The Operative Treatment of Intra-articular
Fractures of the Lower End of the Tibia
THOMAS
P. RUEDI A N D MARTINALLGOWER
The intra-articular fractures of the lower
end of the tibia, the so-called pilon tibia1
fractures (Fig. l ) , were for many years considered as “not amenable to surgery” and the
patients were forced to accept the usually
poor late result as a matter of bad luck. And
even in those instanceswhereopen reduction
was tried and some sort of mostly inadequate
screw or wire fixation was attempted, the
results were usually not encouraging (Table
1). The modern concept offracture treatment
by means of open, anatomical reconstruction, stable internal fixation and functional
aftercare has been able to change this rather
fatalistic attitude dramatically (Fig. 2).
In 1968/69 we7*8
reported for the first time
on a consecutive series of 84 pilon fractures
exclusively treated by internal fixation following the four principles of the Swiss Study
Group’: (1) Reconstruction of the correct
length of the fibula. (2) Reconstruction ofthe
articular surface of the tibia. (3) Introduction
of a cancellous autograft to fill in the bone
defect in the metaphysis of the tibia. (4)
Stabilization of the medial aspect of the tibia
by a plate.
In comparison to the results after conservative or poor operative treatment, our 74%
of good and excellent functional results an
From the Department of Surgery, University Hospital, Kantonsspital, Basle, Switzerland.
Received: May 11, 1978.
average 4 years postoperatively seemed to
prove the success of the method. A second
follow-up of the same group of patients on
average 9 years postoperativelys gave even
more unexpected data, as quite a number of
patients presented a better functional result
than after 4 years (Fig. 3). It was concluded
that, if an intra-articularfracture of the distal
tibia can be reconstructed anatomically and
the fragments be held in place by rigid internal fixation, the late outcome is usually predictable and may then be good for a long
period of time. On the other hand the study
also showed that poor surgery, that is unsatisfactory reconstruction of the articular
surface or unstable internal fixation, will almost always lead to progressing arthritic
changes with painful limitations of motion.
These findings were confirmed by Heim and
Nasera applying the same operative principles to a series of 128 cases with even 90% of
good functional results.
Both studies of Heim and Ruediconcerned
an unusually uniform selection of young patients (on average 37 years old) with skiing
injuries producing the fracture in 90% and
75% of the cases respectively.
In the Heim series practically all 128 fractures were operated upon by the author himself, whereas in the Ruedi series the surgery
was performed by 4-5 fully trained surgeons
familiar with these fracture problems.
0009-921X/79/0100/0105/$00.80
@ J. B. Lippincott Company
1 05
106
Cllnlul 0tthop.edIcs
and Related Reaemmh
Ruedi and Allgower
FIG. 1. The 3 types of
“pilon tibial” fractures.
Type I: cleavage fracture of distal tibia without major dislocation of
articular surface. Type
11: significant fracture
dislocation of joint surface without comminution. Type 111: impaction and comminution of
distal tibia. (Reproduced with permission
from Ruedi, Th. and
Allgower, M.:Fractures
of the lower end of the
tibia into the ankle joint:
results 9 years after
open reduction, Injury.
2130, 1973).
We therefore wondered if the strikingly
good results were reproducible at a larger
university and city hospital far from the ski
slopes with a group of senior or chief residents doing most of the fracture surgery.
MATERIALS AND METHODS
To answer the above question we tried to
follow-up all 99 patients with pilon fractures that
were treated in our clinic at the University of
Bade between 1968 and 1973. In 1976/77, that is
on average 73 months or 6 years after the accident, 75 patients could be reached and evaluated
for this purpose. Two had died in the meantime
and one patient refused to come, while 19,
mostly foreign laborers who had left Switzerland
for unknown destinations, have not been
reached yet.
The average age at the time of operation was
48 years, with a range between 22 and 84 years,
the latter being an extremely healthy and still
very active man. Fifty-two patients were males
and 23 were females. Forty-seven per cent of the
patients injured their limbs during sports activities including skiing, 34% suffered road or
work accidents and 1% fractured their legs at
home. If we classify the fractures by types 1-111
(Fig. 1) as was originally proposed by US,^.^
47% of our recent series correspond to type 111,
28% to type I1 and 25% to type I. Only 3 cases
had open fractures.
For better preoperative assessment of the osseous lesions, we performed laminograms in all
unclear cases or with questionable indications,
just as it is done in the tibial plateau fractures.
The tactical approach during surgery remained
unchanged, as the four sequential operative
principles had proved very valuable and satisfactory. A cancellous autograft was used in the
majority of the cases.
TABLE 1. Pilon Tibial Fractures in Literature
Treatment
No. Cases
Bonnier2
Decoulx3
Gay5
Fourquet
Riiedi7
Heim6
1960
1961
1963
1959
1968
1976
30
49
142
29
84
128
Follow-up
30
49
96
29
80
121
Func.
Good Result
Closed
Open
%
20
25
70
8
0
0
10
23
72
21
84*
128*
43
45
50
55
74
90
* Open reduction following the four principles of the Swiss Study Group (see text),
Number 138
Januaty-February. 1979
Operative Treatment of Tibia1 Fractures
FIG. 2A. Illustration of a typical example of
a type I11 pilon tibia1 fracture before and immediately after internal fixation following Swiss
Study Group principles. (Reproduced with permission from Riiedi, Th. and Allgower, M.:
Fractures of the lower end of the tibia into the
ankle joint: results 9 years after open reduction,
Injury. 5:130. 1973).
In our previous series a plaster of paris cast
was applied routinely for 4 to 6 weeks postoperatively. Today we rely on the U-shaped splint for
5 days, that is until the patient is allowed to get
up. The application of a cast has been abandoned completely, as most patients seem to
move the ankle joint more readily once the swelling had subsided. However, the walking caliper
designed by Allgower is given to those patients
able to handle it properly, as it enables walking
without crutches. Partial weight-bearing was
usually delayed for 8-10 weeks although a
touch-down, corresponding to about 10-15 kg,
was permitted somewhat earlier, full weightbearing was started between 14-20 weeks postoperatively.
COMPLICATIONS
The early postoperative course was uneventful in the majority of the cases. Six patients displayed a temporarily disturbed wound healing
(including 2 of the 3 open fractures) but not one
of them developed an osteitis; while 2 patients
had a clinically significant thrombophlebitis. A
radiological “non-union” was observed in one
instance; the patient has. however, very little
discomfort and refuses further treatment.
RESULTS
In evaluating a specific method of fracture treatment, the most important criteria
appear to be: (1) the degree of disability and
discomfort in daily and professional use, (2)
joint motion as judged objectively, and (3)
FIG. 2B. The same patient 2 years (109
weeks) and 7 years (360 weeks) postoperatively
with a pain-free ankle joint and an almost symmetrical range of movement. (Reproduced with
permission from Riiedi, Th. and Allgower, M.:
Fractures of the lower end of the tibia into the
ankle joint: results 9 years after open reduction,
Injury. 5:130, 1973).
107
108
Clinical Orthopasdla
and Related Rwearch
Ruedi and Allgower
1965/66
1971/72
Very good
25
30
Good
20
16
ModeIrate
6
7
FIG.3. Comparison of
results (4 and 9 years
postoperatively) in 54
c a s e s . (Reproduced
with permission from
Ruedi,
Th.
and
Allgower, M.: Fractures
of the lower end of the
tibia into the ankle joint:
results 9 years after
open reduction, Injury.
5:130, 1973).
1
Poor
in the case of articular fractures, the late
result after several years.
Of the 75 patients (Table 2) who could be
reviewed personally on average 6 years
postoperatively, 60 or 80% of the cases
judged their injured limb to be fit for normal
use, 1 1 patients or 14.6%complained about
some disability or discomfort, while in 4 instances (5.3%) a fusion had to be performed
in the meantime for severe posttraumatic
arthritis. Forty-one patients or 54% are
back to sports, 13% have not taken up
sporting activities, while 33% had not performed any kind of sports before the accident. Sixty-three patients or 84% have the
same profession and income as before the
accident; 12 or 16% had to look for a new
job, some with a smaller income.
In contrast to the subjective judgments
the objective measurements of the actual
range of motion in the tibiotalar joint was
done by comparing the left and right leg and
revealed somewhat poorer results. Fiftytwo per cent of the patients had a symmetrical function, while 17.4%displayed a limitation of motion totaling 10". which was still
considered as "acceptable" (Table 3). In 14
patients or 18.6%, however, the limitation of
motion in the ankle joint reached 15-25'. An
even more restricted range of motion (totaling more than 25") was found in 9 cases
(12%) including the 4 fused cases.
DISCUSSION
In comminuted intra-articular fractures of
the distal tibia a good functional result may
be obtained and should be expected, if the
articular surfaces of the talotibial joint have
been re-established anatomically. Trojan
and Jahna'O claim this to be possible by
closed methods (reduction and traction for
at least 6 weeks) even in type I11 cases,
although most other authors (Table 1 ) who
TABLE 2.
Results as judged by the patient
"No disability of discomfort in daily use
Constant discomfort or disability
Ankle fusion
Objective measurements of range of motion
in tibiotalar joint
Symmetrical
Minus 10"
Minus 15-25'
More than 25" or fusion
Number
%
60
I1
80
14.6
4
5.3
52
17.4
18.6
12
Number 138
Janualy-February, 1979
Operative Treatment of Tibial Fractures
109
TABLE 3. Comparison of Overall Results (Subjective and
Objective) After Pilon Tibial Fractures
~
1977f
5n%
1968/9$
No complaint or pain
+- symmetrical range of motion*
69.4
73.7
Occasional pain or discomfort
Range of motion* minus 15-25'
18.6
11.3
12
15
n=80
%
~~~~
Constant pain,
Very limited motion* (>25')
or
Fusion of ankle joint
* Summation of loss of motion in tibiotalar joint. t On average 6 years postoperatively. $ On average 4 years
postoperatively.
support the closed methods have not been
able to achieve similar results.
In our experience, the reconstruction of
normal anatomy is only possible by means of
open reduction and stable internal fixation.
If this difficult task has been achieved and
early physiotherapy is performed, the result
is usually good and predictable, and it will
remain as such over a long period of time as
shown in the present and former series. In
the presence of a flake fracture of the talus,
however, the outcome may be less satisfactory since a cartilaginous lesion of both joint
partners may result in posttraumatic arthritis, which usually manifests itself early, that
is within 1-2 years after the accident.
In this regard we believe it to be important
that the patients exercise their joint motion
but restrain from full weight-bearing for
14-20 weeks postoperatively as circumscribed cartilaginous defects appear to
have a chance to fill in with a repair tissue of
mostly fibrous cartilage. Arthritic changes
will also be observed more frequently in
those patients with unsatisfactory reduction
or unstable fixation and secondary dislocation of the joint surface.
The comparison between the subjective
judgment and objective measurement of the
late results appeared interesting as it revealed that many patients seem to get used
to their postinjury status and do not feel
disabled, even if the range of motion of their
ankle is somewhat limited.
In comparing the present series of patients
treated at the University Clinic of Basle with
the 2 former groups from the district hospitals in Chur (Ruedi 1968' and Heim 1976)(?,
the results seem to differ, the present series
having a somewhat poorer outcome (Table
4). In an attempt to explain this, we found
the .3 groups to differ considerably in the
following respects: the average age of the
patients, the mechanism of accident and the
"quality" of the surgeon. The university
hospital patient was on average 10 years
older than the one of the other 2 series. Although age generally does not affect fracture
hedingper se, it may be an important factor
when rehabilitation is taken into account, as
well as the posttraumatic complications, i.e.
venous thrombosis, etc. The poorer adaptability of the older patient to a new situation
may be another factor influencing the late
outcome.
In regard to the type of accident, the skiing injuries present probably more favorable
soft tissue conditions than road or working
accidents, which reflects itself in less skin
problems and quicker restitution of normal
function.
As skiing accidents generally occur during
110
Clinlcal Orthopndia
and Rela1.d R I l w o h
Rued and Allgower
a holiday and are self-inflicted, the personal
attitude of the patient to his injured limb is
quite different from the attitude of a person
who suffered a working or road accident
with no apparent fault of his own.
Finally the quality of surgery or the capability of the surgeon seems to reflect itself in
the result as well. As in other fields of
surgery, there is no doubt that the experienced surgeon not only handles the fracture
problem in a better way, he also has a smaller number of complications. Although the
presence of a consultant is always required
at our institution, the teaching hospital appears to be handicapped compared to a
smaller clinic with a “one-man-show.”
Despite these aspects which seem rather
unfavorable for the larger city center, the
overall results of our present series of Basle
are such that the operative treatment ofpilon
tibial fractures may be advocated all the
same. These fractures are the most difficult
to treat, but with some skill, careful soft
tissue handling and by followingthe 4 operative principles as mentioned earlier, the results may be most rewarding.
SUMMARY
Intra-articularfractures of the lower end of
the tibia are an interesting challenge. The
best functional results in the past series were
observed in patients treated according to the
following 4 sequential principles: (1) recon-
struction of the correct length of the fibula;
(2) anatomical reconstruction of the articular
surface of the tibia; (3) insertion of a cancell-
ous autograft to fill gaps left by impaction and
comminution; (4)stable internal fixation of
the fragments by a plate placed on the medial
aspect of the tibia. Seventy-five cases had a
good or excellent late result (on average 6
years postoperatively)in 70% as compared to
43% to 55% in cases treated by closed and/or
open methods.
REFERENCES
I . Allgower, M., Muller, M. E. and Willenegger, H.:
Technik der operativen Frakturbehandlung. New
York, Springer Verlag, 1%3.
2. Bonnier, P.: Les fractures du pilon tibial. Lyon.
Thbse, 1%1.
3. Decoulx, P., Razemon J. P., and Rouselle Y .: Fractures du pilon tibial, Rev. Chir. Orthop. 47563,
1%1.
4. Fourquet D.: Contribution B I’Ctude des fractures
rkcentes du pilon tibial, Paris, These, 1959.
5. Gay, R. and Evrard, J.: Les fractures recentes du
pilon tibialchezl’adulte. Rev. Chir. Orthop. 49:397,
1%3.
6. Heim, U.and Nber, M.:Dieoperative Behandlung
der Pilon-tibial-Fraktur. Technik der Osteosynthese und Resultate bei 128Patienten, Arch. Orthrop.
Unfall-Chk. 86341, 1976.
7. Ruedi, Th., Matter, P. and Allgower, M.: Die intraartikuliiren Frakturen des distalen Unterschenkelendes, Helv. chir. Acta 35556, 1968.
8. Ruedi,Th. and Allgower, M.: Fracturesofthelower
end of the tibia into the ankle-joint, Injury. 1:92,
1%9.
9. Ruedi,Th. and Allgower, M.: Fracturesofthelower
end of the tibia into the ankle joint: results 9 years
after open reduction and internal futation, Injury,
9130, 1973.
10. Trojan and Jahna: Personal communication, 1977.