Date: Sat, 9 Mar 2002 15:01:12 EST
Subject: Pilon Fx Approach
Does anyone have any experience with ORIF of the pilon fracture using an anterolateral approach ie. lateral to the extensor tendons?
It appears to me that the interval between the extensor tendons and the fibula could reconstruct the anterolateral tibia, syndesmosis and fibula. There is a small risk to the superficial peroneal nerve.
There is more soft tissue coverage in this approach compared to the anteromedial incision.
Virtual Hospital Anatomy
Date: Sat, 09 Mar 2002 21:10:19 -0600
From: Adam Starr
I've used a two incision approach for a long time. John Early taught me how to do it.
You use a medial incision just like you would for a medial malleolus fracture, just make it longer...and a lateral incision just like you would for a lateral malleolus fracture. To reach the anterolateral tibia, you dissect anterior to the fibula. It's a great way to get at the tibia. To reach the anteromedial tibia, just dissect anteriorly and lift the tendons away from the front of the bone.
It's a familiar approach - just like fixing a bimalleolar ankle fracture. You just have to make the incisions a bit longer than usual to keep from stretching the skin too much.
Date: Sun, 10 Mar 2002 07:44:38 -0500
From: Kevin Pugh
This approach works very well, just remember to make the fibular incision over the fibula or just anterior. Many get into the mindset that with pilon fractures, the lateral incision must be made posteriorly to preserve a skin bridge, and this is not the case with this approach.
You can also carefully go through the anterolateral area. Many times I will make my approach directly over the primary fracture line as seen on CT. This results in less stripping.
Date: Sun, 10 Mar 2002 16:15:04 -0500
From: michael baumgaertner
we've been pleased with a single incision lateral approach and find it particularly helpful for pilons with valgus deformity.
Date: Sun, 10 Mar 2002 23:46:21 EST
Dr Herscovici et al., published the Bohler incision in the JOT several months ago . This approach is what you are looking for.
Roy Sanders, MD,
Date: Sun, 17 Mar 2002 17:16:13 -0600
From: John Early
Sorry for the slow reply I was out of town. In addition to the other replies you have gotten on your request. I also have a fair amount of experience with this approach. In fact we never use the anterior medial approach to the pilon. I will use the isolated antero lateral approach if i have no significant medial tibial injury or is there is significant soft tissue injury. Usually i use it in combination with a straight medial approach to address the medial tibial injury. we have over 85 from this approach and presented the first 65 from the point of view of wound complications at last years OTA as an e-poster. Let me know if I can answer any other questions you may have.
John S. Early MD
Univ Texas Southwestern Medical Center
Date: Sun, 17 Mar 2002 21:57:18 EST
Thank you John for your reply and link to your e-poster re pilon fractures.
I would like to make a few comments:
1. I suppose you use the calcaneus and cuneiforms pins so that you can avoid a pin in the talus which would compromise soft tissue coverage. Is there a problem with talar congruency in the ankle mortise on short or long term xrays when a pin is placed into it or not? Can better talar alignment be obtained with a talar pin?
2. The e-poster shows small fragment plates applied on the medial side of the tibial plafond. Any experience with prebent "L" plates on the anterolateral tibial plafond like Zimmer has?
3. If one of the goals is to limit soft tissue dissection, would a low profile plate with locking screws that don't toggle in the plate allow a shorter construct?
4. It seems that a plate on the fibula from this approach may result in significant soft tissue stripping. Are there any tricks to secure the fibula thru a separate route and maintain length and rotation:
Date: Thu, 21 Mar 2002 13:38:03 -0600
From: John Early
Thanks for your further inquiry. Sorry to be so slow to respond.
Can better talar alignment be obtained with a talar pin?
1. The reason for the cuneiform pin is two fold. First, it did get in the way of the medial approach and i did not like the idea of operating through a colonized pin site 7-10 days after placement. also since I often rely on my colleagues on call to place the initial frame, I found this pin easier and safer than the talar pin with physicians not accustomed to the querky anatomy.
Another reason was that in some cases plantar contractures of the forefoot, plantar subluxation of the navicular and cuboid off the talus and calcaneus, was occuring. By fixing out to the cuneiforms I now have control of the Chopart joint and can better maintain a plantigrade position. I have found no problems with controlling mortise or talar dome position with this placement as long as the talus is stable in the subtalar complex cradle. calcaneal or talar fractures can complicate matters.
Any experience with prebent "L" plates on the anterolateral tibial plafond like Zimmer has?
2. The majority of the cases in this report were done before the availability of the newer plates. I have since become a fan of the L-plate for anterolateral support. I have not really warmed up to the medially contoured plate. Part of that may be my willingness to use external fixation in combination with internal fixation if I think the metaphyseal comminution is too significant for good plate support alone.
to limit soft tissue dissection, would a low profile plate with locking screws that don't toggle in the plate allow a shorter construct?
3. I have used the L-plate as a percutaneous plate for proximal screw placement and it is effective. My personal bias is to rely on the plate as a mechanical butress to the comminuted bone and therefore want compression of the plate onto the near surface with screw fixation on the far surface. I worry that locking into the plate will give one a false sense of security. I want the cortical bone rigid not the plate construct.
Personal bias - I know through the anterolateral approach, I'm going at the anterior border of the fibula all the way to the anterior talar fibular ligament. with seemingly little disection the lateral cortex of the fibula is exposed for plating. I have found no problem with standard fixation of a 1/3 tubular plate and screws when needed. With a simple transverse fracture of the fibula an intermedulary device can easily support this also and i have placed those percutaneously. I have never felt the need for another incision for access and am not sure if a safe zone is available. I do agree with supplemental syndesmosis screws and use them liberally to support the lateral column of the tibia if there is significant metaphyseal comminution, especialy if the fibula is intact. Also they can help support medial fractures in the face of medial soft tissue compromise as presented in the other articles suggested to you.
Hope this answers you questions / comments. Let me know if I can be of further assistance.
Univ Texas Southwestern Medical Center