Distal Tibial Intra-Articular Plating Failed Fixation

The treatment of moderate to high-energy tibial pilon fractures continues to be associated with a high risk of complications. Anatomical reduction of the fracture, restoration of joint congruence, reconstruction of the medial, lateral, anterior, and posterior columns, and minimal soft tissue damage are highly recommended. Fixation failure can occur due to both implant-related and soft-tissue-related problems. Soft tissue problems account for more than 50% of these complications, generally requiring additional procedures and potentially leading to implant exposure, fracture-related infection, and fixation failure. Technical problems, which include malreduction and/or inadequate fixation, result in mechanical instability with subsequent hardware failure, potentially leading to intra- and/or extra-articular malunion or non-union, joint stiffness and posttraumatic arthritis. The most common cause of hardware failure is the inability to achieve a stable fixation construct due to an incorrect interpretation of the fracture pattern. Plate location is usually determined by which side of the fracture the periosteum is intact. Therefore, in a valgus fracture pattern, the use of an anterolateral plate is recommended, while in a varus fracture pattern, the use of a medial plate is recommended. Minimally invasive or percutaneous approaches can be used whenever possible; however, extensive skin and soft tissue damage are factors that increase the risk of complications. We describe the case of a 66-year-old male patient, who suffered a Gustilo I open fracture of the right tibial pilon after falling from a folding ladder, associated with a comminuted fracture of the fibula at the same level. The patient was initially treated by emergency debridement and definitive fixation at 10 days (360° fixation). Despite the initial fixation strategy, 2 months after starting partial weight bearing, the fracture site gradually collapsed into a varus. At 3 months, it was decided to remove the hardware and take a biopsy with negative results for infection. At 4 months, it was decided to perform an extensive posterior approach and osteosynthesis using a posterior tibia plate, associated with fibula osteotomy and re-osteosynthesis. Autogenous bone graft harvested using the Reamer-Irrigator-Aspirator (RIA) system and demineralised bone matrix were placed on the medial metaphyseal defect of the tibia. At 6 months, the pilon fracture consolidated uneventfully clinically and radiologically, and the patient returned to his pre-injury level of activity.