TECHNICAL TRICK

The Extensile Approach for the Operative Treatment of

High-Energy Pilon Fractures: Surgical Technique
and Soft-Tissue Healing
Mathieu Assal, MD, Adrien Ray, MD, and Richard Stern, MD

is draped in the sterile field from the level of the tourniquet to

Summary: Perhaps the most important advancement in the surgical the toes. Exsanguination of the limb is accomplished only by
treatment of high-energy pilon fractures has been the recognition of elevating the lower extremity and not with use of any com-
the need to delay primary surgery. However, at open reduction pressive bandages. Figure 1A and B shows the line of the skin
internal fixation an adequate incision must be made to clearly incision as it is marked on the right limb. The incision is begun
visualize the articular surface in an attempt to restore intraarticular 10 mm below the tip of the medial malleolus and proceeds
anatomy. This article illustrates our extensile approach and its effect transversely across the ankle to a point just lateral to the
on soft-tissue healing. The approach allows complete access to the midline and then turns at a 105- to 110-degree angle,
ankle joint to achieve reduction and fixation of the articular surface, proceeding proximally 10 mm lateral to the tibial crest. Thus,
as far medially or laterally as is necessary. In addition, it allows for the incision lies laterally to the tibialis anterior tendon. It is
easy placement of plates medially, laterally, or anteriorly. For fractures important to make the turn in the incision at the 105- to 110-
extending more proximally, plates can be placed subcutaneously from degree angle and not more acutely approaching 90 degrees.
distal to proximal through the open incision. Generally, the vertical limb of the incision measures 15 cm but
Key Words: pilon fracture, surgical technique, extensile approach, can be extended more proximally as desired. In situations with
soft-tissue technique, open reduction internal fixation, lateral pilon more extensive injury to the lateral column of the distal tibia,
fracture the point of the turn can be moved a bit more laterally. The
transverse and vertical limbs of the incision are made using
(J Orthop Trauma 2007;21:198–206) a No. 24 scalpel blade, but the 105- to 110-degree turn is made
with a No. 15 blade, which permits the incision to be perfectly
perpendicular to the plane of the skin, and skiving of the
INTRODUCTION tissues is avoided.
Various operative exposures for complex pilon fractures The incision is carried down through the subcutaneous
have been reported,1–8 but no clear description and illustration tissue (Fig. 2A) and a full-thickness flap is elevated (Fig. 2B).
have thus far been provided. This article describes and illus- The incision continues onto the extensor retinaculum (Fig.
trates in detail the extensile approach, which permits complete 2C), exposing the underlying tibialis anterior tendon. The
visualization of the articular surface and offers the ability for retinaculum is incised, with an attempt to leave the tibialis
plate placement medially, laterally, or anteriorly, as necessary. anterior tendon undisturbed in its sheath. This is not always
In addition, we report on the effect of this approach on soft- possible, because it is intimately connected to the retinaculum,
tissue healing in a cohort of 21 patients all treated in a similar and thus frequently the sheath is opened (Fig. 3A). The inferior
fashion. extensor retinaculum is opened, following the line of the
incision. The full-thickness flap is retracted medially while the
tendon of the tibialis anterior is retracted laterally (Fig. 3B, C).
Surgical Technique The flap is handled atraumatically without strong retraction or
A tourniquet is applied. If an external fixator has been use of forceps, frequently using nylon sutures in the skin to
previously placed, it is usually left in place and the lower limb apply traction. At the level of the ankle joint, the articular
capsule is opened longitudinally, exposing the talus (Fig. 4;
arrow points to talus). Subperiosteal dissection exposes the
ankle joint and fracture site (Fig. 5A), and retraction of the
Accepted for publication December 12, 2006. tissues laterally exposes the entire lateral articular fragment of
Orthopaedic Surgery Service, University Hospital of Geneva, Geneva,
Switzerland Chaput (Fig. 5B, C).
No financial support of the project has occurred. The authors have received The articular surface is reduced progressively, frequently
nothing of value. beginning with any displaced lateral column fragments
The devices that are subject of this article are FDA approved. (Chaput). The reduction proceeds from posterior to anterior
Correspondence: Richard Stern, MD, Orthopaedic Surgery Service
University Hospital of Geneva, 24 rue Micheli-du-Crest, 1211 Geneva,
and lateral to medial, and the articular fragments are pro-
14 Switzerland (e-mail: [email protected]). visionally stabilized with Kirschner wires, first the Chaput
Copyright Ó 2007 by Lippincott Williams & Wilkins fragment (Fig. 6A) and then the anteromedial articular

198 J Orthop Trauma
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 The Extensile Approach for the Operative Treatment of High-Energy
J Orthop Trauma
Volume 21, Number 3, March 2007 Pilon Fractures: Surgical Technique and Soft-Tissue Healing

FIGURE 1. Patient 7 (Table 1)

operated on 15 days postinjury.
The skin incision as marked (A) and
the corresponding illustration (B)
showing the 105- to 110-degree
angle between the transverse and
vertical limbs of the incision.

fragment (Fig. 6B). Once the articular block has been plate placement is determined by the nature of the fracture, but
reconstituted, it is joined to the proximal fragment. It is not frequently 2 plates are used, one anterolateral and the other
necessary to anatomically reduce metaphyseal or diaphyseal medial. For proximal extension of the fracture, the plates are
fragments, but length and alignment are restored. Specific introduced through the open incision and slid proximally

FIGURE 2. The incision is carried down through the subcutaneous tissue (A), and a full-thickness flap is elevated (B, C).

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FIGURE 3. The retinaculum is incised, in this case exposing the tibialis anterior tendon (A), and the full-thickness flap is
retracted medially while the tendon of the tibialis anterior is retracted laterally (B). The line of the articular capsule incision is noted
(C, dotted line).

subcutaneously. The holes in the plate can be easily palpated Previously, we always fixed the fibula when we placed
and screws inserted through small incisions. Depending on the the bridging external fixator, which followed the guidelines of
size of the metaphyseal defect, autogenous bone graft or bone *the AO and others who described an anterolateral fragment of
graft substitute is added. tibia that remained connected to the fibula, and if one
reduced the fibula, this fragment would be in near-anatomic
position. Thus, it could be used as a template for the reduction
of the pilon. However, we found that there were cases of
malreduction of the fibula, which made reduction of the pilon
more difficult. Therefore, we changed our approach and
decided not to fix the fibula initially. At definitive surgery,
the pilon is approached first. After fixation of the pilon
fracture, we use a posterolateral skin incision to place the plate
(one-third tubular, or 3.5 mm) on the lateral aspect of
the fibula. The fibula is fixed to increase the stability of the
pilon fixation.
Closure of the wound begins with the extensor
retinaculum, with interrupted 2-0 Vicryl (polyglactin 910;
Johnson & Johnson International, Brussels, Belgium) sutures
(Fig. 7). The subcutaneous tissue is then closed with the
same size Vicryl suture, and the skin, with interrupted 3-0
nylon suture using the Allgöwer modification of Donati
(Fig. 8A, B).9
Postoperatively, patients are maintained at bed rest for
48 to 72 hours, with the limb elevated. If the wound appears
satisfactory after that time, the patient begins ambulation,
allowing only 10 kg of weight-bearing for 10 to 12 weeks.
Range-of-motion and muscle-strengthening exercises are
prescribed. The patient is discharged with a removable splint
to prevent equinus deformity.

FIGURE 4. The articular capsule is opened longitudinally,

exposing the talus (arrow points to talus). *the Arbeitsgemeinschaft für Osteosynthese fragen and others..

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Volume 21, Number 3, March 2007 Pilon Fractures: Surgical Technique and Soft-Tissue Healing

FIGURE 5. Subperiosteal dissection exposes the ankle joint and fracture site, and retraction of the tissues laterally exposes
the entire lateral articular fragment of Chaput (A and B, arrows). The Chaput fragment is then retracted laterally (C, behind
retractor).

PATIENTS AND RESULTS AO/OTA 43-C, with extension to the metaphyseal-diaphyseal

Between January 2003 and December 2004, we used junction and frequently more proximal. In all patients,
this approach in the operative treatment of 21 patients with a spanning external fixator was applied urgently. In only 2
21 closed fractures (Table 1). There were 16 male and 5 female of 17 patients with a fibular fracture was the fibula fixed at the
patients, with a mean age of 32.5 years (range, 16–48 years). same time the external fixator was applied; in the remaining
All fractures were complete articular injuries, classified as 15 patients, it was fixed at the definitive pilon surgery. The

FIGURE 6. After the reduction of the

posterior articular surface, 3 Kirsch-
ner wires were placed into the lateral
articular fragment of Chaput (A),
followed by reduction and Kirsch-
ner-wire fixation of the anteromedial
articular fragment (B).

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TABLE 1. Patient and Treatment Characteristics

No. Age/Sex Side Injured Mechanism AO/OTA Time in Ex Fix* Fibula Fixation† Follow-up‡ Wound Healing
1 48/M R MVA 43-C1 12 Delayed 12 Good
2 42/F L Fall 43-C2 21 Urgent 12 Good
3 39/M R MVA 43-C3 16 Delayed 14 Good
4 38/M R Hang gliding 43-C3 16 Delayed 13 Good
5 40/F R MVA 43-C3 17 Delayed 14 Good
6 26/M R MVA 43-C3 18 Delayed 15 Good
7 37/M R Fall 43-C3 15 Delayed 17 Good
8 38/M L MVA 43-C3 14 None§ 18 Good
9 19/F R Hang gliding 43-C3 13 None§ 12 Good
10 27/M L MVA 43-C3 16 Delayed 15 Disturbedk
11 17/M R MVA 43-C3 18 Delayed 19 Good
12 19/M R MVA 43-C2 16 Delayed 16 Good
13 37/M R Fall 43-C3 17 None§ 12 Good
14 26/F R MVA 43-C3 15 Delayed 13 Good
15 23/F R MVA 43-C3 15 Delayed 12 Good
16 44/M L MVA 43-C3 18 Urgent 12 Good
17 35/M L MVA 43-C2 17 Delayed 13 Good
18 30/M L Fall 43-C3 20 Delayed 12 Good
19 39/M L Fall 43-C3 19 None§ 14 Good
20 26/M R MVA 43-C3 16 Delayed 12 Good
21 32/M L MVA 43-C3 15 Delayed 13 Good
*Length of time (days) between initial application of external fixator and definitive surgery.
†Fibula fixation (if performed) either at urgent bridging external fixation or delayed.
§None implies that there was no fibula fracture.
‡Latest follow-up (months).
kSuperficial infection at proximal portion of wound.

average time between application of the bridging external

fixator and definitive surgery was 16.4 days (range, 127–21
days). The extensile approach was used in all patients. In some
patients, the external fixator was removed before the definitive
surgery; however, in most cases the fixator was left in place to
help with distraction intraoperatively.
A representative example is that of a 37-year-old man
who sustained a closed pilon fracture of the right lower
extremity in a motor vehicle crash. The preoperative radio-
graphs at admission to the hospital (Fig. 9), immediately after
application of an external fixator (Fig. 10A, B), and after
computed tomography (Fig. 11A, B, C) showed a complete
articular fracture localized to the epiphysiometaphyseal region
without extension into the diaphysis, with a multifragmentary
articular surface and a fibular fracture. The AO/OTA classi-
fication was 432C3.2. Anteroposterior and lateral radiographs
(Fig. 12A, B) 1 week postoperatively showed satisfactory
reduction of the articular surface and stabilization with
anterolateral and medial plates. Excellent healing of the soft
tissues was observed at 3 months postoperatively (Fig. 13),
and radiographs at 6 months postoperatively (Fig. 14) showed
a well-healed fracture.
All patients were followed up for a minimum of
12 months postoperatively to allow for accurate assessment
of wound and fracture healing. All patients except 1 had
uneventful wound healing, with no flap necrosis or infection.
FIGURE 7. Closure of the extensor retinaculum. One patient developed a local infection at the most proximal

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J Orthop Trauma
Volume 21, Number 3, March 2007 Pilon Fractures: Surgical Technique and Soft-Tissue Healing

FIGURE 8. Photograph (A) at 48 hours

postoperatively and illustration (B) showing
the extensile incision closed with the All-
göwer modification of the Donati suture.

portion of the vertical incision and not at the lateral inferior the pin site. The infection was treated by local incision and
corner of the flap at the articular margin. We believe this drainage and appropriate antibiotics, with early and complete
occurred because a technical error placed one of the tibial pins resolution. The lesson learned from this complication is that, if
for the bridging external fixator very close to the planned possible, it is important to try and place the external fixation
surgical incision, and the incision was carried to within 1 cm of pins in the very proximal tibia. All fractures united without

FIGURE 9. Anteroposterior (A) and lateral (B)

radiographs of a 37-year-old man (patient 7;
Table 1) who was involved in a high-energy
motor vehicle crash, sustaining this multi-
fragmentary pilon fracture of his right ankle
(AO/OTA classification, 43-C3.2). This is the
same patient shown in the previous figures.

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FIGURE 10. Anteroposterior (A) and lateral

(B) radiographs after application of an
external fixator.

radiographic evidence of avascular necrosis of any of the of these patients for other parameters such as range of motion,
articular fragments. The most important aspect of this report is gait, radiologic assessment, return to work and sporting
to describe our experience with the extensile approach and its activities, and health impairment parameters is peripheral to
effect on the soft tissues. Given that goal, the clinical outcome the main objective of this study.

FIGURE 11. Sagittal (A), coronal (B), and transverse (C) FIGURE 12. Anteroposterior (A) and lateral (B) radiographs 1
computed tomographic views. week postoperatively, showing the anatomic reduction.

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Volume 21, Number 3, March 2007 Pilon Fractures: Surgical Technique and Soft-Tissue Healing

FIGURE 14. Anteroposterior (A) and lateral (B) radiographs 16

months postoperatively.

FIGURE 13. Photograph at 3 months postoperatively. Note fracture, which has led some to consider the ideal treatment to
good healing of the wound. be a limited exposure of the joint with use of cannulated
screws for fixation of articular fragments, followed by either
a spanning external fixator or a nonspanning hybrid fixator for
DISCUSSION definitive treatment of the fracture.8,12–14 The rationale for such
The most important advancement in management of the an approach has been related to the concern for wound-healing
high-energy pilon fracture has been the recognition of the need problems, including deep infection with use of more extensile
to delay primary surgery. The use of a bridging external approaches. However, if the goal is to restore articular
fixator, with or without fixation of any fracture of the fibula, congruity, then limited incisions may fail to adequately
has become common to stabilize the soft tissues and prevent visualize the joint surface and achieve an anatomic reduction.
wound-healing complications.2,3,5,6,10,11 Second has been the Minimally invasive techniques for joint reduction are therefore
interest in minimally invasive techniques to stabilize the frequently inadequate but may permit less surgical dissection

TABLE 2. Pitfalls and Tips

Pitfall Effect Tip
Transverse limb of incision is made too proximal Difficult to visualize articular surface Be sure the transverse incision begins 10 mm inferior
to medial malleolus
Transition from transverse to vertical limbs Difficult to visualize lateral pilon Make the transition midway between the malleoli or
is made too medial slightly more lateral
Transition from transverse to vertical limbs Anterior tibial tendon lies directly under scar Be sure the incision is at least 10 mm lateral to the
is made too medial tibial crest
Junction between transverse and vertical limbs Puts the corner of the flap at risk Make this a transition at 105°–110°
is made #90°
Not keeping knife edge perpendicular to skin at Skives the incision; may disturb wound Keep knife edge perfectly perpendicular during the
transition from transverse to vertical limbs healing at corner of flap transition
Using too long a scalpel blade Skives the incision (as above) Use a No. 24 scalpel blade for the incision, but at the
corner change to a No. 15 blade
Separating the layers as flap is developed Negatively affects vascularity to the flap Raise up the medial flap as a full-thickness flap
Rough retraction of the flap Will disturb the blood supply to the flap Be gentle! Use full-thickness nylon sutures to apply
traction to the flap
Letting the flap or tendon desiccate May lead to skin or tendon necrosis Frequently moisten the flap and any exposed tendon

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