Purpose: We report a series of 50 pilon fractures treated by osteosynthesis and report outcome at minimum seven years.

Material and methods: The series included 28 men and 22 women, mean age 44 years. Thirty-one patients were fall victims. The AO classification was type B (n=24) and type C (n=26). According to the De Lestang classification there were 12 simple fractures and 38 complex fractures (including 26 complete fractures) Sixteen fractures were open and 39 were associated with a fracture of the lateral malleolus. Most of the fixations were achieved via an anterolateral approach (n=22) using a prebent plate, or via a medial approach using a clover-leaf plate. A cancellous graft was used in seven cases. The Kitaoka classification was established at last follow-up.

Results: The radiographic work up included a lateral view and an anteroposterior view with moderate medial rotation. Mean follow-up was fourteen years. There were ten secondary displacements. Late complications were: non-union (n=14, including 10 cases requiring revision for arthrodesis), reflex dystrophy (n=6), deformed callus formation requiring revision, and one case of amputation after infection. At last follow-up, 33 ankles were painful (including 13 permanently painful ankles). Twenty-four patients had a residual limp (13 permanent) limiting walking distance in half of them. The talocrural joint motion was normal in 20 patients and the subtalar joint was normal in 24. Twenty-three patients resumed their former activities. For patients with sports activities, 64% resumed activities at the same level. The Kitaoka score was 79 points at last follow-up with outcome scored good in 70%, fair in 16% and poor in 14%. Excepting the patients who had secondary arthrodesis, 24 patients developed secondary osteoarthritis (including ten stage 2 and 3).

Discussion: Good outcome depends on the intraoperative reduction, both at the epiphyseal level (for complete fractures) and the metaphyseal level. This reduction must be maintained over time with a good fixation rigid enough to avoid secondary displacement which is a cause of callus deformation. The severity and complexity of the initial fracture constitute the main factors affecting outcome. In our opinion, computed tomography provides the best means of establishing the therapeutic indications. Pilon fractures remain a difficult challenge in orthopaedic surgery. Perfect reduction is the best guarantee of good outcome.