Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table to allow access for both debridement and subsequent fixation procedures.

Anatomical surgical approach:  The surgical approach for the ORIF of the pilon fracture was an anteromedial incision. Careful dissection was performed to avoid injury to the anterior tibial artery and deep peroneal nerve, which were noted to be in close proximity to the fracture site. The approach allowed for direct visualization and reduction of the fracture fragments, with particular attention to the impacted articular surface.

The surgeon emphasized the critical importance of a thorough and systematic debridement in the initial stage, as the outcome is heavily dependent on the quality of this procedure. The fibular fixation was performed to ensure proper alignment and facilitate later pilon reconstruction. During the ORIF, careful handling of neurovascular structures was paramount due to their proximity to the fracture. The surgeon noted the challenges posed by the articular impaction and emphasized the need for innovative solutions in such cases.

Postoperative protocol:   Postoperatively, the patient was allowed progressive weight bearing as tolerated in a CAM boot starting at 3 months post-surgery. The rehabilitation protocol included gradual increase in weight bearing, with transition out of the boot as tolerated by 6 months.

Follow up:   At 6 months postoperatively, the patient returned for follow-up, ambulating without assistive devices but still using a CAM boot. He reported some medial side soreness after prolonged standing but overall satisfactory progress. Surgical and traumatic wounds healed uneventfully with no signs of infection.

Orthopaedic implants used:   External fixator, fibular plate fixation, CAM boot.