We describe a new surgical approach designed for use with minimally invasive fixation and a circular frame. Tibial pilon injuries are often associated with significant soft tissue injury, which may not be evident at the time of injury. In such cases standard surgical approaches can lead to problems with wound healing, thus increase the risk of deep infection. AO Type C valgus fractures are commonly associated with fibula fractures. We found that the anterior syndesmotic ligaments are often disrupted with sparing of the lateral soft tissue envelope.

Our technique utilizes a direct lateral approach to expose the lateral malleolus/distal fibula, which is reflected postero-laterally through the fracture and intact posterior syndesmotic ligaments. This creates a direct view of posterolateral and anterolateral comminution and talar dome allowing direct fixation of fragments with minimal internal fixation. Fibula fixation is performed with a 1/3^rd tubular plate and the anterior syndesmotic ligaments are repaired.

From 2007–2009, we used this approach in 12 patients (Male 9: Female 3; age 19–42) with AO Type C3 fractures with significant soft tissue injury (open = 2/ closed = 10; Tscherne Grade 1 = 4; Grade 2 = 8). We used circular frame stabilization in all cases (in four patients an additional foot frame was applied to protect the articular surface).

All fractures united in satisfactory alignment. Wound healed well in all cases. One case of gouty arthritis developed superficial infection, which went on to heal after wound wash out and oral antibiotic therapy. Follow-up (minimum 3 months and maximum 2 years) showed no ankle instability. Clinical evaluation revealed a mean dorsiflexion of 10° (5–15°) and mean plantar flexion of 35° (15–60°).

We conclude that transfibular approach gives good exposure of lower tibial articular surface in selected cases of pilon fractures with least soft tissue disruption.