Aims. A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures. Methods. A randomized controlled trial (RCT) of 334 adult patients diagnosed with a closed type C pilon fracture will be conducted. Internal locking plate fixation will be compared with external frame fixation. The primary outcome and endpoint will be the Disability Rating Index (a patient self-reported assessment of physical disability) at 12 months. This will also be measured at baseline, three, six, and 24 months after randomization. Secondary outcomes include the Olerud and Molander Ankle Score (OMAS), the five-level EuroQol five-dimenison score (EQ-5D-5L), complications (including bone healing), resource use, work impact, and patient treatment preference. The acceptability of the treatments and study design to patients and health care professionals will be explored through qualitative methods. Discussion. The two treatments being compared are the most commonly used for this injury, however there is uncertainty over which is most clinically and cost-effective. The Articular Pilon Fracture (ACTIVE) Trial is a sufficiently powered and rigorously designed study to inform clinical decisions for the treatment of adults with this injury. Cite this article: Bone Jt Open 2021;2(3):150–163

Objectives. Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Different techniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole, very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgical management options can influence postoperative complications, and if this can influence future management protocols. Materials and methods. We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications and functional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD42020184213). The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation, osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was also measured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions. Results. The search yielded 309 results and a total of 18 studies consisting of 484 patients were included. All fractures included were open, and consisted of 64 Gustilo-Anderson Type I, 148 Type II, 103 Type IIIa, 90 Type IIIb and 9 Type IIIc. 60 Type III fractures could not be further separated and 12 were ungraded. Both ORIF and Ex-Fix were found to have statistically similar AOFAS scores (p=0.682). For all included studies, the Ex-Fix group had significantly higher rates of superficial infections (p=0.001), non-unions (p=0.001), osteoarthritis (p=0.001) and bone grafting (p=0.001). The meta-analysis found no significant difference in non-union (pooled OR=0.25, 95% CI: 0.03 to 2.24, p = 0.44) or deep infection rates (pooled OR=1.35, 95% CI: 0.11 to 16.69, p = 0.12) between the ORIF and Ex-fix groups. Conclusion. Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to have a significantly higher risk of postoperative complications which must be considered by surgeons when choosing surgical management options. Further research, ideally in a randomised control trial format, is required to definitively demonstrate ORIF superiority in the management of open pilon fractures

Tibial Pilon fractures pose a difficult management problem. For logical fracture treatment, precise understanding of the 3-D anatomy is essential. We have studied a consecutive series of 126 pilon fractures. Digitised X-rays and CT scans were analysed using a CAD programme. We have defined six main fragments at the articular surface, their relative frequency and their proportion: Anterior (A) present in 89%, 28% of area. Posterior (P) present in 89%, 40% of area. Medial (M) present in 74%, 29% of area. Anterolateral (AL) present in 34%, 8% of area. Posterolateral (PL) present in 21%, 9% of area. Die-punch (DP) present in 43%, 4% of area. The primary fracture line varied in orientation from coronal (93%) to sagittal (7%), in contrast to the classic description. Within those cases where the primary fracture line was coronal we found hitherto undescribed variations in the articular pattern, there being ‘T’, ‘V’, ‘Y’ and pure split fractures with respect to the medial fragment. Fractures which displace into varus show a “T” configuration, those in valgus a “Y” or “V” configuration, (p < 0.001). Fractures with no coronal mal-alignment produce a talo-fibular joint disruption. Once recognised these different articular patterns require individual techniques for anatomic reduction and fixation

Background: Tibial Pilon fractures pose a difþcult management problem. For logical fracture treatment, precise understanding of the 3-D anatomy is essential. Methods: We have studied a consecutive series of 126 pilon fractures. Digitised Xrays and CT scans were analysed using a CAD programme. Results: We have deþned 6 main fragments, at the articular surface. The primary fracture line varied in orientation from coronal (93%) to sagittal (7%), in contrast to the classic description. Observation of the articular fracture patterns revealed ñTñ, ñVñ, ñYñ and pure split fractures with respect to the medial fragment. Fractures, which displace into varus, show a ÒTÒ conþguration, those in valgus a ÒYÒ or ÒVÒ conþguration, (p < 0.001). Fractures with no coronal mal-alignment produce a talo-þbular joint disruption. These different articular patterns require individual techniques for anatomic reduction and þxation

Introduction: Tibial pilon fractures are complex and difficult to manage. Results with extensile approaches, rigid internal fixation and bone grafting remain poor. Percutaneous treatment does not allow anatomic restoration. Current classifications are not helpful. Understanding the anatomy and behaviour of the fracture would allow development of logical algorithms for treatment. Method: We have analysed plain radiographs and CT scans in a consecutive series of 126 pilon fractures and have defined the fracture anatomy and developed a new classification. Results: There are six constant articular fragments: anterior, anterolateral (insertion of AITFL), medial, posterior, posterolateral (insertion of PITFL) and die-punch. Two main fracture families exist depending on the articular fracture pattern. T-type and V/Y-type fractures. A lateral disruption type fracture represents a further important group. An evolution of fracture is evident within the groups. T-type fractures tend to occur in varus and result from higher energy injuries in younger patients. V/Y-type fractures tend to occur in valgus and result from lower energy injuries in older patients. Conclusions: We have defined distinct articular fragments, allowing development of safe direct surgical exposures. Stabilisation of the tibial fracture with fine-wire fixators or plates may be employed. The Pathoanatomy could be used in optimal design of such plates. Defining the fracture types gives us a useful and reproducible classification of injury

Optimal treatment of articular fractures is open anatomic reduction and rigid internal fixation. In pilon fractures, this has been associated with unacceptable complication rates. The cutaneous blood supply of the anterior aspect of the distal tibia is from short direct radial vessels which themselves arise from arteries closely adherent to the deep fascia. On the anteromedial aspect of the leg the deep fascia is fused with the periosteum. We hypothesise that shearing associated with displaced fractures divide these short radial vessels, rendering the skin critically ischaemic. Standard extensile approaches lead to further devitalisation and wound breakdown. It follows that a direct approach onto the fracture line should do minimal extra damage to the blood supply. Of 97 pilon fractures, 53 have required an open reduction. Median age 43, 39 male. Mechanism of Injury: fall-41, RTA-10, other-two. 19% open (60% IIIB). Time to surgery nine days. A longitudinal incision with full thickness flaps is based directly over the fracture, not necessarily following internervous planes. Anatomic reduction was achieved in all cases. There was only one complication of wound breakdown (2%). This technique affords a safe and reliable approach to the fractured articular surface. Lack of wound breakdown may rely on the use of fine-wire circular frame external fixators for stabilisation of the proximal fracture. Whether this approach will allow plate fixation, remains to be seen

Introduction: Classification systems are useful in research and clinical practise as it provides a common mode of communication and evaluation. Tibial pilon injuries are a complex group of fractures, whose classification and radiological assessment in clinical practise remains undetermined. Methods: 50 CT scans and radiographs of tibial pilon fractures were evaluated independently by 6 orthopaedic surgeons, comprising 3 consultants, 2 registrars and 1 research fellow. Fractures were classified according to ruedi allgower, AO, Topliss et al. Each surgeon was given a period of 48 hours to review copy of the original article as well as written and diagrammatic representations. Assessment was done on two occasions, 4 weeks apart. The kappa coefficient of agreement was calculated with SPSS to determine interobserver reliability and intraobserver reproducibility of the classification systems. The evaluator was blinded as to treatment and functional outcome. Each evaluator was also asked to decide upon the fracture management based on the classification types and was compared with the actual management. Result: The interobserver agreement for ruedi allgower, Ao and Topliss et al., was fair, moderate and poor respectively. The intraobserver agreement for ruedi allgower, AO and Topliss et al., classifications was moderate at best. There was poor agreement amongst observers regarding definite management plan based on these classification systems. Discussion: The interobserver agreement was directly proportional to the familiarity and inversely proportional to the specificity of the classification system. The intraobserver agreement improved with experience. CT scan helped in delineating the fracture segments accurately but did not significantly affect inter or intraob-server agreement. Conclusion: Existing classification systems help in understanding the pathoanatomy of osseous part of tibial pilon fracture complex. However, Soft tissue injury forms an integral part of this complex. Without inclusion of soft tissue injury, these classification systems have limited role in definitive management

Objective and Purpose: Pilon fractures are complex fractures of the tibial articular surface usually associated with high energy trauma and major soft tissue injury. We investigated the effectiveness of Ilizarov external fixator in such cases. At our hospital, we obtain excellent results performing reconstruction using vascularised fibular grafts for the infectious non-union. Methods and Materials: We examined 21 cases treated with the Ilizarov apparatus for the fresh pilon fracture from 1999. There were 13 males and 8 females, with an average of 44 years. The AO classification was A2 type in 2 cases, B1 in 4, C1 in 3, C2 in 3, and C3 in 9, with open fractures of Gustilo type?Uor ?Va in 7 cases. 11 cases were treated by the Ilizarov technique only. 10 cases were treated by the additional limited open reduction with screw, K-wire and fibular plating. The average time between injury and surgery was 4 days. We examined 6 cases treated with the vascularised fibular graft for the infectious non-union cases after internal fixation. Age at the surgery was from 19 to 70 (mean 46). Results: All fractures were united and removed at an average of 10 weeks (range 8–12 weeks). Complications included 5 cases of superficial pin tract infections. There is no deep infections and no pseudarthrosies. Conclusion: The use of Ilizarov fixator is a safer method of treatment of pilon fractures, especially for the severe soft tissue injury and we don ft delay surgery for soft tissue considerations

Pilon injuries without fibula fractures may be associated with increased tibial plafond fracture severity. To evaluate this, we used the rank order technique, with traumatologists blinded to the fibular injury, who ranked the radiographic severity of forty pilon injuries with and without fibula fractures. Pilon injuries with fibular fractures were ranked as more severe than those without. C-type injuries were ranked as more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type. The presence of an intact fibula is not predictive of a more severe injury to the tibial pilon. To determine if the absence of a fibular fracture is predictive of tibial pilon fracture severity. Fibular status is not predictive of a more severe injury to the tibial pilon, and is more commonly associated with the less severe B-type injuries. Absence of an ipsilateral fibular fracture in patients with tibial pilon injuries may predict a more severe tibial plafond injury pattern. Presumably, the energy is completely absorbed by the tibia resulting in more severe epimetaphyseal injury. The reverse relationship, however, was identified. This fact may aid in prognosis and treatment strategies. Twenty consecutive pilon injuries without associated fibular fractures were matched 1:1 to an age/gender-matched cohort of pilon injuries with fibular fractures. Initial radiographs were digitized, the fibular image concealed, and then independently ranked (One, least severe; forty, most severe) by three orthopaedic traumatologists according to tibial plafond fracture severity. Injuries were classified using AO/OTA guidelines. Inter-observer agreement was moderate (κ =0.6). Mean rank for pilon injuries with fibula fractures was 24.4 versus 16.7 for those without (t = 0.02). C-type injuries demonstrated a mean of 10.3 for those with fibular fractures versus 8.7 for those without (t = 0.5). Mean rank for B-type injuries was 11.1 versus 24.5 for C-type injuries (t = 0.001). Overall, tibial pilon injuries with fibular fractures are more severe than those without. C-type injuries with or without fibular fractures are equally severe. C-type injuries were ranked significantly more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type

We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel. In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries. Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01). Conclusion/Significance. In older patients local complications are relatively common and clinical vigilance must be maintained in order to allow appropriate intervention during their post-operative course. Despite the incidence of radiological post-traumatic arthrosis, none of the patients progressed to ankle fusion

Aims. Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis. Methods. The inclusion criteria applied in PubMed, Scopus, and Medline database searches were: all adult studies published between 2012 and 2022; and studies written in English. Outcome of TP entrapment in patients with ankle injuries was assessed by two reviewers independently. Results. Four retrospective studies and eight case reports were accepted in this systematic review. Collectively there were 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 trimalleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fractures at initial presentation. The diagnosis of TP entrapment was made in the early period in two (25%) cases, and delayed diagnosis in six (75%) cases reported. Using modified Clavien-Dindo complication classification, 60 (67%) of the injuries reported grade IIIa complications and 29 (33%) grade IIIb complications. Conclusion. TP tendon was the commonest tendon injury associated with pilon fracture and, to a lesser extent, trimalleolar ankle fracture. Early identification using a clinical suspicion and CT imaging could lead to early management of TP entrapment in these injuries, which could lead to better patient outcomes and reduced morbidity. Cite this article: Bone Jt Open 2024;5(3):252–259

Introduction. Tibial Pilon fractures are potentially limb threatening, yet standards of care are lacking from BOFAS and the BOA. The mantra of “span, scan, plan” describes staged management with external fixation to allow soft tissue resuscitation, followed by a planning CT-scan. Our aim was to evaluate how Tibial Pilon fractures are acutely managed. Methods. ENFORCE was a multi-centre retrospective observational study of the acute management of partial and complete articular Tibial Pilon fractures over a three-year period. Mechanism, imaging, fracture classification, time to fracture reduction and cast, and soft tissue damage control details were determined. Results. 656 patients (670 fractures) across 27 centres were reported. AO fracture classifications were: partial articular (n=294) and complete articular (n=376). Initial diagnostic imaging mobilities were: plain radiographs (n=602) and CT-scan (n=54), with all but 38 cases having a planning CT-scan. 526 fractures had a cast applied in the Emergency Department (91 before radiological diagnosis), with the times taken to obtain post cast imaging being: mean 2.7 hours, median 2.3 hours, range 28 mins – 14 hours). 35% (102/294) of partial articular and 57% (216/376) of complete articular (length unstable) fractures had an external fixator applied, all of which underwent a planning CT-scan. Definitive management consisted of: open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intramedullary nail (n=25), other (n=18). Conclusion. The management of Tibial Pilon fractures is variable, with prolonged delays in obtaining post cast reduction radiographs, and just over half of length unstable complete articular fractures being managed with the gold standard “span, scan, plan” staged soft tissue resuscitation. A BOFAS endorsed BOAST (British Orthopaedic Association Standard for Trauma) for Tibial Pilon fractures is suggested for standardisation of the acute management of these potentially limb threatening injuries, together with setting them apart from more straightforward ankle fractures

This study investigated concurrent talar dome injuries associated with tibial pilon fractures, mapping their distribution across the proximal talar dome articular surface. It compared the two main mechanisms of injury (MOI), falling from a height and motor vehicle accident (MVA), and whether the fractures were open or closed. From a previously compiled database of acute distal tibial pilon fractures (AO/OTA 43B/C) in adults of 105 cases, 53 cases were identified with a concurrent injury to the talar dome with a known mechanism of injury and in 44 it was known if the fracture was open or closed. Case specific 2D injury maps were created using a 1x1mm grid, which were overlayed in an Excel document to allow for comparative analyses. A two-way ANOVA was conducted that examined the effect of both MOI and if the fracture was open or closed on what percentage of the talar dome surface was injured. There was a statistically-significant difference between the average percentage of injured squares on the talar dome by both whether the fracture was open or closed (f(1)=5.27, p= .027) and the mechanism of injury (f(1)=8.08, p= .007), though the interaction between these was not significant (p= .156). Open injuries and injuries that occurred during an MVA were more likely to increase the surface area of the talar dome injuries. We have identified both MOI and if the fracture was either open or closed impacts the size of the injury present on the talar dome. Future research will investigate the aetiology of the differences noted, highlighting the clinical implications. Surgeons treating tibial pilon fractures caused by either a MVA or an open fracture, should be aware of an increased risk of large injuries to the surface of the talar dome

Tibial pilon fractures are typically the result of high-energy axial loads, with complex intra- articular fractures that are often difficult to reconstruct anatomically. Only nine simultaneous pilon and talus fractures have been published previously, but we hypothesised the chondral surface of the dome is affected more frequently. Data was acquired prospectively from 154 acute distal tibial pilon fractures (AO/OTA 43B/C) in adults. Radiographs, photographs, and intra-operative drawings of each case were utilised to document the presence of any macroscopic injuries of the talus. Detailed 1x1mm maps were created of the injuries in each case and transposed onto a statistical shape model of a talus; this enables the cumulative data to be analysed in Excel. Data was analysed using a Chi-squared test. From 154 cases, 104 were considered at risk and their talar domes were inspected; of these, macroscopic injuries were identified in 55 (52.4%). The prevalence of talar dome injury was greater with B-type fractures (53.5%) than C-type fractures (31.5%) (ρ = .01). Injuries were more common in men than women and presented with different distribution of injuries (ρ = .032). A significant difference in the distribution of injuries was also identified when comparing falls and motor vehicle accidents (ρ = .007). Concomitant injuries to the articular surface of the dome of the talus are relatively common, and this perhaps explains the discordance between the post-operative appearance following internal fixation and the clinical outcomes observed. These injuries were focused on the lateral third of the dome in men and MVAs, whereas women and fall mechanism were more evenly distributed. Surgeons who operatively manage high-energy pilon fractures should consider routine inspection of the talar dome to assess the possibility of associated macroscopic osteochondral injuries

Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

Introduction. Pilon fractures are complex, high-energy, intra-articular fractures of the distal tibia. Achieving good outcomes is challenging due to fracture complexity and extensive soft tissue damage. The purpose of this study was to determine the long-term functional and clinical outcomes of definitive management with fine wire Ilizarov fixation for closed pilon fractures. Materials and Methods. 185 patients treated over a 14-year period (2004–2018) were included. All patients had Ilizarov frames applied to restore mechanical axis and fine wires to control periarticular fragments. CT scans were performed post operatively to confirm satisfactory restoration of the articular surface. All frames were dynamized prior to removal. Patients' functional outcome was assessed using the validated Chertsey Outcome Score for Trauma (“COST”). Review of clinical notes and imaging was used to determine complications and time to union. Results. The mean functional outcome in the studied cohort was determined to be “average” on the “COST” score. Poorer functional outcomes were associated with younger age at time of injury and multi-fragment fracture patterns. Mean time in frame was 170 days. Complication rates were low. There were no deep infections, no amputations and only 8 patients went on to have ankle fusions. Conclusions. Good functional results and low complication rates can be achieved by managing pilon fractures with fine wire Ilizarov fixation. Nonetheless, at time of injury patients should be counselled as to the severity of the injury and impact on their functional status

Introduction. The BOAST (British Orthopaedic Association Standards for Trauma) guidelines do advise that open pilon fractures amongst other open lower limb fractures need to be treated at a specialist centre with Orthoplastic care. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures treated as per BOAST guidelines including relatively aggressive bone debridement. Methods. A retrospective analysis of a single surgeon series of open pilon fractures treated between 2014 and 2019 was conducted. Injuries were graded according to the Gustillo-Anderson classification and all patients were included for the assessment of the rate of infection and fracture healing. Functional outcome assessment was performed in all patients according to the American Orthopedic Foot and Ankle Score (AOFAS) at 6 months after definitive surgery. Initial wound with bone debridement and application of a spanning external fixator was performed within an average of 13.5 (Range: 3–24) hours. Fixation with FWF (Fine Wire Frame) was performed when the wound was healed, with the mean time from primary surgery to application of FWF being 24.5 (Range: 7–60) days. Results. There was a total of 20 patients including 16 males and 4 females. The mean age was 50.45 (Range: 16–88) years. Follow-up was for an average of 23.2 (Range: 5–51) months. There were 3 patients with Gustilo Type I injuries, 6 with Type II, 4 Type with type IIIa and 7 with Type IIIb injuries. Average time to bone union was 9.3 (Range: 2–18) months. The mean AOFAS score was 66 (Range: 15–97) points. TSF was used on 18 patients, while 2 patients had an Ilizarov frame. A corticotomy was performed on 4 patients with critical bone defect post debridement, while 2 patients had Stimulan beads with antibiotics. There was 1 case (5%) of deep infection and 9 cases (45%) of superficial infection. There were also 2 cases (10%) of non-union which required bone grafting from their femur using a RIA (Reamer Irrigation Aspirator). Other complications included 1 case of acute compartment syndrome, 1 case of pulmonary embolism, 1 case of necrotic skin and 1 case of amputation. Conclusion. Results of our study suggests that the use of staged wound debridement including relatively aggressive bone debridement in conjunction with antibiotics, external fixators and patient tailored conversion from spanning external fixator to fine wire frame achieves low rates of wound infection and complications for patients with open pilon fractures

Introduction and Objective. Despite the low incidence of pilon fractures among lower limb injuries, their high-impact nature presents difficulties in surgical management and recovery. Current literature includes a wide range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm that was applied consistently over the span of this study. Materials and Methods. This retrospective study was conducted at a single institution, including 141 pilon fractures in 135 patients, from August 2014 to January 2021. AO/OTA classification was used to classify fractures. Among closed fractures, 12 had type 43A, 18 had type 43B, 61 had type 43C. Among open fractures, 11 had type 43A, 12 had type 43B, 27 had type 43C. Open fractures were further classified with Gustilo-Anderson (GA); type 1: n=8, type 2: n=10, type 3A: n=12, type 3B: n=20. Our treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis (MIO) was performed in combination with FWF to improve joint congruency. All open fractures, and closed fractures with severe soft tissue injury (skin contusion, fracture blister, severe oedema) were initially treated with temporary ankle-spanning external fixation. For all open fracture patients, surgical debridement, soft tissue cover with a free or pedicled flap were performed. For GA types 1 and 2, this was done with ORIF in the same operating session. Those with severe soft tissue injury (GA type 3) were treated with FWF four to six weeks after soft tissue management was completed. Primary outcome was AOFAS Ankle-Hindfoot score at 3, 6 and 12-months post-treatment. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time. All complications were recorded. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of the 141 fractures healed without further intervention (84.4%). Average time to bone union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). Union took longer in closed fracture patients treated with FWF than ORIF (p=0.025). On average, open and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042; OR=2.558, 95% CI 1.016–6.441), bone defect (p=0.001; OR=5.973, 95% CI 1.986–17.967), and superficial infection (p<0.001; OR=4.167, 95% CI 1.978–8.781). Conclusions. The use of a two-staged approach involving temporary external fixation followed by definitive fixation, provides a stable milieu for soft tissue recovery. FWF combined with MIO, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery

Purpose. Pilon fracture is a severe injury which has a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had pilon fractures. Materials & Methods. We have evaluated the gait pattern of patients who were treated with circular Ilizarov frame following pilon fractures in our department. The gait was tested by using a force plate in a walking platform. Ground Reaction Forces (GRF) and timing of gait phases data were collected during level walking at self-selected speeds. The patients performed two walking tasks for each limb and the collected data were averaged for each limb. Demographic, clinical, radiological, trauma outcome (COST) and quality of life questionnaire (SF-12) data were also collected. Results. We have analysed the gait through the GRF of twelve patients (aged 44.9 ±12.4 years), who had undergone treatment with circular Ilizarov frame following pilon fractures (67% were male). The tests were performed at an average of 10.5 months after the initial treatment. SF-12 Mental scores have returned to normal (mean 56.4 ±11.6) but physical scores remained impaired (mean 41.8 ±8.4). COST questionnaire scores reached average levels (47.1 ±15) in all dimensions (Symptoms: 51.4 ±16, Function: 44 ±14 and Mental Status: 56.6 ±16). During the push-off phase all the plantar flexor muscles are activated and the ankle plantar flexes to achieve the push off. It seems that this motion, is not achieved adequately with the affected limb and the patients are using their normal limb earlier (pre-swing is the start of the double support of the gait) in order to progress in their gait circle. Conclusions. Ten months following treatment with circular ilizarov frame for pilon fracture the patients still have impaired gait pattern. The differences can be explained by the lack of plantar flexion of the ankle which results to poorer push-off of the affected limb

Abstract. Objectives. Current literature on pilon fracture includes a range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm applied consistently over the span of this study. Methods. 135 patients over a 6-year period were included. Primary outcome was AOFAS score at 3, 6, 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB), full weight-bear (FWB), bone union time, follow-up time. AO/OTA classification was used (43A: n=23, 43B: n=30, 43C: n=82). Treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis was performed in combination with FWF to improve joint congruency. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of 141 fractures healed without further intervention (84.4%). Average time to union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). On average, open, and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042;OR=2.558,95% CI 1.016–6.441), bone defect (p=0.001;OR=5.973,95% CI 1.986–17.967), and superficial infection (p<0.001;OR=4.167,95% CI 1.978–8.781). Conclusions. FWF with minimally invasive osteosynthesis, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery