Intramedullary/Intraosseus Osteosynthesis of Pilon and Ankle Fractures

Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems, especially in type C fractures. From July 2000, the authors started to use XS and XXS nail, first for fibula and then for pilon and ankle fractures. Material and methods: the XS nail is a 4.5mm and the XXS a 3.5mm straight nail which is locked by threaded wires which are placed with an aiming device and allows also dynamic fracture site compression with a set screw. The fibula is fixed percutaneously and after distal locking with traction of the aiming device also tibia length and axis can be restored and fixed with the proximal locking. The tibia is than fixed with one nail introduced from the medial malleolus and if necessary a second from proximal medial to distal lateral so that stable fixation is obtained. The authors have studied 26 pilon fractures (with follow-up of 13 patients) and 214 ankle fractures with reevaluation after 6 months of 91 patients. Results. The results were evaluated according to the Ovadia score (clinical and radiological). All articular and fibula fractures healed without problems except 3 delayed unions for metaphyseal fractures that required bone grafting. In no case osteomyelitis occurred. In one case compartment syndrome required surgical decompression. According to the Ovadia Score after one year the results were very good or good in the subjective criteria in 69% of the patients and 61% in the objective criteria. For ankle fractures we have observed two hematoma (with revision surgery) and two proximal fractures of the fibula due to the oblique nail insertion. In no case infection of the bone was seen, in no case fracture or implant dislocation occurred. The results were excellent in 71% cases, good in 25% cases, and 3 patients had fair and unsatisfactory results. Conclusion. The minimal invasive stabilization of pilon fractures with the XS nail and the absence of plates on the bone surface reduce significantly the healing problems and the rate of severe complications of pilon fractures. The Xs nail is also a new option for ankle stabilization.