is a broad consensus that surgical fixation and reduction is the treatment of choice for tibial pilon fractures. However, in an ageing population, surgery sometimes cannot be carried out safely, in which case treatment consists of reduction and immobilization without weight bearing for 6 to 10 weeks with a heavy cast. In light of spinal anesthesia and modern methods of treatment, it is likely that at least external fixation is possible in most patients [4].

Until the beginning of the twenty-first century, the predominant criterion for the surgical treatment of tibial pilon fractures was that it should be performed as early as possible in order to reduce the associated complications and hospital stay. This view of surgical treatment reported good results when it came to low-energy injuries (Rüedi-Allgöwer I and II), but the results were not similar in high-energy trauma, highly comminuted and displaced tibial pylon fractures, and when there were comorbidities in the patient [5].

Due to this extremely high complication rate, the criterion of two-stage surgical treatment was established, which remains the most widely used treatment method for tibial pilon fractures today [6]. In recent decades, the therapeutic algorithm for pylon fractures has undergone a paradigm shift [7,8]. While 30 years ago pylon fractures underwent primary osteosynthesis and a single-stage surgical algorithm was proposed, today a two-stage protocol prevails [9,10]. Various studies confirm that meticulous planning, Respect for soft tissues and the choice of the optimal time for definitive osteosynthesis and general treatment according to standardized protocols can optimize the prognosis of this serious injury. However, the initial severity of the fracture in terms of initial absorbed energy, bone comminution, and soft tissue trauma still affects the prognosis.

Staged treatment

Tibial pilon fractures, particularly high-energy fractures, significantly affect the bone and soft tissues. Given the high rate of soft tissue complications associated with immediate open reduction and internal fixation, since the 1990s, and in particular after Sirkin’s work in 1999, treatment considers two stages: an initial external fixation for alignment and stabilization of the fracture and a delayed second stage, once the soft tissues are in good condition. for fracture reduction and osteosynthesis [6].

Although step therapy is currently the most widely used, there are cases in which there is no soft tissue involvement and immediate resolution of the fracture is doable, even in the first 72 hours, without increasing the risk of complications [11,12].

To counteract the risk factors and reduce the potential complications that define the prognosis of these serious injuries, clearly defined surgical principles and standardized treatment protocols are required [13,14]. During the initial management of tibial pilon fractures, closed reduction and external fixation are, in most cases, the first step of treatment, as fractures are too unstable and the soft tissues are compromised for retention with plaster [15]. An additional Steinmann nail in the calcaneus is frequently required to maintain length [16]. Proximal pins in the tibia should be placed proximal enough not to interfere with definitive osteosynthesis, while the entire structure of the external fixator should not be in the future surgical area to minimize metal artifacts during diagnosis by subsequent CT [17]. Several authors also recommend primary osteosynthesis of the fibula at this time to achieve, by means of ligamentotaxia, a better reduction of anterolateral and posterolateral tibial fragments [18]. However, this step should be carried out with caution, even in cases of simple fibula fractures, since it implies that the choice of surgical approach for definitive osteosynthesis can be established at this time. In addition, you should look for signs of compartment syndrome, which has been reported in up to 12% of cases; in which case an immediate dermatofasciotomy should be performed.

At the time of skeletal stabilization, the good results described by Ruëdi and Allgöwer in their publications of 1969 and 1973 [19,20] gave rise to the treatments that are still used today. These are sequential principles of fracture fixation, the objectives of which are to achieve anatomical reduction and stable osteosynthesis:
a) Recovery of fibula length.
b) Reconstruction of the articular surface.
c) Bone grafting in the metaphyseal region.
d) Stabilization of the tibia fracture with a medial plate.

Anatomical principles: columns and joint fragments

The concepts defined by Ruëdi and Allgöwer were based on radiographic studies; after the advent of CT scans in recent decades, we have better understood the morphology and patterns of fractures, which has led to new anatomical principles that better guide the treatment decision. In his 2013 study, based on CT images of tibial pylon fractures type C3 AO/OTA, Cole describes a constant fracture pattern at the joint level (more than 90% of cases); in which three main fragments can be seen: medial, anterolateral and posterolateral, with a Y-shaped base at the level of the fibular notch. In turn, the areas of greatest comminution are usually the central one, coinciding with the central point of the talus, and the anterolateral one [21]; (Figure 1).

Figure 1:Joint fragments in a pylon fracture. Note the fragments (1) medial, (2) posterolateral and (3) anterolateral of the pilon fracture. Anterolateral comminution is observed [21].

As for the columns or pillars, it refers to an anatomical continuum between the articular or epiphyseal fragments, with their respective metaphyseal and diaphyseal zones. Assal [22] in 2015, describes three spines, exclusively tibial: medial, lateral and posterior. More recent studies already consider four columns, by adding the distal fibula as one more column, which provides reduction and stability [23]; (Figure 2).

Figure 2:The four columns of the tibial pilon [23].

These four columns are:
a) Lateral spine: distal fibula
b) Posterior spine: posterior part of the articular fragment and one-third of the distal portion of the posterior tibia
c) Anterior spine: anterior part of the articular fragment and a distal third of the tibia anterior
d) Medial spine: one-third of the medial portion of the articular fragment and distal tibia.

The importance of these anatomical concepts lies in the fact that they recognize the joint areas and columns with greater comminution, which allows us to plan more precisely where to use the implants to stabilize the fracture. In the same way, we can plan the surgical approaches necessary to perform the surgery.

Prior to definitive osteosynthesis and after primary reduction and external fixation, a preoperative planning CT scan is mandatory, following the principle of “fracture planning”. 2D and 3D computed tomography reconstructions are of great help in understanding the nature of the fracture and carrying out meticulous surgical planning (surgical approaches, osteosynthesis technique and type of implants). Six typical fragments can be identified [24,25]:
a) Fragment of the medial malleolus
b) Anterolateral fragment
c) Posterolateral fragment
d) Ventral tibial fragment
e) Dorsal tibial fragment
f) Fragment of the central pylon (die-punch fragment)

Reconstruction of the articular surface and respect for soft tissues greatly influence the prognosis of tibial pilon fractures [26,27]. The choice of surgical approach is important to allow adequate visualization of the fragments and placement of the implants without further compromising already damaged soft tissues. As a rule, a minimum distance of 5 to 7cm between two skin incisions should be preserved to avoid further skin necrosis. Several surgical approaches can be chosen (anteromedial, anterolateral, medial, posteromedial, lateral, and posterolateral) [28]. Each approach, or its combination, offers certain advantages and has certain limitations that must be taken into account in terms of reduction potential, implant placement, and iatrogenic soft tissue injury.

Fibula fracture occurs in 90% of tibial pilon fractures and many authors agree that fibula fixation is crucial in this type of fracture. It provides stability to the lateral column, which would prevent valgus displacement and reduce angular displacement. It helps to reduce the tibia in terms of length, alignment and translation. Insertions of the syndesmotic ligaments help reduce anterolateral and posterolateral tibial joint fragments. Facilitates stability and reduction of syndesmosis in the event of injury [29,30].

We can perform fibular fixation in two moments:
a) Emergency along with external fixation as part of staged treatment
b) Together with the definitive osteosynthesis of the fracture.

Emergency fibular fixation, together with external fixator, corresponds to the initial phase of staged treatment, where the goal of fibular fixation is to provide adequate stability to the lateral spine. In contrast, medial stability is provided by the fixator. Several studies support emergency fibular fixation because of the benefits already mentioned and because it would help reduce the operative time in definitive surgery.

On the other hand, and considering the real clinical context, we must consider that urgent management of this type of fracture is usually performed by a general traumatologist, who does not perform the definitive treatment. In this scenario, a variety of factors are often overlooked, such as the approaches and types of implants that will be used later. Therefore, emergency fibular fixation may result in a procedure that hinders definitive management of the fracture.

A poor initial reduction of the fibula in complex or comminuted fractures, resulting in recurvatum, shortening and rotation of the fibula, influences the tibial reduction when performing the definitive treatment. Borrelli and Catalano, in their study, showed that even leaving a long fibula can cause a varus deformity of the tibia and overload of the lateral pylon region (Figure 3).

Figure 3:Example of two patients undergoing emergency fibula fixation. One case resulted in valgus (A, B) and the other in recurvatum (C, D). Both stabilizations were reviewed at the time of definitive surgery [23].

If possible, Minimally Invasive Plaque Osteosynthesis (MIPO) should be opted for to minimize soft tissue trauma, without compromising the quality of anatomical reduction [31]. Ideal fractures for MIPO are those with no or minimal displacement. Alternatively, MIPO techniques can also be used in cases of severe soft tissue injury. In cases of implementation of the MIPO technique, fibula fixation is the first step, as it allows, by means of ligamentotaxis, the initial reduction of the tibial components, which can later be momentarily reduced by Kirschner needles (joystick technique), percutaneous reduction forceps or even arthroscopic assistance [32]. Percutaneous traction screws and locked bridge plates are frequently used for fracture fixation

In cases that do not allow the MIPO technique, open reduction and internal fixation with screws and osteosynthesis with plaque remain the reference method. The principles published 50 years ago by Rüedi. Osteosynthesis of the fibula, tibial articular surface reconstruction, bone grafting for bone defects, and medial osteosynthetic support remain relevant [20].

To facilitate the visualization of the tibial joint surface, a separator can be used. The anterolateral and medial fragments must be mobilized to identify them accurately, as well as to inspect the articular surface of the talus. Reduction begins in most cases with the posterolateral fragment, followed by reduction of the central and medial fragment, which can be temporarily held in place with Kirschner needles. Particularly complex type B and C fractures require additional fixation with a bridge plate that holds the joint block to the tibial shaft. The anterolateral or medial plate is introduced from distal to proximal, either sub muscularly or subcutaneously, and is also temporarily fixed with Kirschner needles after radiological control of the reduction. The screws on the distal plate are initially placed, so that the entire articular surface is fixed. The plate should be fixed proximally with 3 or 4 biocritical locking screws, especially in osteoporotic bone. Once osteosynthesis is complete, the external fixator can be left in situ, if necessary (the calcaneal nail can be removed at this point), to promote soft tissue healing. Life-saving procedures, such as Ilizarov fixator or primary arthrodesis, should be performed only in cases of massive bone comminution with extreme soft tissue injuries [10].

In this context, applying and following a staged treatment algorithm, proposed by several authors, contributes to reducing the rates of complications and failures when treating these difficult tibial pilon fractures [33]; (Figure 4).

Figure 4:Surgical algorithm for the treatment of tibial pilon fractures. (ARIF: arthroscopic reduction and internal fixation, AA: arthroscopically assisted, MIS: minimally invasive surgery, ORIF: open reduction and internal fixation) [33].

The great difficulties caused by the treatment of tibial pilon fractures for traumatologists makes it necessary to establish a differentiated and standardized treatment protocol in two stages, to achieve a satisfactory result of this complex injury and thus reduce the risk of postoperative complications. The studies confirm the need for meticulous planning, respecting the surrounding soft tissues and determining the correct time for the performance of the definitive osteosynthesis, based on standardized protocols that allow optimizing the final result of this severe injury.

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