Journal of Orthopaedic Trauma
Vol. 15, No. 3, pp. 153–160
© 2001 Lippincott Williams & Wilkins, Inc., Philadelphia
Surgical Options for the Treatment of Severe Tibial Pilon
Fractures: A Study of Three Techniques
M. Blauth, L. Bastian, C. Krettek, C. Knop, and *S. Evans
Unfallchirurgische Klinik, Medizinische Hochschule, Hanover, Germany; and *The Chelsea and Westminster Hospital,
London, United Kingdom
Objective: To determine whether long-term results of one of
three different management protocols for severe tibial pilon
fractures offer advantages over the other two.
Design: In a retrospective study, patients were examined clini-
cally and radiologically after internal fixation of severe tibial
plafond fractures (i.e., 92 percent Type C fractures according to
the AO–ASIF classification).
Setting: Department of Traumatology, Hanover Medical
School. Level I trauma center.
Patients: Fifty-one of seventy-seven patients treated between
1982 and 1992 were examined clinically and radiologically at
an average of sixty-eight months (range 13 to 130 months) after
injury.
Interventions: The patients were treated in three different
ways: primary internal fixation with a plate following the AO–
ASIF principles (n ⳱ 15), which was reserved for patients with
closed fractures without severe soft tissue trauma; one-stage
minimally invasive osteosynthesis for reconstruction of the ar-
ticular surface with long-term transarticular external fixation of
the ankle for at least four weeks (n ⳱ 28); and a two-stage
procedure entailing primary reduction and reconstruction of the
articular surface with minimally invasive osteosynthesis and
short-term transarticular external fixation of the ankle joint fol-
lowed by secondary medial stabilization with a plate using a
technique requiring only limited skin incisions (a reduced in-
vasive technique) (n ⳱ 8).
Main Outcome Measurements: Objective evaluation criteria
were infection rate, amount of posttraumatic arthritis, range of
ankle movement, and number of arthrodeses. Subjective crite-
ria were pain, swelling, and restriction of work or leisure ac-
tivities.
Intraarticular fractures of the distal tibia are among the
most complex injuries of the lower limb. The best results
Accepted May 18, 2000.
Address correspondence and reprint requests to Prof. Michael
Blauth, Universitätsklinik für Unfallchirurgie, A-6020 Innsbruck, Aus-
tria.
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
manuscript.
The devices that are the subject of this manuscript are FDA-
approved.
153
Results: Because only closed fractures were treated by primary
internal fixation with a plate, there was a statistically significant
difference (p < 0.005) in the distribution of open fractures
between the three treatment groups. Fracture classification in
these groups were not significantly different. All but four frac-
tures were classified as Type C lesions according to the AO–
ASIF system. The soft tissue was closed in 63 percent (n ⳱ 32)
and open in 37 percent (n ⳱ 19). No significant relationship
could be found between the soft tissue damage and degree of
arthritis or between the type of surgical treatment and extent of
posttraumatic arthritis. However, none of the patients who re-
quired secondary arthrodesis (23 percent of all cases) were in
the group who had undergone two-step surgery (p < 0.05). The
range of ankle movement was much greater in the two-step
group than in the others; these patients also had less pain, more
frequently continued working in their previous profession, and
had fewer limitations in their leisure activities. These differ-
ences did not reach statistical significance. The incidence of
wound infection did not differ significantly among the three
groups.
Conclusions: On the basis of our results, we now prefer a
two-step procedure for the treatment of severe tibial pilon frac-
tures with extensive soft tissue damage. In the first stage, pri-
mary reduction and internal fixation of the articular surface is
performed using stab incisions, screws, and K-wires. Tempo-
rary external fixation is applied across the ankle joint. After
recovery of the soft tissues, the second stage entails internal
fixation with a medial plate using a reduced invasive technique.
Key Words: External fixation, Internal fixation, Minimally
invasive osteosynthesis, Pilon fracture, Soft tissue injury, Tibial
plafond fracture.
have been achieved with reconstruction of the articular
surface of the tibia, stable fixation, and only a short
period of joint immobilization (29,31,36). The surgical
treatment of pilon fractures consists of four steps: resto-
ration of the correct length and stabilization of the fibula,
reconstruction of the articular surface of the tibia, inser-
tion of cancellous autografts, and stabilization of the me-
dial aspect of the tibia (35). These principles have to be
modified in fractures with severe comminution and soft
tissue trauma (4,6,19,21,22,30,42,44). Achieving and
maintaining anatomic reduction is technically difficult
154 M. BLAUTH ET AL.
and sometimes impossible (18). Because internal fixation
inevitably leads to localized devitalization of bone, fur-
ther damage to surrounding soft tissue may follow. The
nature and timing of surgery influence soft tissue recov-
ery (21,44). In this respect, a two-step procedure may
have advantages over definitive primary internal fixation
for fractures with second- or third-degree open or closed
soft tissue injury (26,30,41,42).
The purpose of this study was to determine whether
the long-term results of one of three different manage-
ment protocols for severe tibial pilon fractures has ad-
vantages over the other two.
PATIENTS AND METHODS
Between 1982 and 1992, seventy-seven tibial pilon
fractures were treated at our clinic by primary internal
fixation. The initial chart data of these patients were
analyzed. Four patients died before review (two patients
of multiple trauma and two of cardiac failure), and two
underwent amputation (one patient with multiple trauma
because of severe soft tissue injury and one because of a
severe infection after one-stage minimally invasive os-
teosynthesis). These patients were excluded from further
investigation.
Of the seventy-one remaining patients, six could not
be traced and fourteen refused to take part, most fre-
quently because of the travel required. Therefore, fifty-
one patients were examined clinically and radiologically
sixty-eight months after injury (range 13 to 130 months).
The average age was 40 years (range 18 to 70 years). The
mechanism of injury was high-energy falls in 49 percent,
motor vehicle accidents in 41 percent, and sports injuries
and minor trauma in 10 percent. Thirty-seven percent
were occupational accidents and 55 percent were acci-
dents outside work. Eight percent of the injuries were
caused by suicide attempts.
All fourteen patients who were not able or willing to
participate in a personal examination at Hanover Medical
School were interviewed by telephone. Adding these an-
swers did not change the statistical results of our study.
Fracture Classification and Soft Tissue Damage
Fractures were classified using the AO–ASIF system
(28). Eight percent (n ⳱ 4) were Type B injuries (three
Type B2 and one Type B3) and 92 percent (n ⳱ 47) were
Type C injuries (two Type C1, twenty-six Type C2, and
nineteen Type C3). No statistically significant difference
could be found in the contribution to the three different
treatment groups.
There were thirty-two (63 percent) closed and nine-
teen (37 percent) open fractures. Closed soft tissue dam-
age was classified in the manner described by Oestern
and Tscherne (45); open soft tissue damage was graded
according to Gustilo and Anderson (12). Because pri-
mary plating (Group 1) was only performed in patients
with closed fractures, there was a statistically significant
difference (p < 0.005) in the distribution of open frac-
J Orthop Trauma, Vol. 15, No. 3, 2001
tures among the three treatment protocols. No other sig-
nificant differences could be detected when all the pa-
tients who had been operated on (n ⳱ 77) were analyzed.
Associated Injuries
In 80 percent of the cases, there was a concomitant
fracture of the fibula. Fractures of the talus, calcaneus,
metatarsals, proximal tibia, femoral shaft, and tibial shaft
were seen in a few patients. Peroneal paralysis was seen
in three patients: two with third-degree closed soft tissue
injury and one with a Type IIIa open fracture. Approxi-
mately one third of the patients had injuries of the con-
tralateral leg or foot. Six percent had suffered a
polytrauma. The number of polytraumatized patients in
each group was not significantly different.
Surgical Procedures and Timing
Thirty (59 percent) patients underwent primary sur-
gery within twenty-four hours of injury. The remaining
twenty-one patients had surgery after soft tissue recov-
ery. The maximal interval between injury and surgery
was twenty-three days. Five (33 percent) of the fifteen
patients in Group 1, eighteen (64 percent) of twenty-
eight patients in Group 2, and seven (87.5 percent) of
eight patients in Group 3 were treated in less than
twenty-four hours.
Three surgical protocols were used.
1. In fifteen (29 percent) patients, all with closed frac-
tures, primary internal fixation was performed with a
plate according to the AO–ASIF technique. Postop-
eratively, the patients were mobilized with partial
weight-bearing without a cast.
2. In twenty-eight (55 percent) patients, a one-stage
minimally invasive osteosynthesis with long-term
transarticular external fixation of the ankle joint was
chosen. The distal end of the tibia was reduced by a
distractor or an external fixator; if necessary, direct
reduction through short incisions was added. Limited
internal fixation was performed using 3.5-millimeter
cortical screws and K-wires (Fig. 1). In most cases,
the external fixator was applied to the tibia, calcaneus,
or metatarsals. A fibula fracture was always internally
fixed with a plate. When primary cancellous bone
grafting was performed, an anteromedial approach
was used, but for some open fractures, the graft was
inserted through the open wound. On average, a total
immobilization time of sixty days (range 40 to 87
days) was required; the ankle joint was routinely held
initially with an external fixation bridging the ankle
part that was subsequently replaced by a cast for an
average of forty-three days (range 20 to 68 days) with
partial weight-bearing in cast.
3. In eight (16 percent) patients, the surgeon chose a
two-stage procedure with minimally invasive osteo-
synthesis. Closed reduction was performed with the
aid of an external fixator. After primary reduction and
plating of the fibula, reconstruction of the articular
 SEVERE TIBIAL PILON FRACTURES
FIG. 1. A: Anteroposterior and B: lateral films of a severely comminuted closed pilon fracture (C2.2 according to the AO–ASIF classi-
fication) in a sixty-four-year-old man. The soft tissue injury was graded as Type 2 according to the classification of Tscherne. C:
Anteroposterior and D: lateral radiographs after one-step minimally invasive osteosynthesis with restoration and fixation of the articular
surface and application of an external fixator. E: Anteroposterior and F: lateral radiographs six months after surgery.
surface of the tibia was performed using small frag-
ment screws and K-wires inserted under fluoroscopic
control through stab incisions or a short anteromedial
approach. Short-term transarticular external fixation,
averaging seventeen days (range 5 to 33 days), per-
mitted recovery of the soft tissue. After this delay, a
second stabilization was performed using a medial
plate (Fig. 2). The tibial plate was applied with a
reduced invasive technique; a short distal incision was
made, through which the plate was introduced and
pushed proximally, hence tunneling under the skin.
The plate was held using screws inserted through stab
incisions (Fig. 3). The external fixation could then be
removed, and mobilization with partial weight-
bearing began.
The single-stage minimally invasive osteosynthesis pro-
cedure was used for thirteen open fractures and the two-
step procedure for six. There was no statistically signifi-
cant difference in fracture classification between the
three surgical procedures, but all fractures treated with
the two-stage reduced invasive internal fixation (Group
3) were Type C injuries.
Additional Treatment Steps
Fasciotomy for threatened compartment syndrome
was performed in four cases; three had third-degree
closed fractures and one had a Type IIIa open fracture.
Bone grafting was required in twenty-four (47 percent)
patients; fifteen bone defects were filled with autografts
and nine with allografts.
Wounds were closed primarily in twenty-six (51 per-
cent) patients, and temporary coverage with artificial
skin, Epigard (ORMED Medizintechnik, Vienna, Aus-
tria), was necessary in twenty-five (49 percent) patients.
Ten (20 percent) patients subsequently underwent split
skin grafting, and two received free flaps (one latissimus
dorsi transfer and one forearm flap).
155
Statistics
To obtain valid results with the small number of cases
in each group the permutation test and the Kruskal-
Wallis test were used (10,23).
Time of Follow-up
The mean follow up was eighty-four months in Group
1, sixty-eight months in Group 2, and thirty-five months
in Group 3. There were statistically significant differ-
ences between Groups 1 and 3 (p < 0.005) and between
Groups 2 and 3 (p < 0.05).
RESULTS
Infection and Osteomyelitis
Thirteen (25 percent) of fifty-one patients required
surgical debridement and therefore were defined as in-
fected. Soft tissue infection did not differ significantly
among the treatment groups. Five (10 percent) patients
developed osteomyelitis, and all had Type C injuries,
four with second-degree open fractures.
Posttraumatic Arthritis
Posttraumatic changes were evaluated using the clas-
sification described by Bargon (3). Only three (6 percent)
patients had no signs of arthritis; two were treated in
Group 1 (seventy-two and thirty-nine months of follow-
up) and one in Group 3. No relationship was found be-
tween arthritis and soft tissue damage or surgical proce-
dure.
Arthrodesis
None of the patients underwent a primary arthrodesis,
but in 23 percent (n ⳱ 12), arthrodesis was performed
later. In Group 3 (two-stage minimally invasive
osteosynthesis), no arthrodesis was necessary. This
J Orthop Trauma, Vol. 15, No. 3, 2001
156 M. BLAUTH ET AL.

FIG. 2. A Left: Anteroposte-

rior and Right: lateral views of
a second-degree open C2.2
pilon fracture after a fall from a
ladder in a forty-year-old man.
Two-stage minimally invasive
osteosynthesis. B Left: An-
teroposterior and Right: later-
al radiographs on the day of
accident; plating of the fibula,
reduction and screw fixation of
the pilon, partly through the
open wound and partly using
stab incisions, and application
of an external fixator and arti-
ficial skin were performed. C
Left: Anteroposterior and
Right: lateral radiographs
three weeks later; plate fixa-
tion of the medial aspect of the
tibia with minimal soft tissue
dissection and removal of the
external fixator was per-
formed. D: Hardware removal
after two years, follow-up ex-
amination after forty-four
months. Left: Anteroposterior
and Right: lateral radiographs.
Functional result with E Top:
flexion and Bottom: exten-
sion.

differed significantly (p < 0.05) from Group 2 (eight Range of Motion

arthrodeses) and showed a tendency (p ⳱ 0.058), as
The range of ankle motion was measured with a go-
compared with Group 1 (four arthrodeses). In Groups 1
niometer. In comparison with the contralateral side, it
and 2, secondary arthrodesis was performed at an aver-
was used as an objective criterion of the functional result.
age of sixteen months after the injury. Despite the sig-
In 54 percent (n ⳱ 27) of patients, the limitation was less
nificant difference in the follow-up interval, the time of
than 25 percent, and in 23 percent (n ⳱ 12) of patients,
arthrodesis in the first two groups was within the average
it was more than 25 percent. Twelve (23 percent) patients
follow-up interval of Group 3 (thirty-five months). There
had undergone arthrodesis. Although not statistically sig-
were no significant associations with the fracture classi-
nificant, patients in Group 3 had better movement than
fication, soft tissue damage, sex, and age of the patients.
those in the other groups. Six (75 percent) of eight pa-
Including the patients who were interviewed by tele-
tients had less than 25 percent movement restriction.
phone (n ⳱ 14), we have information concerning ar-
throdesis in sixty-five of seventy-one patients. The over-
Pain
all rate amounts to 20.6 percent, whereas in Group 3,
eleven of twelve patients did not need an arthrodesis. Pain was classified into four grades: no pain (Grade 1),
One patient in this group could not be located. pain after loading or after walking more than 500 meters

J Orthop Trauma, Vol. 15, No. 3, 2001

 SEVERE TIBIAL PILON FRACTURES 157

FIG. 3. A, B: Insertion of a precontoured narrow low contact dynamic

compression plate using a short distal incision and tunneling under the
skin. C, D: Screw fixation via stab incisions, simple skin closure. E Left:
Anteroposterior and Right: lateral radiographs of fracture fixation.

(Grade 2), pain on walking less than 500 meters (Grade
3), and pain at rest (Grade 4). It was noteworthy that in
Group 3, all patients had a pain grade of 1 or 2, but this
was not statistically significant. In this group, no patient
walked with a limp or used a cane. More details are
shown in Figure 4. Ninety-two percent (n ⳱ 47) of pa-
tients were happy or satisfied with the results.
the injury; four had to change their profession because of
pain; and three became unemployed.
Fifty-nine percent (n ⳱ 30) took up their former sport-
ing activities; 27 percent were able to play at a reduced
level; and 14 percent were unable to partake at all. Once
again the two-stage procedure (Group 3) showed slightly
better results.

Work and Sports

Despite the severity of the injury, 80 percent (n ⳱ 41)
of patients resumed their former employment. There was
a significant difference between Groups 2 and 3 (p <
0.01), with more patients in the latter group returning to
their previous work. Three patients received annuity after
DISCUSSION
In 1959 Jergesen (17) stated that open reduction and
stabilization of severe tibial pilon fractures would be
impossible. Despite improvements in surgical techniques
and implants, treatment remains difficult. Disappointing

J Orthop Trauma, Vol. 15, No. 3, 2001

158 M. BLAUTH ET AL.
FIG. 4. Specification of pain in the three different groups.
long-term results are often caused by severe damage of
the articular surface, as a consequence of high-energy
dissipation and the complications of surgery. The opera-
tive treatment of severe tibial pilon fractures has become
standard practice (27). Stable internal fixation is essential
for early joint movement and postoperative mobilization
(14,18,21,36).
Because these principles do not account for soft tissue
damage, additional injuries, or the time between injury
and surgical treatment, modification may be necessary in
certain cases (30,42). A low infection rate has been
shown by using temporary transarticular external fixa-
tion in combination with reconstruction of the articular
surface using minimally invasive osteosynthesis (4,15,
40). After soft tissue recovery, a secondary medial sta-
bilization can be performed to allow early postoperative
mobilization of the ankle with partial weight-bearing (18,
21,36).
Infection is the most important early postoperative
complication and may require further surgery, sometimes
to the extent of arthrodesis or amputation (5,6,8,25). In
our study, revision surgery was necessary in 25 percent
of patients. The infection rate was less in Group 3 than
with primary definitive treatment (Group 1; 12.5 percent
versus 33 percent), and although this did not reach sta-
tistical significance, it should be considered that there
were no open fractures in Group 1. This result is consis-
tent with the work of other authors who report infection
rates of up to 50 percent using primary plate fixation
(25,41,43), but lower rates after two-stage reduced inva-
sive procedures (15,33,40).
Posttraumatic arthritis is an important outcome mea-
sure, but there is often inconsistency between the radio-
logic findings and the clinical results (11,32,34). Degen-
erative changes are caused by comminution of the ar-
ticular surface, soft tissue damage, the type of surgery
and postoperative complications, the most important of
the last being infection (8,16,21,29,33,38,46). Steps in
the articular surface after operative treatment are more
J Orthop Trauma, Vol. 15, No. 3, 2001
frequently associated with posttraumatic arthritis than
comparable steps in fractures treated nonoperatively
(31). One explanation may lie in the reduced vascularity
of bone after surgical exploration (21,26). Schweiberer et
al. (41) showed that conditions for bony healing are im-
proved if the hypervascularization has already started
approximately five to ten days after the injury. Resch et
al. (32) reported that medial stabilization leads to further
trophic changes of the cartilage. The findings could be a
possible explanation for the increased infection rate after
primary internal fixation (15,33,41).
Arthrodesis is indicated for the most severe arthritic
changes. In our study, Type C injuries accounted for 92
percent of the cases, and arthrodesis had been performed
in 23 percent at the time of follow-up. In Group 3, no
arthrodesis had been required; this differed significantly
from Group 2 (p < 0.05) and showed a trend, as com-
pared with Group 1 (p ⳱ 0.058). In Groups 1 and 2,
secondary arthrodesis was performed at an average of
sixteen months after the injury. Despite the significant
difference in follow-up interval, it is therefore likely that
arthrodesis would have been performed before the fol-
low-up time in Group 3 (mean thirty-five months). No
significant associations could be found between fracture
classification, soft tissue damage, sex, and age of the
patients.
Previous authors have reported rates of arthrodesis
from 5 to 30 percent (11,24,36), but comparison is dif-
ficult because no standard fracture classification has
been used. There have been a few reported cases of pri-
mary arthrodesis, but the indications for this are unclear
because initial malposition and joint damage are not re-
liable indicators of ultimate joint degeneration. If ar-
throdesis subsequently becomes necessary, restoration of
the position of the main fragments at the time of the
original injury facilitates the procedure (8,27).
Ankle movement can be improved by early mobiliza-
tion and partial weight-bearing, which provides better
cartilage nutrition and recovery (18,21,37). Rigid inter-
nal fixation is required to achieve this improvement. In
our study, the fractures stabilized by secondary internal
fixation (Group 3), a mean of seventeen days after the
initial treatment, had the best ankle movement. The ap-
parently worse results in Group 2 are possibly caused by
long-term immobilization with external fixators and
plaster casts (for an average of sixty days). These results
are supported by other authors (2,18). Conversely,
Höntzsch et al. (15) and Bone et al. (5,6) did not find any
functional disadvantage with long-term external fixation,
and Saleh et al. (37) and De Bastiani et al. (9) used
dynamic external fixation with good results. Circular
frames or hybrid systems, which may be applied without
crossing of the ankle joint, may become useful alterna-
tives (20) but do not seem always to solve the problems
inherent in severe pilon fractures always (1).
Our bone grafting rate of 47 percent is similar to that
in the current literature (2,38). The requirements for bone
grafting can be decreased as in other fractures by using
minimally invasive techniques (39).
 SEVERE TIBIAL PILON FRACTURES
Subjective impressions are important, and some indi-
cation may be obtained from assessment of pain, work,
15.
and leisure activities. The patients in Group 3 had less
pain on walking than did those in the other two groups.
More patients in Group 3 returned to their former sport- 16.
ing and working activities. Comparison of our results
with the literature is difficult because no standard frac-
17.
ture classification has been used and no standard evalu- 18.
ation system exists. In addition, previous studies have
contained only small numbers of patients in the treatment
groups. Overall, the reported rate of acceptable results 19.
has ranged from 30 to 90 percent (7,13,18,29,35,36).
Although our retrospective study consisted of three 20.
groups of unequal size, the nature of the fracture was
similar in each. Our results lead us to recommend that
Type C tibial pilon fractures should be treated with a 21.
two-step procedure. At initial presentation, an external
fixator is applied across the ankle joint, and after reduc- 22.
tion, limited internal fixation of the articular surface is
performed using screws and K-wires. After recovery of 23.
the soft tissues, a plate is inserted using a reduced inva-
24.
sive technique. An alternative is temporary external fixa-
tion of the tibia as the first step until the swelling has 25.
subsided and, subsequently, limited but open reduction
and internal fixation of displaced articular fragments, fol-
lowed by minimally invasive plate osteosynthesis. 26.
27.
REFERENCES
1. Anglen JO. Early outcome of hybrid external fixation for fracture
of the distal tibia. J Orthop Trauma 1999;13:92–97. 28.
2. Babis GC, Vayanos ED, Papaioannou N, et al. Results of surgical
treatment of tibial plafond fractures. Clin Orthop 1997;341:99–
105. 29.
3. Bargon G. Röntgenmorphologische Gradeinteilung der posttrau-
30.
matischen Arthrose im oberen Sprunggelenk. Hefte Unfallheilk
1978;133:28–34.
4. Bonar SK, Marsh JL. Unilateral external fixation for severe pilon
31.
fractures. Foot Ankle 1993;14:57–64.
5. Bone L, Stegemann P, McNamara K, et al. External fixation of
32.
severely comminuted and open pilon fractures. In: Major Frac-
tures of the Pilon, the Talus, and the Calcaneus, ed by Tscherne H,
Schatzker J. Berlin, Springer-Verlag, 1993, pp 53–58.
33.
6. Bone L, Stegemann P, McNamara K, et al. External fixation of
severely comminuted and open tibial pilon fractures. Clin Orthop
1993;292:101–107.
34.
7. Bourne RB, Rorabec CH, Macnab J. Intra-articular fractures of the
distal tibia: the pilon fracture. J Trauma 1983;23:591–595.
8. Börner M. Einteilung, Behandlung und Ergebnisse der Frakturen 35.
des Pilon tibiale. Unfallchirurgie 1982;8:230–235.
9. De Bastiani G, Aldegheri R, Renzi-Brevia L. The treatment of 36.
fractures with a dynamic axial fixator. J Bone Joint Surg [Br]
1984;66:538–545.
10. Egington ES. Randomization Tests. Basel, Marcel Dekker Inc., 37.
1987.
11. Etter C. Operatives Behandlungskonzept und Ergebnisse nach 8
Jahren bei Frakturen des Pilon-Tibial. Hefte Unfallheilk 1987;189: 38.
1191–1197.
12. Gustilo RB, Anderson JT. Prevention of inspection in the treatment
of one thousand and twenty-five open fractures of long bones. 39.
Retrospective and prospective analysis. J Bone Joint Surg [Br]
1976;58:453–458. 40.
13. Heim U. Die Pilon-tibial-Fraktur. Berlin, Springer-Verlag, 1991.
14. Heim U, Naser M. Die operative Behandlung der Pilon tibial-
159
Fraktur: Technik der Osteosynthese und Resultate bei 128 Pa-
tienten. Arch Orthop Unfallchir 1976;86:341–356.
Höntzsch D, Karnatz N, Jansen T. Ein- oder zweizeitige (mit Fix-
ateur externe) Vesorgung der schweren Pilon-Tibial-Fraktur. Akt
Traumatol 1990;20:199–204.
Jahna H, Wittich H, Hartenstein H. Ursachen von Arthrosen nach
Stauchungsbrüchen am distalen Schienbeinende. Unfallchirurgie
1979;5:250–255.
Jergesen F. Fractures of the ankle. Am J Surg 1959;98:136–145.
Kellam JF, Waddell JP. Fractures of the distal tibia metaphysis
with intra-articular extension: the distal tibial explosion fracture. J
Trauma 1979;19:593–609.
Kim HS, Jahng JS, Kim SS, et al. Treatment of tibial pilon frac-
tures using ring fixators and arthroscopy. Clin Orthop 1997;334:
244–250.
Laughlin RT, Calhoun JH. Ring fixators for reconstruction of trau-
matic disorders of the foot and ankle. Orthop Clin North Am 1995;
26:287–294.
Mast J. A test of surgical judgement. In: Major Fractures of the
Pilon, the Talus, and the Calcaneus, ed by Tscherne H, Schatzker
J. Berlin, Springer-Verlag, 1993, pp 7–27.
McDonald MG, Burgess RC, Bolano LE, et al. Ilizarov treatment
of pilon fractures. Clin Orthop 1996;325:244–250.
Mehta C, Patel N. StatXact-Turbo User Manual. Cambridge, MA:
Cytel Software Corporation, 1992.
Mischkowski T, Dichgans M. Behandlung und Spätergebnisse von
33 Frakturen des Pilon tibiale. Unfallchirurgie 1980;6:253–255.
Muhr G, Breitfuss H. Complications after pilon fractures. In: Ma-
jor Fractures of the Pilon, the Talus, and the Calcaneus, ed by
Tscherne H, Schatzker J. Berlin, Springer-Verlag, 1993, pp 65–68.
Müller KH, Prescher W. Posttraumatische Osteomyelitis nach dis-
talen intraartikulären Unterschenkelbrüchen (Frakturen des Pilon
tibial). Hefte Unfallheilk 1978;131:163–183.
Müller ME, Allgöwer M, Schneider R, et al. Manual of Internal
Fixation. Techniques Recommended by the AO–ASIF Group. Ber-
lin, Springer-Verlag, 1991.
Müller ME, Nazarian S, Koch P, et al. The Comprehensive Clas-
sification of Fractures of the Long Bones. Berlin, Springer-Verlag,
1990.
Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint
Surg [Am] 1986;68:543–551.
Patterson MJ, Cole JD. Two-staged delayed open reduction and
internal fixation of severe pilon fractures. J Orthop Trauma 1999;
13:85–91.
Resch H. Die Entwicklung der posttraumatischen Arthrose nach
Pilon- Tibialfrakturen. Unfallchirurgie 1986;89:8–15.
Resch H, Pechlaner S, Benedetto P. Spätergebnisse nach konser-
vativer und operativer Behandlung von Pilon Tibial-Frakturen. Akt
Traumatol 1986;16:117–123.
Rommens PM, Claes P, De Boodt P, et al. Therapeutisches Vorge-
hen und Langzeitergebnisse bei der Pilonfraktur in Abhängigkeit
vom primären Weichteilschaden. Unfallchirurgie 1994;97:39–46.
Rüedi T. Fractures of the lower end of the tibia into the ankle joint:
results 9 years after open reduction and internal fixation. Injury
1973;5:130–134.
Rüedi T. Die Frakturen des Pilon tibial. Unfallheilkunde 1983;86:
259–261.
Rüedi T, Allgöwer M. Spätresultate nach operativer Behandlung
der Gelenkbrüche am distalen Tibiaende. Unfallheilkunde 1978;
81:319–323.
Saleh M, Shanahan G, Fern ED. Intra-articular fractures of the
distal tibia: surgical management by limited internal and articu-
lated distraction. Injury 1993;24:37–40.
Sands A, Grujic L, Byck DC, et al. Clinical and functional out-
comes of internal fixation of displaced pilon fractures. Clin Orthop
1998;347:131–137.
Schatzker J. Fractures of the distal femur revisited. Clin Orthop
1998;347:43–56.
Scheck M. Treatment of comminuted distal tibial fractures by com-
bined dual- pin fixation and limited open reduction. J Bone Joint
Surg [Am] 1965;47:1537–1553.
J Orthop Trauma, Vol. 15, No. 3, 2001
160 M. BLAUTH ET AL.
41. Schweiberer L, Betz A, Nast-Kolb D, et al. Spezielle Behandlungs-
methodik am distalen Unterschenkel und bei Pilonfrakturen. Un-
fallchirurgie 1987;90:253–259.
42. Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft
tissue management in the treatment of complex pilon fractures. J
Orthop Trauma 1999;13:78–84.
43. Teeny S, Wiss D. Open reduction and internal fixation of tibial
plafond fractures. Clin Orthop 1993;292:108–117.
44. Trentz O, Friedl HP. Critical soft tissue conditions in pilon frac-
J Orthop Trauma, Vol. 15, No. 3, 2001
tures. In: Major Fractures of the Pilon, the Talus, and the Calca-
neus, ed by Tscherne H, Schatzker J. Berlin, Springer-Verlag,
1993, pp 59–64.
45. Tscherne H, Oestern HJ. Die Klassifizierung des Weichteilschad-
ens bei offenen und geschlossenen Frakturen. Unfallheilkunde
1982;85:111–115.
46. Waddell JP. Tibial plafond fractures. In: Major Fractures of the
Pilon, the Talus, and the Calcaneus, ed by Tscherne H, Schatzker
J. Berlin, Springer-Verlag, 1993, pp 43–48.