[Surgical access routes and their selection for osteosynthesis of pilon fractures]

The operative management of pilon fractures requires individually tailored preoperative planning, taking the fracture morphology, the intended reconstruction strategy and the local soft tissue situation into account. The goal is the anatomical restoration of the articular surface by means of open reduction and internal fixation (ORIF), combined with soft tissue-preserving stabilization of the metadiaphyseal component using minimally invasive plate osteosynthesis (MIPO). The choice of surgical approach is based on the analysis of computed tomography (CT) imaging, particularly the location of the main articular fracture fragments and the planned implant positioning. The anterior fracture extension represents an important landmark for selecting the primary approach. Valgus and varus deformities influence the required direction of buttress support and, consequently, the final plate position. Articular reconstruction is preferably performed using an open-the-window technique with longitudinal arthrotomy and opening of the fracture along the main epimetaphyseal fracture line, enabling direct visualization of the articular surface and the talar dome. The different surgical approaches complement each other depending on the individual fracture configuration. Successful treatment of pilon fractures therefore relies on precise preoperative planning, anatomical reconstruction of the articular surface and consistent preservation of the soft tissues.