

o Nonoperative
 cast immobilization
 indications
 stable fracture patterns without articular surface displacement
 critically ill or non-ambulatory patients
 significant risk of skin problems (diabetes, vascular disease, peripheral neuropathy)
 outcomes
 intra-articular fragments are unlikely to reduce with manipulation of displaced fractures
 loss of reduction is common
 inability to monitor soft tissue injuries is a major disadvantage
o Operative
 temporizing spanning external fixation across ankle joint               
 indications
 acute management of most length unstable fractures
 provides stabilization to allow for soft tissue healing and monitoring
 capsuloligamentotaxis to indirectly reduce the fracture by tensioning the soft tissues
about the ankle
 keeps fracture fragments out to length
 fractures with significant joint depression or displacement
 leave until swelling resolves (generally 10-14 days)
 not always warranted in length stable pilon fractures
 outcomes
 placement of pins out of the zone of injury and planned surgical site is important to
reduce infection risks
 open reduction and internal fixation (ORIF)  
 indications
 definitive fixation for a majority of pilon fractures
 limited or definitive ORIF can be performed acutely with low complications in certain
situations
 outcomes
 dependent on articular reduction
 high rates of wound complications and infections are associated with early open fixation
through compromised soft tissue
 ability to drive
 brake travel time returns to normal 6 weeks after weight bearing     
 fibula fixation
 not a necessary step in the reconstruction of pilon fractures
 may be helpful in specific cases to aid in tibial plafond reduction or augment external
fixation
 higher rates of fibula hardware removal     
 external fixation/circular frame fixation alone
 indications
 select cases where bone or soft tissue injury precludes internal fixation
 outcomes
 thin wire frames and hybrid fixators have high union rate
 high rates of pin tract infections
 osteomyelitis and deep infection are rare
 meta-analysis comparing this method with open reduction and internal fixation found no
difference in infection or complication rates between the two groups
 intramedullary nailing with percutaneous screw fixation    
 indications
 alternative to ORIF for fractures with simple intra-articular component
 outcomes
 minimizes soft tissue stripping and useful in patients with soft tissue compromise
 high union rates
 increased valgus malunion and recurvatum seen with IMN compared to plate
osteosynthesis
 primary ankle arthrodesis
 indications
 no definitive indications
 potential indications
 severely comminuted, non-reconstructable plafond fractures
 select elderly populations who cannot tolerate multiple surgeries or prolonged
immobilization
 manual laborers
 techniques
 plate and screw fixation
 retrograde intramedullary TTC nail
 outcomes
 theorized quicker recovery process and decreased long term pain
 increases the risk of adjacent joint arthritis including the subtalar joint and midfoot
 Techniques
o Cast immobilization
 technique
 long leg cast for 6 weeks followed by fracture brace and ROM exercises
 close follow-up and imaging needed to ensure articular congruity and axial alignment
o External fixation (temporary and definitive)
 technique
 fixator constructs vary with ‘delta’ and ‘A’ frames assemblies being most common
 2 tibial shaft half pins outside the zone of injury connected to a single transcalcaneal pin
 consider trans-navicular pin if associated calcaneal fracture
 consider connecting fixator to the forefoot 1  metatarsal to prevent an equinus
st

contracture
 joint-spanning articulated vs. nonspanning hybrid ring
 none have been shown to be superior with respect to ankle stiffness
 can combine with limited percutaneous fixation using lag screws
 complications
 pin site drainage
 pin/wire tract infections
 pin site fracture
 ankle stiffness
 injury to neurovascular structures
 anatomic articular reconstruction may not be possible, especially with central
depression
o Circular frame fixation  
 technique
 distraction is the key to reduction
 proximal fixation
 tibial shaft is used as a fixation base to reduce the fracture
 two half-pins in the AP plane with rings in an orthogonal position
 used to support the distal fixation rings
 distal fixation  
 determined by the configuration of the fracture and the soft-tissue injury
 rings placed at the level of the plafond or calcaneus to distract and reduce the fracture
 pins should be placed at least 1-2 cm from the joint line in order to avoid possible septic
arthritis
 safe zones for wire placement form a 60-degree arc in the medial-lateral plane  
 can include limited internal fixation if soft tissues permit
 consider the need for soft tissue coverage with position of the fixator
 hydroxyapatite coated pins
 provides better fixation and decreases frequency of loosening
o Open reduction and rigid internal fixation (ORIF)  
 timing to definitive surgery
 once skin wrinkles present, blister epithelization, and ecchymosis resolution (10-14
days)
 approach(es)
 single or multiple incisions based on fracture pattern and goals of fixation
 keep full thickness skin bridge >7cm between incisions
 positioning of patient dependent on approach(es) being utilized
 direct anterior approach to ankle  
 anterolateral approach to ankle  
 useful with fractures impacted in valgus or with an intact fibula
 puts the deep peroneal nerve at risk during exposure and dissection in the anterior
compartment
 superficial peroneal nerve at risk during superficial dissection in the lateral
compartment   
 anteromedial approach to ankle  
 medial approach  
 posteromedial approach  
 posterolateral approach  
 lateral approach  
 technique
 reduction and fixation
 goal is for anatomic reduction of articular surface  
 location of plates/screws are fracture and soft-tissue dependent
 restore alignment
 <5-10 degrees varus/valgus
 <5-10 degrees procurvatum/recurvatum
 restore length
 consider provisionally leaving the external fixator in place
 reconstruct metaphyseal shell
 bone graft (if warranted)
 reattach metaphysis to diaphysis
 fibula fixation if needed
 can be with intramedullary screw/wire or plate/screw construct
 postoperative care
 ankle ROM exercises beginning 2 weeks post-op
 non-weightbearing for ~6-12 weeks depending on radiographic evidence of fracture
consolidation
o Primary ankle arthrodesis
 approach
 direct anterior  
 technique
 plate and screw fixation
 debride fibrous tissue, fracture callous, and cartilage
 small comminuted articular fragments are removed
 remove talar dome cartilage
 pack metaphyseal defects and the tibiotalar joint with autologous or allograft bone graft
 iliac crest
 demineralized bone matrix
 optimal position
 neutral dorsiflexion
 5-10° of external rotation
 5° of hindfoot valgus
 5 mm of posterior talar translation
 fixation with an anterior plate and screw construct
 post-op care
 apply cast or splint for 8 weeks
 progress weight bearing between 8 and 12 weeks in removable boot
 full weight bearing with ankle brace at 12 weeks post-op
 CT at 3 months to assess for successful fusion
 tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail
 sacrifices subtalar joint motion
 accelerates transverse tarsal joint motion
 immediate weightbearing permissible
 Complications
o Wound slough and dehiscence
 incidence
 9-30%
 wait for soft tissue edema to subside before ORIF (1-2 weeks)
 treatment
 free flap for postoperative wound breakdown
o Infection
 incidence
 5-15%
 risk factors
 significant soft tissue swelling at time of definitive surgery
 treatment
 irrigation and debridement, antibiotics, possible hardware removal
o Malunion
 incidence
 6-14%
 treatment
 joint-preserving correction with secondary anatomic reconstruction
 corrective ankle fusion
o Nonunion
 incidence
 5% of patients undergoing ORIF
 usually at the metaphyseal junction
 risk factors
 metaphyseal comminution
 open fractures
 bone loss
 tobacco use
 NSAID use
 treatment
 must rule out infected non-union (labs to obtain CRP, ESR, WBC)
 other non-union labs (PTH, calcium, total protein, serum albumin, vitamin D, TSH)
 rigid fixation with bone grafting
o Post-traumatic arthritis
 incidence
 chondrocyte cell death at fracture margins is a contributing factor    
 IL-6 is elevated in the synovial fluid following an intra-articular ankle fracture    
 most commonly begins 1-2 years postinjury
 risk factors
 sequalae of cartilage trauma
 non-anatomic articular reduction
 mal-alignment
 treatment
 first line is conservative management (bracing, injections, NSAIDs, activity modification)
 total ankle arthroplasty
 ankle arthrodesis
o Chondrolysis
o Stiffness
 Prognosis
o Poor outcomes and lower return to work associated with
 lower level of education      
 pre-existing medical comorbidities
 male sex
 work-related injuries
 lower income levels
o Outcomes correlate with severity of the fracture pattern and the quality of reduction
 at 2 year follow-up, the majority of type C pilon fractures report lower SF-36 scores than
patients with pelvic fractures, AIDS, or coronary artery disease  
 clinical improvement seen for up to 2 years after injury   
o Return of vehicle braking response time
 6 weeks after initiation of weight bearing