Visualizing access in pilon fractures: A comparative study of eight approaches

Pilon fractures, constituting 3-10 % of all tibia fractures, present significant challenges due to their complex nature and frequent involvement of soft tissue damage. Effective management necessitates careful preoperative planning and strategic surgical approach selection. This study aims to provide a comprehensive cadaveric analysis comparing eight distinct surgical approaches to tibial pilon fractures, focusing on the consistently exposed segment and the extent of the exposed bone area for each approach.

Sixteen foot and ankle specimens, obtained through our university's body donation program, were utilized for this study. Each specimen underwent two different approaches, resulting in four repetitions for each assessed method. The approaches analyzed included anteromedial, anterolateral, lateral, posterolateral, posteromedial, posterior modified posteromedial, anterior modified posteromedial, and medial approaches. Standardized incisions and retraction techniques were employed to measure the exposed bone area using ImageJ software, while the consistently exposed segment was determined through axial cuts and photographic analysis.

The anteromedial approach yielded the largest exposed area (18.36 cm²), whereas the anterolateral approach provided the greatest exposed segment (72°). The posteromedial approach proved most effective for exposing the Volkmann fragment, and the anterolateral approach was optimal for accessing the Chaput fragment and comminution areas. Combining the posteromedial and posterior modified posteromedial approaches could be suggested for extensive posterior malleolus fractures to maximize bone surface exposure while minimizing soft tissue damage.

This study offers objective data on the exposed area and segment for various surgical approaches, providing a valuable resource for orthopedic surgeons in preoperative planning and decision-making. By enhancing the understanding of the capabilities and limitations of each approach, this research aims to improve surgical outcomes for patients with complex tibial pilon fractures.