Joint-preserving osteotomy of malunited ankle and pilon fractures

Abstract

Malunion and nonunion after ankle and pilon fractures regularly lead to the development of painful functional impairment even in cases of only mild axial deviation or residual joint incongruity. Involvement of the tibial pilon results in rapid progression of posttraumatic ankle arthritis. Corrective osteotomy with joint preservation aims at secondary anatomical reconstruction with functional rehabilitation. This requires a careful preoperative analysis and will be possible in carefully selected cases only. Prerequisites for successful reconstruction are intact cartilage, sufficient bone quality, residual joint function and good patient compliance. Since the works of B. G. Weber, joint-sparing osteotomy is an established treatment option for malunited malleolar fractures with reliable long-term results and low rates of complications and secondary fusions. Key to success is the re-establishment of the length of the distal fibula and repositioning into the tibial incisura in cases of syndesmotic instability. Corrections of the medial malleolus and posterior tibial fragment are less frequent. Corrective intra-articular osteotomies for malunited pilon fractures are rarely feasible because of manifest arthritis at the time of patient presentation in most cases. Besides case reports there is only one series of 14 patients available in the literature. At 5-year follow-up, a good to excellent result was seen in 10 cases and secondary ankle fusion was done in 2 patients with a poor result. Anatomical reconstruction of malunited tibial pilon fractures appears to be a viable treatment option besides arthroplasty and fusion in carefully selected patients.