Injury 55 (2024) 111478

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

The management of pilon fractures: An expert survey of AO trauma Italy

members and evidence-based treatment recommendations✰
C. Simonini a, b, #, E. Lunini b, #, *, F. Chiodini c, G. Coviello d, F. Bove b, A. Carolla e, L. Daci e,
F. Ceccarelli 5, E. Santolini f, F. Calderazzi e, C. Buono g, G. Vicenti g, S. Rammelt h
a
Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
b
Orthopaedics & Trauma Unit, ASST Niguarda Hospital, Milano, Italy
c
Orthopaedics & Trauma Unit ASST, Papa Giovanni XXIII Hospital, Bergamo, BG, Italy
d
Orthopaedics & Trauma Unit, Bufalini Hospital, Cesena, Italy
e
Department of Surgery, Orthopaedic Clinic, Parma University Hospital 43100, Parma, Italy
f
Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK
g
School of Medicine, University of Bari Aldo Moro, AOU Consorziale “Policlinico” Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic
& Trauma Unit, Bari, Italy
h
University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: Operative decision-making of tibial pilon fractures is still of great complexity. The AO Trauma Italy has inves-
Tibial Pilon fracture tigated the trend in the management of this fractures among orthopedic surgeons in Italy. A literature-based
Plafond fracture survey focused on preoperative planning and surgical strategies has been submitted to all the participants and
Distal tibia fracture
the results were discussed in an online webinar in light of the most recent literature with the aim to outline
Intra-articular fracture
common treatment recommendations especially useful for young surgeons.

Introduction developed a literature based-survey in order to better understand the

trends regarding the management of complex pilon fractures, especially
Tibial plafond, or pilon, fractures are relative infrequent (5-7 % of all about preoperative planning and surgical strategies, among orthopedic
tibial fractures) but nevertheless can be some of the most difficult surgeons in Italy. The data collecting from this poll have been compared
fractures to manage [1]. As they are often associated with high-energy to recent literature and discussed in an online webinar, in presence of
trauma, both the metaphyseal and articular involvement pose chal- eminent experts, with the aim to outline common treatment recom-
lenges to reduction and fixation. Furthermore, they occur in an area of mendations especially useful for young surgeons.
relatively poor soft tissue coverage and frequently present a surgical
challenge in deciding which approaches will be best to perform open Material and methods
reduction internal fixation. The importance of appropriate soft tissue
management has became one of the main key factors in the treatment A survey with objective type questions has been developed from data
choice of pillon frctures. For this reason the staged protocol (restoration collected from recent literature.
of fibular length and temporary external fixation, followed by anatomic The studies selection was conducted using the Preferred Reporting
ORIF once soft tissue swelling has solved) especially for complex frac- Items for Systematic Reviews and Meta-Analyses (PRISMA) methods.
ture patterns remains nowadays the most suitable treatment in different
trauma center. But, despite the large number of studies published in
Search strategy
recent years, no clear guidelines have been given in the correct treat-
ment of tibial plafond fractures. For this reason AO trauma Italy has
Cochrane Library, Google Scholar and PubMed were searched from

✰
This paper is part of a Supplement supported by Club Italiano Osteosintesi (CIO)
* Corresponding and first author. ASST Great Metropolitan Niguarda Hospital, Piazza dell’Ospedale Maggiore, 3, Milano, Italy
E-mail address: [email protected] (E. Lunini).
#
The first two authors contributed equally to this work.

https://doi.org/10.1016/j.injury.2024.111478

Available online 13 November 2024

0020-1383/© 2024 Elsevier Ltd. All rights reserved.
C. Simonini et al. Injury 55 (2024) 111478

January 2010 to December 2023 to identify relevant studies for further of potentially relevant articles, Search strategy included the following
analysis. terms: Pilon fracture, Plafond fracture, Distal tibia fracture and
The main keywords were: Pilon fracture; Plafond fracture; Distal Intra-articular fracture. The second step consisted of revising the liter-
tibia fracture; Intra-articular fracture. ature review to identify relevant unsolved questions that could be
A manual search of the reference lists of the selected publications included in the survey questionnaire.
was also performed, to identify additional studies for potential inclusion.
Potentially relevant articles were acquired for full-length text and Results
Authors were contacted when the article was not available.
Study selection
Eligibility criteria
Cochrane Library, Google Scholar and PubMed database searches
Full-text articles alone published between January 2005 and provided a total of 178 studies for potential inclusion in the develop-
December 2023 were included. ment of the questionnaire. After adjusting for duplicates, 112 studies
The inclusion criteria were: remained. Of these, 60 studies were discarded after reading titles and
reviewing abstracts.
○ Human and biomechanical studies that considered different surgery The full text of the remaining 52 studies was examined in greater
techniques outcomes and rehabilitation programs in the treatment of detail. Of these, 16 studies did not meet the inclusion criteria. 36 studies
tibial plafond fractures were finally included in this study.
○ Articles written in English
Survey results
The exclusion criteria were:
A total of 69 orthopedic surgeons in Italy were interviewed (with a
○ Articles published before 2005 response rate of ~97 %). Of these, 73 % were trauma surgeons, 5 % were
○ Articles that not considered ORIF as a definitive treatment specialty orthopedic surgeons (eg, sports injuries, shoulder surgery,
pelvis surgery), 5 % were general orthopedic surgeons (joint replace-
The most thorough publication was selected when multiple reports ment, etc.).
from the same center or trial were found. The results are summarized in the Tables 2.
(Q1) A total of 8.7 % of all respondents had more than 20 years of
Data extraction experience in the treatment of fractures, 15.9 % between 6 and 19 years,
26.1 % less than 5 years and 49.3 % were resident surgeons. (Q2) In this
Information was extracted from each study by three review authors sample, 46.4 % treated less than 5 cases of pilon fractures per year, 43.5
and checked by another Author. % treated between 5 and 20 cases, and 10.1 % more than 20 cases per
Several articles were excluded after reviewing the titles and ab- year.
stracts. From the remaining articles, data regarding possible complica- (Q3) In case of closed pilon fractures first presentation in the
tions were extracted. Emergency Room, 71 % of the respondents declared to treat them ac-
The following data were extracted (when reported): authors and year cording to the principles of DCO (Damage Control Orthopedics) using an
of publication, number of patients enrolled, types of complications, external fixation until soft tissue healing, 15.9 % treat it with ETC (Early
types of surgical approaches and strategies. Total Care) if allowed by the condition of the soft tissue envelope, 7.2 %
would use skeletal traction, and 5.8 % cast immobilization until the
Survey definite treatment.(Q4) For radiographic evaluation, 73.9 % would use
conventional radiographs (XR) with antero-posterior (AP) and lateral
A postal survey was developed according to guidelines provided by a (LL) views of the ankle and lower leg, and CT scanning after external
meta-analysis of randomized studies of postal surveys to optimize fixation is applied, 21.7 % would perform ankle and leg XR and CT scan
response rates [2]. Three Trauma surgeons from a level-3 trauma center at once, and 3 % XR only.
developed a questionnaire shown in the table below (Table1). These (Q5) When temporary external fixation was applied, 5.8 % of or-
questions were derived from recent literature. The aims of the survey thopedic surgeons performed ORIF (Open Reduction and Open Fixation)
were explained in a personally addressed accompanying e-mail in which within 72 h, 24.6 % between the seventh and fourteenth day, 4.3 %
some clinical cases were presented. After 1 week a re-minder was sent. within three weeks. The majority of the respondents (65.2 %) stated that
This survey was sent different AO/OTA Italian members (71) including they delay definitive surgery until the soft tissues are amenable to sur-
resident surgeons. The first step consisted of a scoping literature search gery (presence of skin wrinkles) without giving a time frame.
done by two reviewers, using PubMed database to select an initial pool (Q6) In order to achieve the goals of surgical treatment, almost

Table. 1
The questions included in the survey.
Questions about management of complex pilon fractures

Q1) What is your professional experience?

Q2) How many pilon fractures do you surgically treat per year?
Q3) How do you manage a closed pilon fracture’s first presentation in the ER?
Q4) What kind of radiological exams do you prescribe in case of a pilon fracture?
Q5) After applying a temporary external fixation, how many times do you wait until definitive ORIF? Is there an ideal range of time?
Q6) What is your key to reaching the surgical treatment goals?
Q7) How do you manage a pilon fracture associated with a fibular fracture?
Q8) What is your consideration about planning ORIF of a complex pilon fracture?
Q9) What is your strategy to simplify tibial pilon fracture type C?
Q10) What are the biomechanical principles to guide your ORIF?
Q11) What is the frequency of syndesmosis lesions associated with tibial plafond fractures?
Q12) What is your post-operative rehabilitation protocol after ORIF?

2
C. Simonini et al. Injury 55 (2024) 111478

Table. 2 Table. 2 (continued )

Survey: main results. Items Options Answers Frequency
Items Options Answers Frequency
Begin from the 0 0%
1. Years of experience. Resident 34 49.3 % metaphysis if anatomical
0-5 18 26.1 % reduction to the articular
5 - 20 11 15.9 % fragment is achieved
> 20 6 8.7 % Begin with reduction and 6 8.7 %
2. Pilon fractures surgically <5 32 46.4 % fixation of the articular
treated per year. joint surface in case of
5 - 20 30 43.5 % metaphyseal
> 20 7 10.1 % comminution
3. Closed pilon fracture’s External fixation until soft 49 71 % All of the previous 53 76.8 %
management in the ER. tissue healing (DCO) answers
Early Total Care (ETC) if 11 15.9 % 10. Biomechanical Principal buttress plate on 6 8.7 %
soft tissue’s healthy principles that guide the compression side
Skeletal traction until 5 7.2 % your ORIF.
definitive treatment Supporting plate on the 0 0%
Cast until definitive 4 5.8 % tension side
treatment Absolute stability for the 3 4.3 %
articular block
4. Radiological exams. Ankle XR (AP and LL 2 2.9 % Absolute or relative 2 2.9 %
views) stability in the
Ankle and lower leg XR 1 1.5 % metaphyseal area based
(AP and LL views) on the individual fracture
Ankle and lower leg XR + 15 21.7 % pattern.
CT All of the previous 58 84.1 %
Ankle and lower leg XR + 51 73.9 % answers
CT after External Fixation 11. Frequency of Never 4 5.8 %
syndesmosis lesions
5. Waiting time until ORIF Within 72 h 4 5.8 % associated with tibial
(after EF). plafond fractures
Until the soft tissues are 45 65.2 % Always 1 1.4 %
amenable to surgery 15 % of the pilon fractures 38 37.7 %
Within 3 weeks 3 4.3 % More than 50 % of the 26 55.1 %
Between the 7th and 14th 17 24.6 % pilon fractures
day 12. Post-operative Early weight-bearing and 4 5.8 %
6. Key to surgical treatment Surgical approach to 2 2.9 % rehabilitation protocol mobilization to all the
goals. preserve or minimize soft after ORIF patients
tissue damage Weight-bearing depend 13 18.8 %
Anatomical reduction of 1 1.5 % on the fracture pattern
the articular surface and/or patient
Stable fixation of the 1 1.5 % Early mobilization but 46 66.7 %
articular fragment to the offloading for the first
shaft fragment month
Grafts in case of 0 0% Immobilization and no 6 8.7 %
metaphyseal bone defects weight-bearing for a
All of the previous 64 94.1 % month
answers
7. Management of pilon Fibular ORIF during DCO 4 5.8 %
fracture + fibular everyone (94.1 %) agreed to consider all the following key points: 1)
fracture. choose the surgical approach to preserve or minimize soft tissue dam-
Fibular ORIF during DCO, 10 14.5 %
age; 2) strive for anatomical reduction of the articular surface; 3) obtain
only in case of a simple
fibular fracture stable fixation of the articular (block) fragment to the shaft fragment;
Fibular ORIF during 50 72.5 % and 4) eventually use grafts to fill metaphyseal bone defects.
definitive treatment (Q7) In case of pilon fracture associated with a fibular fracture, 72.5
No fixation of fibular 5 7.2 % % of responders perform fibular ORIF only at the time of definitive
fracture
8. What are your questions Which surgical approach 2 2.9 %
treatment, 5.8 % during the DCO, 14.5 % during the DCO only in case of
about planning ORIF of a to better expose the a simple fibular fracture, and 7.2 % do not perform fixation of the fibular
complex pilon fracture. articular surface fracture at all.
How manage the reduce 0 0% (Q8) Otherwise, to plan a complex pilon fracture ORIF, almost the
and fixation of the Die-
entire sample (92.8 %) agreed to consider all of the following questions:
punch fragment
Where to place the 0 0% 1) which surgical approach choose to better expose the articular sur-
principal buttress plate face? 2) how manage the reduce and fixation of the Die-punch fragment?
Same approach to fix the 1 1.4 % 3) where to place the principal buttress plate? 4) Is it possible to use the
fibular fracture or use an same approach to fix the fibular fracture too or is an additional one
additional one
Conditions of the soft 2 2.9 %
needed? 5) How are the conditions of the soft tissues close to the planned
tissues surgical approach?
All of the previous 64 92.8 % (Q9) In order to “simplify” a type C pilon fracture, most orthopedic
answers surgeons (76.8 %) agreed to begin with fibular fixation in case of a
9. Strategy to simplify Begin with fibular fixation 10 14.5 %
simple fibular fracture (to restore the lateral column length), begin from
tibial pilon fracture type in case of a simple fibular
C. fracture the metaphysis if anatomical reduction to the articular fragment is
achieved, and to begin with reduction and fixation of the articular joint
surface in case of metaphyseal comminution.

3
C. Simonini et al. Injury 55 (2024) 111478

(Q10) The choice of surgical treatment based on biomechanical Early vs staged management
principles was approved by most of the respondents (84.1 %), such as: 1)
using the principal buttress plate on the compression side 2) using the Pilon fractures are often due to high-energy trauma and thus
supporting plate on the tension side 3) reaching absolute stability for the frequently associated with significant soft tissue damage. Otherwise in
articular block, and 4) choosing absolute or relative stability in the the elderly patients is possible to diagnose lower energy variants with
metaphyseal area based on the individual fracture pattern. soft tissue injury as severe as age-related tissue fragility. The soft tissues
(Q11) Different opinions emerged regarding the frequency of asso- should be evaluated and continuously monitored from the initial
ciation between tibial plafond fractures and syndesmosis lesions; but encounter, assessing for the degree of swelling, presence or absence of
only a small group (5.8 %) claimed that there was no association at all. skin wrinkles, blistering, and open wounds. Compartment syndrome has
The majority (55.1 %) argued that there was an association in 15 % of to be ruled out by repeated examinations to prevent the devastating
the pilon fractures, 37,7 % argued that were more than 50 %, only one sequelae. Therefore, it is mandatory to understand that is the state of the
person assumed that was always an association between them. soft tissues that dictates the timing of surgery and the choice of surgical
(Q12) The post-operative rehabilitation protocol adopted by 66.7 % techniques [1,8,10].
of the orthopedic surgeons consisted in early mobilization but offloading In the past, acute open reduction and internal fixation (ORIF) of
for the first month, while 18.8 % stated that weight-bearing should pilon fractures resulted in a high rate of infections and wound compli-
depend on the individual fracture pattern and/or patient characteristics, cations that lead to the establishment of staged protocols to perform a
8.7 % would perform an immobilization and no weight-bearing for a primary gross reduction (“damage control”) using traction, splints, or
month and 5.8 % would allow early weight-bearing and mobilization to preferably external fixators until the soft tissue envelope was consoli-
all the patients. dated. In the clinical practice, and according to our survey [see Q5],
surgeons use the presence of skin wrinkles or epithelialization of frac-
Discussion ture blisters to establish the moment of definitive treatment.
On the other hand, concerns about the potential complications of
With 69 respondents from all Italian hospitals and 73 % of them staged treatment, such as the pour quality of reduction, prolonged time
being traumatologists, this survey gives a useful insight into the preva- to definitive treatment, increased healthcare costs, and pin site infection
lent nationwide opinion in managing tibial pilon fractures. The purpose with the use of external fixators, have lead several surgeons to consider
of the survey was to provide common treatment recommendations to proceeding with definitive internal fixation acutely [11–13], .A number
better treat these fractures given the lack of a gold standard. of recent studies indeed have found similar complication rates and
outcomes of fractures treated with Early Total Care performed within 72
Classifications and diagnosis h, to the ones treated with staged fixation [11–15] However, this re-
quires the presence of an experienced team and full availability of re-
Tibial pilon fractures are relatively infrequent (5–7 % of all tibial sources at any given time and thus should be considered in specialized
fractures), caused mainly by axial loading in which the talus is driven trauma centers. In general clinical practice, in line with our survey [see
into the plafond resulting in articular impaction of the distal tibia. Q3] the mainstay of treatment are staged protocols (mostly with primary
Although a number of distal tibial articular fractures are caused pre- external fixation) until definite treatment while only a small part prefers
dominately by rotational forces with only minimal axial load (typically early total care, if allowed by the soft tissue conditions and logistic
in low-energy trauma), most of them are caused by high-energy trauma circumstances.
associated with severe soft tissue damage and comminuted fracture
patterns. Traditional goals of surgical treatment
Despite the degree of variability derived from the position of the foot
at the time of impact, in conjunction with the direction and amplitude of Since 1979 Rüedi and Allgöwer proposed four sequential principles
the force, CT-mapping has demonstrated involvement of three relatively to manage pilon fractures that have evolved overtime. These principles
consistent main fragments: posterolateral (Volkmann), anterolateral include (1) restoration of fibular length, (2) anatomic reduction of the
(Chaput), and medial fragments [3]. Each of these fragments are asso- articular surface, (3) filling the residual bone defect with cancellous
ciated with soft tissue attachments of the posterior inferior tibiofibular autograft, and (4) stabilization of the medial column [16].
ligament, anterior inferior tibiofibular ligament, and deltoid ligament,
respectively. Restoration of fibular length
Traditional classifications of AO/OTA [4] and Rüedi-Allgöwer [5] Frequently, a metaphyseal comminution is present in tibial plafond
were primarily based on plain radiographs. The classical AO system fractures, that makes tibial length hard to restore. If the fibula is less
divides fractures patterns in A for extraarticular, B for partial articular comminuted and easier to reduce, once reduced, it may provide a lateral
and C for complex articular and allows further subclassification into 27 buttress to assist tibial alignment in coronal and translational planes. On
groups. [6] The AO classification has been shown to be of prognostic the other hand, early fibular fixation limits the choice of approaches for
value in several clinical studies [7].Leonetti and Tigani proposed a new tibial reduction and fixation. It should therefore only be performed by
CT- based classification system relative to the type of displacement, the the same surgeon who plans to do the definite internal fixation. Other
number of articular fragments, the plane of the main fracture line, and drawbacks of early fibular reduction and fixation include the risk of
the degree of comminution [8]. They recognized four main groups and varus malalignment and tibial non-union. Furthermore, there is no ev-
respective subgroups, ranging from type 1 (not displaced) to type 4 idence, that fibular fixation is necessary at all [17], or necessary only in
(with 4 or more fragments and high comminution). There is general case of syndesmotic injury [18] . Thus, most experts recommend
agreement that CT scanning, eventually obtained after the initial gross anatomic reduction and fixation of the fibula at the time of definitive
reduction and external stabilization procedure [9], is essential to fixation of the tibial pilon [1,10,17,18]. In our survey we collected
recognize the main fragments, type of fracture and planning both sur- similar results [see Q7], with the majority agreeing to fix the fibula,
gical approaches and fixation [8,10]. Our survey confirms the essential mostly during the definitive treatment.
role of CT scanning in studying and planning the best surgical strategy to
treat tibial plafond fractures, obtained after the initial stabilization Anatomic reduction of the articular surface
procedure [see Q4]. According to AO principles of providing anatomic reduction an ab-
solute stability for any intra-articular fractures, the articular surface of
the tibial plafond fractures should be reduced and fixed in an anatomic

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C. Simonini et al. Injury 55 (2024) 111478

position. To reach this target, the body of the talus can be used as a the end, these fragments are relatively the main consistent fragments
template, and the aim is to obtain less than 2 mm of articular step-off or and that’s why were considered “constant key fragments” for starting
gapping. Once length, alignment and rotation are restored, the recon- reduction. The importance of these key fragments cannot be over-
structed articular block should be assembled to the shaft [9]. A recent estimated as it has been demonstrated recently that their mere presence
prospective study by Sommer et al. found no correlation found between and, most importantly, malreduction result in syndesmotic malposition
articular step-off and articular gap [19], There is evidence from multiple and inferior outcomes following operative treatment of pilon fractures
studies, that restoration of the articular surface decreases the risk of [28,29].
post-traumatic arthritis and leads to improved clinical outcomes[17,
20–22]. In contrast to malleolar fractures, late joint-preserving correc- Column stabilization
tion is feasible only exceptionally following malunited pilon fractures As mentioned before, not only does the medial column have to be
[23]. For this reason, we must continue to strive for an anatomic stabilized, but all damaged pillars in the pilon fracture. Tang et al. were
reduction whenever feasible, which is also reflected by the results from the first authors to propose the “column theory” [30]. Later on, Chen et
our survey [see Q6]. al [31]. following this theory, proposed that every compromised pillar,
when both metaphyseal and articular part are involved, should be
Filling of metaphyseal bone defect treated using two or more plates to achieve adequate stability and
Considering the high energy injuries associated with, a bone defect avoiding malunion or nonunion. Recent clinical studies seem to promote
after reduction of the impacted articular (“die punch”) fragment(s) is not this concept [32,33] . At the end of the webinar, all the experts
rare. Several filling agents have been proposed to support the articular concurred that in order to avoid fixation failure, the plates for tibial
segment and prevent secondary giving way including autologous bone fixation should ideally act as a buttress plate over all the primarily
graft, cancellous and structural allograft, calcium-based bone cements, involved column (i.e. medially in a varus-type fracture and laterally in a
and demineralized bone matrix products. There is no evidence on the valgus-type fracture). On the other hand, as outlined above, increased
necessity of defect filling or the superiority of one graft material over stability through more incisions and implants has to be weighted against
another so far. The majority of respondents generally favored some kind the additional soft tissue compromise.
of defect filling [see Q6].
Simplify the fracture pattern
Fixation of the medial column When the fracture of the tibia and fibula are to be addressed in the
The original theory of Rüedi and Allgöwer proposed independent same setting, the order of stabilization is dependent on the fracture
fixation of the medial column with a buttress plate as the mainstay of pattern starting from the bone that allows anatomical reduction of the
fixation to avoid coronal malalignment. This is based on the concept that fracture. In case of a simple fracture of the fibula, anatomic reduction
in these fractures there is a higher risk of varus deformity, especially in may be obtained and performed first in order to assist the reduction and
case of metaphyseal comminution. Recent concepts instead moved away alignment of the tibia, if deemed helpful by the surgeon. In case of a
from this principle in lieu of locking plate fixation based on the indi- comminuted fibular fracture, it may be beneficial to address the tibia
vidual fracture pattern [1,10,24]. first. In the articular pilon fracture the first step is to restore the articular
surface. In partial articular fracture patterns (AO type B), it is recom-
Surgical strategies mended to build the articular surface to the stable column. In complete
articular patterns (AO type C) the surgical strategy depends on the in-
Approaches dividual articular involvement. In complex articular pattern, it is mostly
A multitude of approaches have been described for the management useful to primarily restore the articular surface and then affix this
of pilon fractures, including anterolateral, anteromedial, direct anterior, segment to the metadiaphysis, i.e., “turning a C type into an A type” [1].
direct lateral, direct medial, posterolateral, and posteromedial [10,12, In more simple articular fracture pattern, it may be beneficial to stabilize
25]. Planning one or more combined incisions should be determined by one of the larger articular fragments to the tibial metaphysis first, i.e.,
the individual fracture pattern. Historically, the need of a minimum “turning a C type into an B type” [10,12]. Similar results emerged from
7-cm skin bridge left between one incision was postulated. Howard et al. our survey demonstrating the importance of simplifying the fracture
demonstrated soft tissue complications in only 9 % even in the “less than regarding the base of fracture pattern (see Q9).
7 cm skin bridges” that have been performed in 83 % of patients in their
study [26]. Regardless, it is important to respect the soft tissue envelope Association with syndesmosis lesion
with precise handling through straight and parallel incisions, full-
thickness skin flaps and a meticulous soft tissue care, using more gentle Tibial plafond fractures are highly morbid musculoskeletal injuries
retraction on the skin edges to prevent wound necrosis [12]. Further- and may feature detectable syndesmosis lesions in 15 % of cases, as
more, the use of limited incisions has the potential to reduce wound recognized from the majority of respondents of our survey (see Q11).
healing complications which have infamously complicated pilon frac- Failure to identify and adequately address a syndesmosis injury is
ture surgery. Analyzing the discussion during the webinar, besides all related to increasing rate of post-traumatic osteoarthritis development
the points already mentioned, all surgeons agreed that the choice of the [28,29]. Surgeons should suspect this additional component of tibial
surgical approache(s) should also consider the best visualization of the plafond fractures, performing an intraoperative stress test to evaluate
articular surface and the adequate exposure for the key fragments each plafond fracture for syndesmosis instability. In particular in the
management and plate(s) positioning. fracture pattern with a Chaput or Volkmann fragment equal or minor
than 10 mm, and/or distal fibular avulsion fracture is recommended to
The reduction “key fragments” scrutinize CT scan and fluoroscopy while proceeding with syndesmotic
This principle began from concept that fibular fractures are reduction and fixation [34]. Likewise, it is important to recognize
commonly associated with pilon fractures, in particular the AO type C anterior, posterior and medial pilon variants in seemingly “simple”
fractures occurring in more than 90 % of cases [27]. For this reason, it is malleolar fractures in order to avoid malalignment and the early
important to recognize that a portion of the lateral plafond typically development of posttraumatic arthritis [35–37].
remains attached to the distal fibula. Specifically, the anterolateral
Chaput fragment and the posterolateral Volkmann fragment may remain Post-operative rehabilitation protocol
in continuity with the lateral malleolus through the anterior inferior and
posterior inferior tibiofibular (syndesmotic) ligaments, respectively. In Concerning the post-operative rehabilitation program after pilon

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C. Simonini et al. Injury 55 (2024) 111478

fracture ORIF there is no consensus in literature but the majority of the 6. Recognizing the mechanism of injury is mandatory to set a proper
participants were in line with the “aftercare” proposed by the AO [10, fixation strategy considering that not only the medial column must
38]: be stabilized, but all the columns that are compromised meta-
physically should be addressed following the “four columns”
1- Physiotherapy with active assisted exercises is started immediately principles.
after surgery. 7. Figure out the best approach for articular visualization, key fragment
2- Depending on the articular involvement, bone quality and fracture management and plate positioning while minimizing the soft tissue
pattern, partial weight bearing (15–20 kg) can be started immedi- damage.
ately or as tolerated and then increased after 6–8 weeks on the base 8. In the most complex cases the goal of the surgical treatment remains
on the bony consolidation on follow-up radiographs with full weight the articular congruency, while the meta-diaphyseal bone defects
bearing usually after 3 months. may be restored with bone grafts or bone substitute materials.
9. Post-operative rehabilitation aims at early motion under protected
Conclusions weight-bearing until radiographic fracture union.

Tibial pilon fractures are complex injuries that are difficult to treat CRediT authorship contribution statement
for even the most skilled orthopedic trauma surgeons. The combination
of articular cartilage injury, metaphyseal comminution, and soft tissue C. Simonini: Writing – original draft. E. Lunini: Conceptualization,
insult has often resulted in notoriously poor outcomes. Respect for the Writing – original draft. F. Chiodini: Conceptualization. G. Coviello:
soft tissue envelope is the first step in minimizing complications. Conceptualization. F. Bove: Visualization. A. Carolla: Visualization. L.
Although advances in surgical techniques and implants have led to Daci: Visualization. F. Ceccarelli: Supervision. E. Santolini: Supervi-
improved outcomes over time, the overall prognosis for these injuries sion. F. Calderazzi: Visualization. C. Buono: Writing – review & edit-
often remains poor. What emerges from our survey is that two staged ing. G. Vicenti: Supervision. S. Rammelt: Validation.
protocol is the most suitable and used strategy in the treatment of pillon
fractures among Italian Trauma surgeons. In order to evaluate the
Declaration of competing interest
complexity of the fracture pattern, the majority of the interviews
recommend CT scan after external fixator has applied. Staged manage-
None.
ment seems to be the gold standard of treatment of these lesions
although some experienced authors had excellent results with immedi-
References
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