The Tibial Pilon Fractures: Are there Problems?

decade [2]. These fractures may be caused by falls, road accidents or sport injuries. TPF may be produced by two different dynamics: shear-stress injuries, which separate bone fragments, and compression injuries, which compress and impact bony matter. The mechanism is the implosion of the tibial plafond caused by axial compression between the talus and the distal tibial articular surface, with or without horizontal torsion [3]. It is often associated with significant degloving of the soft tissue surrounding the bone, while the skin, capsule and ligaments are partly spared. The aim of operative treatment is to anatomically reduce the fracture fragments to restore the congruity of the joint surface and promote bony union with minimal disruption of the soft tissue envelope [4]. So the TPF are always complex. Its complexity is related to the number of bone fragments, the decomposition of the bone fragments and the lesion of the neighboring soft tissues. Muller’s AO classification is the more complete and universally accepted system: it characterizes Type A (not articular), type B (partially articular) and type C (completely articular) fractures. TPF can also be classified by Ruedi and Allgower classification that includes three type of fracture depending on the displacement of articular surface, metaphyseal and injury extent of fractures [5]. The treatment of this type of fractures is a very timely topic, since there is no real consensus on the unique methods of treatment, which must take into account not only the stabilization of bone but also soft tissue which frequently leads to complications. Non operative management, such as cast immobilization, is reserved only for nondisplaced articular fractures, patients who have surgical controindications because of medical co-morbidities, or patients with low demand such as those who are nonambulatory. Surgical treatments are varied and different: minimally invasive osteosynthesis (MIO), open reduction and internal fixation (ORIF), minimally invasive plate osteosynthesis (MIPO), esternal fixation (EF), external fixator combined with limited invasive internal fixation (LIFEF), ilizarov treatment. Operative fixation of TPF has presented a significant challenge to the orthopaedic surgeon as the extensive soft tissue damage associated with such injuries makes surgical intervention hazardous. Advantages of minimally invasive osteosynthesis of pilon fractures compared to conventional open reduction and osteosynthesis, include protection of the soft tissue and no further disturbances of circulation-ideal prerequisites for undisturbed bone healing. Ruedi and Allogower [5] believed that anatomical restoration of the articular surface was fundamental surgical point. They considered essential: the restoration of the length and axis of fibula or tibia, the reconstruction of the distal end of the tibia, the filling of the defect resulting from im paction, using cancellous autografts, the support of the medial side of the tibia by plating to prevent a late varus deformity. White et al. say that provided surgery is performed expeditiously by experienced orthopedic trauma surgeons, most tibial pilon fractures can be stabilized by primary ORIF within a safe and effective operative window with relatively low rates of wound complications, a high quality of reduction, and functional outcomes that compare favorably with the published results for all other reported surgical treatments of these severe incurie [6]. A retrospective study by Watson et al. has shown that there is a significantly higher complication rate with the use of open plating techniques in AO type C fractures of the distal tibia, and this is probably related to the amount of dissection and stripping of soft tissues needed to achieve reduction and plate fixation [7].