Pilon Fracture ORIF
Edited by David Oji, MD
Patients who have suffered a displaced Pilon (Tibial Plafond) fracture (Figure 1)often benefit from surgery to reposition the bones that make up the top part of the ankle joint (Figure 2). The goal of surgery is to put the bones back into the position that they were in prior to the injury. This can be a very challenging operation because the fracture involves the weight-bearing portion of the ankle joint itself, and the bones are often broken into a number of pieces. Patients that are healthy and do not have any contraindication for surgery are likely to benefit from this procedure if they have suffered a significantly displaced Pilon fracture.
Initial treatment often involves letting the soft tissue that surrounds the ankle settle. Operating through swollen, angry, soft tissue may increase the chance of having a wound complication. However, if the soft tissues are acceptable or if the swelling has settled, the procedure is performed by exposing the fracture site. It is often necessary to use two or more incisions in order to adequately reposition the fracture fragments and stabilize them with plates and screws. The actual location of the incisions may vary depending on the fracture site, but often includes an incision at the front and inside part (anteromedial) of the ankle, as well as the front outside part (anterolateral) of the ankle. The surgeon will rebuild the broken ankle joint one piece at a time, stabilizing them initially provisionally with wires, and then eventually definitively with screws and a plate(s). In some instances, it may be necessary to bone graft the fracture if there is a significant defect that is left after the fracture has been reduced.
The recovery from this type of injury and the associated surgery is long. It is often 12 weeks before there is enough bone healing to begin any sort of weight bearing. Until the bone is adequately healed, the patient will need to be relatively immobilized, often in a cast or a controlled ankle motion (CAM) boot. During this time, movement of the knee and toes can be instituted. Once the fracture has healed, rehabilitation is oriented toward regaining motion in the ankle joint; rebuilding the muscles of the lower leg; and working on balance and gait retraining. This can take many months of formal and informal physical therapy. It is not uncommon for it to take 18 months or more to reach the point of maximum improvement following this type of injury.
- Nonunion: In some instances, the blood flow due to the high energy trauma can disrupt the blood flow reducing the chance of fracture healing. As a result, the fracture may not heal and mend with the other bones at the fracture site even if the surgery was done very well. This is called a nonunion. A workup to determine the cause of the nonunion such as infection should be done and revision surgery may be needed.
- Post-traumatic ankle arthritis: Arthritis is joint pain and inflammation caused by thinning of the cartilage due to many causes such as trauma, normal wear and tear, and infection. The joint typically becomes narrowed and in severe cases, can result in bone on bone arthritis. With pilon fractures, invariably there will be some arthritis of the ankle joint. The injury itself causes significant damage to the joint surface and over time, the cartilage lining will thin out causing arthritis. Successful surgery to reduce the fracture will help minimize the extent of arthritis however, it cannot eliminate the formation of it especially with severe trauma to the joint.
- Stiffness and reduced range of motion: Many patients with pilon fractures have reduced motion of the ankle joint compared to their other good ankle. This can be due to swelling from healing tissues after surgery, scar tissue, and post traumatic arthritis. Most patients regain much of their motion but stiffness may persist even after 2 years after surgery and may never get back to normal.
- Wound healing issues: Often there is significant swelling around the ankle following this type of injury. There is relatively limited soft tissue around the ankle. This can make the tissue scarred and can predispose to wound healing problems.
- Nerve injuries: There are five nerves that run across the ankle and any of these may be irritated, leading to numbness or a burning sensation over the nerve distribution.
- Blood clotting
- Painful retained hardware. It may be necessary to remove painful hardware once the bones have healed adequately.
Edited February 11, 2020