The surgical approach for osteosynthesis of metaepiphyseal fractures of the distal tibia

Introduction The optimal surgical approach is essential for osteosynthesis of intra-articular fractures of the distal tibial metaphysis (pilon fractures). None of the existing approaches provides complete visualization of the articular surface, increasing the risk of complications and inadequate reduction. The objective was to optimize the choice of surgical approach in preoperative planning of internal osteosynthesis of intra-articular fractures of the distal metaepiphysis of the tibia (pilon) based on 3D prototyping and standardized marking of the articular surface. Material and methods An algorithm developed was based on a full-size 3D prototype and CT data. The articular surface of the tibia was divided into nine standard zones. The surgical approach was selected depending on the location of the key fragment (occupying > 2/3 of the zone) or the fracture line exit point. The method was used in 12 patients with AO/OTA 43-C pilon fractures. Surgical time, blood loss, the quality of postoperative fracture reduction categorized according to the Burwell-Charnley criteria, functional outcomes measured with AOFAS and VAS FA grading scales, and radiographic union determined with the mRUST scale were assessed at six months. Results and discussion The mean operating time was (65.08 ± 7.03) min, blood loss was (119.3 ± 18.51) ml. The wounds healed by primary intention without infectious complications. The quality of reduction was anatomical in eight patients and acceptable in four patients. The mean AOFAS (78.67 ± 8.68) and VAS FA (41.08 ± 5.05) scores indicated good functional recovery. The mean mRUST score (13.5 ± 1.43) suggested complete consolidation. The method objectified the surgical approach avoiding subjectivity and allowed for personalized intervention by combining approaches for optimal visualization of all fragments, including hard-to-reach ones (e.g., Tillaux – Chaput fragment). Conclusion The method integrating 3D planning and a standardized coordinate system improves reposition accuracy, reduces morbidity, and improves functional outcomes in patients with complex pilon fractures.