Percutaneous contoured locking plate fixation of the pilon fracture: surgical technique.

Preservation of the soft tissue is of particular importance in the care of pilon fractures. Improper soft tissue management has been attributed to high rates of nonunion, nerve injury, and failures (1–12). Traditional open reduction internal fixation (ORIF) of pilon fractures allows for direct visualization of the fracture(s) but is criticized for the large exposure and periosteal stripping. As a result, this approach has been blamed for high nonunion rates as well as failure of the soft tissue to accommodate implants (1, 5, 8, 13). External fixation has also been used but has not demonstrated much advantage to internal fixation and requires significant postoperative care. Also, external fixation has a higher incidence of malunion (6, 14) and has inherent risks for pin-tract infections (14, 15). In an attempt to limit the iatrogenic soft tissue injury (5, 6, 7), some surgeons have used a limited ORIF concentrating on restoration of the articular surface combined with ring or hybrid external fixation. The “2-stage” technique combines the benefits of both external and internal fixation, and is thought to limit soft tissue related complications by allowing soft tissue recovery time before the introduction of internal fixation. Initial temporary external fixation combined with limited exposures for internal fixation (2-stage technique) at a later date allows for less disruption of the soft tissue envelope, leading to a decrease in complications associated with traditional open approaches. This may be achieved through relatively “small incisions” extending