FOOT & ANKLE INTERNATIONAL
Copyright  2008 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2008.0914
Ankle Fusion for Definitive Management of Non-Reconstructable Pilon
Fractures
Vladimir Bozic, MD; David B. Thordarson, MD; Jennifer Hertz, MS
ABSTRACT
Background: Highly comminuted pilon fractures, especially
with a compromised soft tissue envelope, present a challenging
treatment scenario. This study presents our results for patients
managed with ankle fusion rather than ORIF. Materials and
Methods: Fourteen patients with ankle joint incongruence after
non-reconstructable tibia pilon fractures were treated with
primary tibiotalar arthrodesis using a fixed-angle cannulated
blade plate. Delayed metaphyseal unions due to bone defects
were treated concurrently. The subtalar joint was preserved in
all cases. Results: Metaphyseal healing and stable arthrodesis
was obtained in each case. There was one case of blade plate
breakage in a patient who still achieved successful arthrodesis
without reoperation. Union was achieved at an average of 15
weeks. No secondary procedures were required to obtain union.
All 14 patients were ambulatory at last followup. Average
followup was 39 weeks. Conclusion: Primary ankle arthrodesis
can be achieved using a cannulated blade plate to address a non-
reconstructable articular surface and metaphyseal bone defects
in complex tibia pilon fractures.
INTRODUCTION
Tibia pilon fractures with their associated articular destruc-
tion, metaphyseal comminution, and soft-tissue injury,
continue to present significant treatment challenges for
orthopaedic surgeons.1,5,8,11,14,16,19 These fractures are the
result of high-energy trauma and the severity of associated
soft-tissue injury often precludes early operative fixation.
Level of Evidence: IV
No benefits in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
Corresponding Author:
David B. Thordarson, MD
USC Department of Orthopaedic Surgery
Orthopaedics
1520 San Pablo Ave, Suite 2000
Los Angeles, CA 90033
E-Mail: dthordarson@faijournal.com
For information on prices and availability of reprints, call 410-494-4994 x226
914
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Los Angeles, CA
Acute operative fixation of the joint surface can result in
high rates of severe complications, leading to below knee
amputation in some series.16 Current treatment recommenda-
tions generally include provisional external fixation to allow
for healing of compromised soft-tissues, followed by delayed
definitive internal fixation of the joint surface.1,8,19 Though
new techniques and implants are available, some severely
comminuted fractures have poor results. Despite appropriate
treatment and internal fixation, many tibial pilon fractures
result in debilitating post-traumatic arthritis.19
Ankle arthrodesis remains the mainstay of treatment for
end-stage arthritis of the ankle. Compression fixation with
internal fixation such as cannulated screws remains the
treatment of choice for ankle arthrodesis, but the degree
of periarticular comminution and metaphyseal bone loss
following many of these injuries makes these techniques
difficult or impossible. When comminution and bone defects
are present, neutralization fixation is an option to prevent
secondary deformities that could result from compression
fixation in the presence of bone defects.4,10,12,14,17,18 A soft
tissue envelope that is already compromised due to trauma
is at significant risk when anterior surgical approaches to the
tibia and ankle are used for internal fixation.
Alternatives to compression screw fixation for ankle
arthrodesis include the use of bridging external fixa-
tion, intramedullary devices and blade-plates.4,10,12 – 15,17,18
External fixation devices are cumbersome and often poorly
tolerated and lead to frequent complications including pin-
tract infections. Tibiotalocalcaneal fusion with an intrame-
dullary rod circumvents these issues, but requires arthrodesis
of the uninjured subtalar joint, further compromising motion
and function. Blade-plates have been successfully used to
achieve arthrodesis of the ankle after tibial pilon fractures
complicated by post-traumatic arthritis and metaphyseal non-
union. However, this technique has most frequently been
used as a late salvage procedure after initial attempts at
reconstruction with internal fixation. The purpose of this
study was to describe our experience using a blade-plate
Foot & Ankle International/Vol. 29, No. 9/September 2008
for primary arthrodesis of the ankle after tibial pilon frac-
tures with severe joint destruction and metaphyseal bone
loss.
MATERIALS AND METHODS
Fourteen patients underwent primary ankle arthrodesis
after nonreconstructable pilon fractures by a single surgeon
(DBT). This number represents less than 5% of the pilon frac-
tures treated at this institution during this time period. During
the 12-year period of this study, we treated approximately
one pilon fracture per week at our institution. Metaphyseal
delayed union where there was no intraoperative evidence of
healing in fractures greater than 12 weeks after injury was
present in five cases. Joint incongruence, articular destruction
and comminution was present in all cases. The average age
of the patients was 42.6 (range, 18 to 64) years. There were
eight men and six women. One man sustained bilateral nonre-
constructable pilon fractures following a suicide attempt with
a high velocity motor vehicle collision with a wall. There-
fore, a total of 15 fractures were treated. Due to the high
energy mechanism of injury, many of the patients had other
injuries which impacted their outcome. The mechanism of
injury was a motor vehicle accident in six patients and a fall
from height in eight patients. Eight fractures involved the
right tibia and seven fractures involved the left tibia.
Eight fractures were open and seven were closed. The
fracture patterns were characterized by the AO Orthopaedic
Trauma Association classification. All of the injuries were
classified as type C3 fractures. Open fractures ranged from
Type-I to Type-IIIA based on the Gustilo-Anderson system.
The initial treatment of the fractures was bridging external
fixation for thirteen fractures and casting for two fractures.
Five of the patients treated with external fixation had
open reduction and internal fixation of the fibula fractures
concurrently. All open fractures were treated with formal
irrigation and debridement in the operating room prior to
any fixation. Only patients who had no prior internal fixation
of the tibia were included in this study. One patient had
a superficial infection treated with dressing changes and
intravenous antibiotics prior to fusion. One patient had a
deep infection requiring repeat irrigation and debridement
and intravenous antibiotics. Both infections had resolved at
the time of fusion.
The time between the initial injury and the arthrodesis
ranged between 5 and 94 weeks. The median time from the
time of injury until fusion was 20 weeks. Ten fractures had
the external fixator in place at the time of arthrodesis. The
external fixators were removed at the time of arthrodesis
in all cases. The indications for fusion included marked
joint incongruence in all patients with a metaphyseal delayed
union in five patients. In two patients the opportunity for
initial treatment was delayed more that one month due to
late presentation (one patient) and myocardial infarction at
the time of injury (one patient). The other 13 fractures were
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PILON FRACTURE MANAGEMENT 915
felt to be non-reconstructable due to the severe joint surface
comminution at the time of injury which the senior author
(DBT) felt precluded surgical reduction which would lead to
an acceptable functional result.
Eleven of the provisional external fixation procedures
were performed at our institution. The patient who sustained
bilateral pilon fractures had external fixators applied at
another hospital.
Surgical technique
A single surgeon (DBT) performed the arthrodesis in
all cases. All but one of the patients were placed in the
prone position. A thigh tourniquet was used. The ipsilateral
posterior iliac crest was included in the surgical field to obtain
cancellous bone graft.
The technique for the posterior approach included a poste-
rior longitudinal incision along the Achilles tendon. Tight
Achilles tendons were treated with a Z tenotomy. Other-
wise the tendon was retracted. The posterior compartment
muscles were elevated subperiosteally between the interval
between the FHL and peroneals along the posterior aspect of
the tibia. This approach was extended to approximately the
mid tibia on some cases. The subtalar joint was identified
and protected. The posterior aspect of the ankle was identi-
fied and all remaining cartilage was denuded from the tibial
plafond and dome of the talus. Any metaphyseal defect was
prepared for bone grafting.
A guide wire was placed using flouroscopic guidance from
the midline posteriorly into the talar head, parallel to the
plantar aspect of the foot. The length of the guide wire was
measured and the cannulated drill was run over the guide
wire. The blade was then inserted backwards over the guide
wire and a trough was countoured with narrow osteotomes
in the distal tibial metaphyseal flare so that the plate sat flush
on the tibia. When the blade is impacted into the talus, it was
critical to center the plate over the tibial shaft at the proximal
end of the wound with the hindfoot held in appropriate valgus
alignment. The metaphyseal bone defect and ankle joint were
then grafted. The plate was then anchored proximally with
cortical screws. We attempted to center the talus beneath the
tibia in proper anatomic alignment on the lateral view and
preserve this position by inserting a distal angled screw into
the body of the talus with a large cancellous screw angled
towards the tip of the blade to provide additional fixation
(Figure 1). The Achilles tendon was repaired, if tenotomized.
The incisions were closed and the patient was placed in a
short leg cast.
Internal fixation was performed with a 90 degree titanium
cannulated Limited Contact Blade Plate (Synthes, Paoli,
PA) in all cases. The length of the side plate ranged from
four holes to ten holes, with the six-hole plate being most
common. A 40- or 50-mm blade was used in all cases. No
plates required modification prior to insertion. Iliac crest
autogenous bone graft was used in all cases.
916 BOZIC ET AL. Foot & Ankle International/Vol. 29, No. 9/September 2008

Fig. 1: (A) AP and lateral radiographs of a patient with a comminuted pilon fracture 1 month after his injury. (B) AP and lateral radiographs following
successful fusion. Despite the distal screw fixation, the talus translated anteriorly.

All patients were casted post-operatively. All patients were RESULTS

instructed to be strictly nonweightbearing for a minimum of
6 weeks. If the fusion appeared to be consolidating, gradual
progression of weightbearing was begun at that time. A
minimum of 12 weeks of immobilization was recommended
with gradual weaning from the camwalker/cast as pain
subsided. The average total time nonweightbearing was 12
weeks (range 6 to 20 weeks). Ten patients were advanced
to partial (50%) weightbearing at 6 to 14 weeks following
arthrodesis. The average time each patient was casted was
15 (range, 2 to 26) weeks. They were then placed in a
camwalker. One patient refused further casting at his 2-week
followup visit and was placed in the camwalker.
A solid arthrodesis was achieved in each case. The average
time to union (defined as full weightbearing with minimal
pain and radiographic evidence of fusion) was 15 (range, 10
to 21) weeks (radiographic, full-weightbearing). No change
in position was evident at the time of final followup with
plantigrade alignment in each case.
There was one case in which the plate broke between
postoperative visits 4 and 5 months after surgery. This patient
went on to successful union without an additional procedure
and was bearing full weight with evidence of a stable
union at his final follow up at 64 weeks after arthrodesis

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Foot & Ankle International/Vol. 29, No. 9/September 2008
Fig. 2: (A) AP and lateral radiographs following a comminuted open pilon fracture with metaphyseal bone loss after a fall from height. (B) Despite breakage
of the plate, AP and lateral radiographs demonstrate successful union.
(Figure 2). There was one case of a deep infection requiring
implant removal and a course of intravenous antibiotics after
successful union. This patient had a previous history of deep
infection.
No secondary procedures were required to obtain union.
The time from fusion to final followup averaged 39 weeks
(18 to 80 weeks). Two patients used a camwalker for
prolonged ambulation at their time of final followup for
either pain in their hind-foot or mid-foot. None had severe
posttraumatic arthritis radiographically yet the boot improved
their ability to ambulate.
DISCUSSION
Comminuted tibial pilon fractures result from high-energy
trauma. The articular injury is often associated with a
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PILON FRACTURE MANAGEMENT 917
prolonged treatment course involving multiple procedures
and occasionally devastating complications.16 Even with
appropriate treatment, pilon fractures with articular destruc-
tion frequently result in post-traumatic arthritis.19 We believe
some pilon fractures are non-reconstructable due to artic-
ular bone loss and destruction and may best be treated with
primary ankle arthrodesis.
Primary ankle fusion using screw fixation techniques
may be compromised by the presence of metaphyseal
comminution. One alternative is to allow the metaphy-
seal and joint comminution to heal first then perform the
ankle arthrodesis.14 Treating the metaphyseal defect with
simultaneous ankle arthrodesis is an attractive option that
avoids multiple procedures and a more prolonged treatment
course when the joint surface is deemed nonreconstructable.
We have used this method in less than 5% of the pilon frac-
tures that we treat.
918 BOZIC ET AL.
Reconstructing a metaphyseal defect with simultaneous
ankle arthrodesis can be performed with several methods.
External fixation requires a prolonged period of external
fixation and puts patients at risk for pin-tract infections.
Blade plates have been successfully used for tibiocalcaneal
fusion through a posterior approach.10,14 The posterior
approach offers the advantage of avoiding the thin soft-
tissue envelope anteriorly. Tibiotalocalcaneal fusion with an
intramedullary-rod has been used successfully for concur-
rent treatment of metaphyseal defects and tibia plafond
joint destruction, but also require fusion of the subtalar
joint.12,13,15 Also the fact that many of these injuries are
initially treated with external fixation raises concerns over
increased risks of infection with the use of an intramedullary
device after a previous extended period of external fixation.
In a previous small series, we evaluated the blade plate
as a method of delayed reconstruction following previously
treated pilon fractures.14 The current study only includes
patients where ankle fusion was the only definitive treat-
ment of the ankle joint surface. Others have described
using an anterior plate but this approach risks violating
the compromised anterior soft-tissue and plate prominence
which could lead to skin compromise and irritation requiring
plate removal.18 A lateral approach has been described and
was used in one patient in this series. We try to avoid
this approach as the skin is frequently compromised and
it provides poorer sagittal plane stability. The posterior
approach used in this series avoids these issues.4
The cannulated blade-plate used in this series offered
several advantages over other implants. This plate, originally
designed for use in the proximal humerus, came in a variety
of sizes and no plate required modification for use. The use
of a guide-wire and a cannulated plate allows for precise
placement of the blade to obtain correct foot position. It has
been used for distal tibial nonunions also.2
Ankle arthrodesis requires stable fixation, which is difficult
to achieve in comminuted bone with compressive internal
fixation techniques. The blade plate used in this series
provided stable fixation with axial and rotational control in
comminuted fractures with extensive bone-loss or non-union
without requiring compression across the fusion site. This
plate was also successful in maintaining correct foot position
in each case. Avoidance of the subtalar joint preserves
motion and decreases the likelihood of arthrosis of adjacent
joints. It is our opinion that the subtalar joint is worth
preserving when no degenerative symptoms are present. Even
if the range of motion is decreased, a small amount of
motion may help protect the adjacent joints of the foot.
Successful ankle arthrodesis with a cannulated blade-plate
can be achieved as the primary, definitive treatment of
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Foot & Ankle International/Vol. 29, No. 9/September 2008
patients with non-reconstructable tibial pilon fractures even
in the presence of metaphyseal bone defects.
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