OBJECTIVEThe anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures. For complex fracture patterns a combined anterolateral/anteromedial approach is suitable but a high rate of complication has been reported. In our retrospective study a two-choice strategy adopting a medial tibial approach was proposed for the treatment of pilon fractures with anterior or posterior fragmentation.

METHODSBased on an anatomic study of tibial pilon fractures, we retrospectively analyzed the fractures with primary posterior, posterior-lateral or anterior, anterior-lateral (Tillaux-Chaput) involvement of the distal tibia. This retrospective study consisted of 18 patients with a closed tibial plafond fracture. The inclusion criteria were: (1) pre- sence of an anterior/anterolateral type fragment or a posterior (Volkmann) type fragment involving larger than 25% of the articular surface, (2) a minimum follow-up of 12 months, (3) a fibula fracture associated with a medial column fracture of the distal tibia, and (4) soft tissue conditions at the time of operation that did not compromise the choice of surgical access (Tscherne classification for closed fractures: grade 0 and grade 1). Tibial plafond fractures were classified into two groups: one presenting anterior and the other with posterior rim (Volkmann) fragments.

RESULTSMost patients achieved a good clinical recovery in terms of range of motion and Olerud-Molander scale scores. Only three patients presented a grade 2 osteoarthritis at the 12 month follow-up.

CONCLUSIONOur two-choice strategy highlights concepts which have been previously debated and described in the literature. But a new extended protocol for surgical approach to the distal tibia, including more fracture patterns and their association should be further investigated.