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Dual Plating of Pilon Fractures
Tibial pilon or plafond fractures involve the weight-bearing surface of the distal tibia. Various treatment options have been used to manage these difficult fractures. Initially, success was achieved with immediate open reduction and internal fixation of low-energy injuries. Use of this method to manage high-energy pilon fractures led to multiple complications, however, mostly involving the soft tissues. This result created a trend toward external fixation techniques with or without limited open fixation. Although this treatment method produced fewer soft-tissue complications, articular reduction was less than perfect. The combination of soft-tissue–friendly approaches and the use of lower-profile, anatomic fixation plates has improved the ability to manage pilon injuries. Within the subset of pilon fractures, high-energy injury patterns are the most difficult to manage because of the amount of articular comminution and soft-tissue compromise that occurs. With this fracture pattern, a posterior malleolar fragment is often displaced. Although initial external fixation stabilizes the fracture through ligamentotaxis, it does not reduce the posterior malleolar fragment. Newer techniques have used limited incisions to stabilize the posterior malleolar fragment and fibula, if fractured, in combination with external fixation. This method creates a stable, posterior buttress to allow for anterior fragments to be stabilized through anterior approaches at the time of final fixation. In essence, a complete articular fracture is converted into a partial articular fracture. This chapter reviews the surgical technique for dual plating of high-energy tibial pilon fractures. In this method, the fibula and posterior plafond fragment are reduced and fixed in the first stage of the procedure, and the remainder of the tibial plafond is reconstructed in the second stage of the procedure.