Ankle Joint Salvage and Reconstruction by Limited Orif Combined with an Ilizarov External Fixator for Complex Open Tibial Pilon Fractures (AO 43-C3.3) with Segmental Bone Defects

SLR - March 2022 - Karim Ead

Reference: Chen Y, Li Y, Ouyang X, Zhang H. Ankle Joint Salvage and Reconstruction by Limited Orif Combined with an Ilizarov External Fixator for Complex Open Tibial Pilon Fractures (AO 43-C3.3) with Segmental Bone Defects. BMC Musculoskelet Disord. 2022 Jan 28;23(1):97. doi: 10.1186/s12891-022-05060-y. PMID:

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: J. Karim Ead, DPM, MS
Residency Program: HCA Florida: Westside Hospital – Plantation, FL

Podiatric Relevance: Tibial pilon fractures are life changing injuries. Their management provides numerous challenges to the podiatric surgeon that includes the  management of any associated soft tissue injuries and obtaining anatomic reduction of the distal tibila/fibular articular surface. The fracture pattern and comminution are generally determined by amplitude of force, force vector direction, and position of foot upon impact. The reviewed retrospective study below demonstrates a novel treatment algorithm based on a staged approach in the treatment of complex pilon fractures: limited ORIF combined with Ilizarov external fixation.

Methods: Chen et al conducted retrospective analysis of open pilon (complex) fractures with sizeable segmental bone defects treated by limited ORIF combined with the Ilizarov external fixator strategy. Inclusion criteria: “(1) AO/OTA C3 open pilon fracture, metaphyseal bone defect ≥4cm; (2) application of the bone transport technique and limited ORIF; and (3) follow-up for more than one year, with complete follow-up data”. Based on the inclusion criteria (out of 834 pilon injuries), 11 patients were eligible to form the study cohort. Key variables of this study were fracture healing, infection rates and functional outcomes. Ankle functional outcomes was based on the AOFAS and Paley Criteria (24 months post injury). The external fixation time (EFT) was a metric that defined the duration of Ilizarov external frame application to fixator removal time period. The external fixation index (EFI) was calculated by dividing the EFT and the traction length. The bone transport time (BTT) refers to the duration of bone transport integration. This metric was calculated by the bone transport time divided by the length of bone transport. The treatment pathways were generally carried out in two stages. First stage included radical wound debridement, reduction/limited fixation of the distal tibial articular surface, transmalleolar triangular external fixator application. Second stage included treating the existing bone defects and the application Ilizarov circular frame external fixator.

Results: The follow period was  a mean of 41.09 months. The mean bone defect size was 5.64 ± 1.21 cm. The average EFI and BTI were 1.56 ± 0.28 months/cm and 11.12 ± 0.74 days/cm, respectively. The success rate of ankle joint reconstruction was 64 percent (7/11). The mean AOFAS functional assessment score was 77.73 ± 8.87.  Ankle range of motion (ROM) at each subjects last follow-up examination was  noted to be “excellent” in four patients (at least 35 degrees), “good” in three patients (20 degrees-35 degrees), fair in three patients (0 degrees-20 degrees), and poor in one patient (0 degrees). It should be noted that all patients were able to ambulate independently at their final respective post-operative visit. Complications included five patients that demonstrated ankle stiffness/posttraumatic arthritis. Three patients developed pin site infections, and one patient developed a deep infection post bone grafting.

Conclusions: A multi-modal treatment strategy that includes limited ORIF in conjunction with Ilizarov external fixation can potentially optimize early ankle function in patients with complex open tibial pilon fractures. The podiatric trauma specialist should be aware of the intricate patho-mechanics of this complex injury and utilize evidence based/patient centered treatment strategies to optimize patient outcomes.