ABSTRACT
Circular tensioned wire fixators (Ilizarov fixators) are powerful tools, that allow a trauma surgeon to construct a custom external fixator to treat tibial pilon fractures. The circular fixator may be a simple three-ring frame to treat extra-articular Type A (11) distal tibia fractures. More complex situations of intra-articular comminution, bone loss, and infection can be addressed with more complex frames for bone transport, acute shortening, arthrodesis, and supplemental fixation of hind foot injuries into the reconstruction. Pilon fractures present a challenge to the trauma surgeon because of a wide spectrum of skeletal and soft tissue injuries. Preexisting comorbidities, especially diabetes, tobacco abuse, and ischemic vascular disease may alter the approach to salvaging the patient’s extremities. The accuracy of reconstruction of the plafond and mortise will have a direct effect on the stability of the joint and the ability of the cartilage to survive and heal after the injury (12-15). The reconstruction goal should be anatomic reconstruction of the joint surface and reconstruction of the normal width of the mortise (16). If anatomic alignment cannot be obtained, the minimal reduction of the joint should be a step off no greater than the thickness of the cartilage (2-3mm) (12,15). The metaphyseal zone of comminution and the axial alignment of the limb require accurate reduction to promote functional outcome (17). This technical effort must be balanced against the morbidity of surgical approaches, introduction of metallic implants, and the use of autograft, allograft, and bone graft substitutes. Avoidance of surgical disasters is an important concept advocated by J. L. Marsh and considered in the preoperative planning (18). The treatment goals of the pilon fracture surgeon are to align the fracture axially, reduce the plafond and mortise, reduce and reconstruct bony comminution and bone loss, protection of the soft tissues from further damage, and rehabilitation of the extremity during healing. Increasing levels of bony comminution and soft tissue injury potentially compromise the functional result. It is the surgeon’s task to balance the goal of anatomic bony reduction with complication avoidance. This chapter will focus on tensioned circular wires as the method of treatment, one of the three strategies of treatment. Other methods include open reduction and internal fixation and bridging half pin frames with limited open reduction and internal fixation. The latter methods have wide application and are beyond the scope of this chapter.
