[Typical pitfalls in the definitive reconstruction of pilon fractures]

The definitive reconstruction of a pilon fracture can be technically demanding and requires meticulous preoperative planning. Besides selecting the appropriate surgical approach and implant, particular attention must be paid to the reduction strategy, including the sequence of reconstruction, the required reduction maneuver and the necessary instruments. Successful execution of the surgical plan also depends on recognizing suboptimal reduction during the definitive reconstruction, a task that can be particularly challenging in the presence of extensive metaphyseal comminution. Various pitfalls can be encountered during definitive treatment, affecting both fracture reduction and stabilization of the tibia or the fibula. Malreduction of one bone, most commonly the fibula as it is frequently addressed first, often compromises the reduction of the other, thereby jeopardizing the anatomical reconstruction of the ankle joint. As the number and length of surgical approaches to the distal tibia are limited due to the often critical soft tissue envelope, assessment of the reduction quality can be hampered. There is also a tendency to minimize the number of implants, which can lead to the surgeon avoiding using an additional plate, which would actually be necessary based on the fracture pattern. This article highlights and illustrates several common pitfalls encountered during definitive reconstruction of pilon fractures. Recognizing these pitfalls and understanding appropriate strategies to avoid them may help surgeons optimize decision-making and improve the quality of definitive treatment and patient outcomes.