The surgical approach for osteosynthesis of metaepiphyseal fractures of the distal tibia

Introduction The optimal surgical approach is essential for osteosynthesis of intra-articular fractures of the distal tibial metaphysis (pilon fractures). None of the existing approaches provides complete visualization of the articular surface, increasing the risk of complications and inadequate reduction.

The objective was to optimize the choice of surgical approach in preoperative planning of internal osteosynthesis of intra-articular fractures of the distal metaepiphysis of the tibia (pilon) based on 3D prototyping and standardized marking of the articular surface.

Material and methods An algorithm developed was based on a full-size 3D prototype and CT data. The articular surface of the tibia was divided into nine standard zones. The surgical approach was selected depending on the location of the key fragment (occupying > 2/3 of the zone) or the fracture line exit point. The method was used in 12 patients with AO/OTA 43-C pilon fractures. Surgical time, blood loss, the quality of postoperative fracture reduction categorized according to the Burwell-Charnley criteria, functional outcomes measured with AOFAS and VAS FA grading scales, and radiographic union determined with the mRUST scale were assessed at six months.

Results and discussion The mean operating time was (65.08 ± 7.03) min, blood loss was (119.3 ± 18.51) ml. The wounds healed by primary intention without infectious complications. The quality of reduction was anatomical in eight patients and acceptable in four patients. The mean AOFAS (78.67 ± 8.68) and VAS FA (41.08 ± 5.05) scores indicated good functional recovery. The mean mRUST score (13.5 ± 1.43) suggested complete consolidation. The method objectified the surgical approach avoiding subjectivity and allowed for personalized intervention by combining approaches for optimal visualization of all fragments, including hard-to-reach ones (e.g., Tillaux – Chaput fragment).

Conclusion The method integrating 3D planning and a standardized coordinate system improves reposition accuracy, reduces morbidity, and improves functional outcomes in patients with complex pilon fractures.

1. Belen’kiy IG, Manukovskiy VA, Mayorov BA, et al. Modern principles of diagnosis and treatment of tibial pilon fractures. Saint Petersburg: Mediapapir; 2022:70. (In Russ.)

2. Mayorov BA, Belen’kiy IG, Sergeev GD, Gadoev KK. Minimally invasive osteosynthesis of closed fracture of the distal tibial metaepiphysis with fragment displacement. Medical-Biological and Socio-Psychological Problems of Safety in Emergency Situations. 2023;(3):38-49. (In Russ.) doi: 10.25016/2541-7487-2023-0-3-38-49.

3. Maiorov BA, Belen’kii IG, Kochish AYu, Sergeev GD. Similarities and special features of modern approaches to surgical treatment of intra-articular fractures of tibial proximal and distal metaepiphyses. Medical Alliance. 2023;11(3):56-68. (In Russ.) doi: 10.36422/23076348-2023-11-3-56-68.

4. Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma. 2013;27(7):e152-6. doi: 10.1097/BOT.0b013e318288a7e9.

5. Kleinertz H, Tessarzyk M, Schoof B, et al.Visualization of the distal tibial plafond articular surface using four established approaches and the efficacy of instrumented distraction: a cadaveric study. Eur J Trauma Emerg Surg. 2022;48(5):4031-4041. doi: 10.1007/s00068-022-01927-w.

6. Parshikov MV, Koshkin AB, Yarigin NV, et al. Our experience in 3D-modelling in pilon (distal tibial plafond) fractures. N.N. Priorov Journal of Traumatology and Orthopedics. 2024;31(1):31-43. (In Russ.) doi: 10.17816/vto606713.

7. Burwell HN, Charnley AD. The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J Bone Joint Surg Br. 1965;47(4):634-660.

8. Fomichev VA, Sorokin EP, Konoval’chuk NS, et al. Cross-Cultural Adaptation and Validation of the Russian-Language Version of the American Orthopaedic Foot and Ankle Society AnkleHindfoot Scale (AOFAS-AHS). Traumatology and Orthopedics of Russia. 2023;29(4):78-86. doi: 10.17816/2311-2905-16494.

9. Saarinen AJ, Uimonen MM, Sandelin H, et al. Minimal important change for the visual analogue scale foot and ankle (VAS-FA). Foot Ankle Surg. 2021;27(2):196-200. doi: 10.1016/j.fas.2020.04.005.

10. Plumarom Y, Wilkinson BG, Willey MC, et al. Sensitivity and specificity of modified RUST score using clinical and radiographic findings as a gold standard. Bone Jt Open. 2021;2(10):796-805. doi: 10.1302/2633-1462.210.BJO-2021-0071.R1.

11. Assal M, Ray A, Stern R. Strategies for surgical approaches in open reduction internal fixation of pilon fractures. J Orthop Trauma. 2015;29(2):69-79. doi: 10.1097/BOT.0000000000000218.

12. Buckley R, Sands A. Anteromedial or anterolateral approach to the distal tibia? AO Surgery Reference. Available from: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/approach/anteromedial-or-anterolateral-approach. Accessed Nov 11, 2025.

13. Liu J, Smith CD, White E, Ebraheim NA. A Systematic Review of the Role of Surgical Approaches on the Outcomes of the Tibia Pilon Fracture. Foot Ankle Spec. 2016;9(2):163-168. doi: 10.1177/1938640015620637.

14. Babovnikov VG, Babovnikov AV, Tsypurskiy IB. Treatment of fractures of the distal tibial metaepiphysis. N.N. Priorov Journal of Traumatology and Orthopedics. 2003;(1):42-45. (In Russ.) doi: 10.17816/vto200310142-45.

15. Urrutia T, Faundez J, Vidal C, et al. Visualizing access in pilon fractures: A comparative study of eight approaches. Foot Ankle Surg. 2025;31(6):539-546. doi: 10.1016/j.fas.2025.02.009.

16. Puha B, Petreuş T, Berea G, et al. Surgical approach in difficult tibial pilon fractures. Chirurgia (Bucur). 2014;109(1):104-110.

17. Mironov AV, Redko IA, Magomedova ZM. The method of the open position and internal fixation in treatment of patients with pylon fractures. Kremlin Medicine. Clinical Bulletin. 2018;4(2):32. (In Russ.) doi:10.26269/s22q-a387.

18. Mair O, Pflüger P, Hoffeld K, et al. Management of Pilon Fractures-Current Concepts. Front Surg. 2021;8:764232. doi: 10.3389/fsurg.2021.764232.

19. Stillhard PF, Frima H, Sommer C. Pilon fractures-considerations for treatment strategies and surgical approaches. Oper Orthop Traumatol. 2018;30(6):435-456. German. doi: 10.1007/s00064-018-0570-8.

20. Zelle BA, Dang KH, Ornell SS. High-energy tibial pilon fractures: an instructional review. Int Orthop. 2019;43(8):1939-1950. doi: 10.1007/s00264-019-04344-8.

21. Zhao Y, Wu J, Wei S, et al. Surgical approach strategies for open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans. J Orthop Surg Res. 2020;15(1):283. doi: 10.1186/s13018-020-01770-y.