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23 Jul 2025
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Pathological Pilon Fracture with Benign Cystic Lesion

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Clinical Details

Clinical and radiological findings:  A 56-year-old male presented following a low-energy fall from a curb while attempting to retrieve his dog. The patient had no prior history of ankle pain. Radiographic evaluation revealed a low-energy pilon fracture with an anteromedial meta/epiphyseal cystic lesion. The lesion was eccentrically positioned, well-marginated, non-expansile, and without cortical destruction or soft tissue involvement, suggestive of a benign process. However, given the patient's demographic, metastatic disease was considered a differential diagnosis.

Preoperative Plan

Planning remarks:  The preoperative plan included obtaining a biopsy with intra-operative frozen section analysis to rule out primary bone malignancy and ensure adequate tissue for final pathological diagnosis. Upon confirmation of non-specific inflammation and absence of malignancy, surgical fixation was planned. The fracture pattern was classified as AO/OTA 43-B type, indicating a partial articular fracture.

Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table with the affected limb prepared for a posteromedial approach.

Anatomical surgical approach:  A posteromedial approach was utilized, involving an incision along the medial aspect of the distal tibia. Subperiosteal dissection was performed to expose the fracture site and underlying cystic lesion.

Operative remarks: 

Intraoperative frozen section analysis revealed non-specific inflammation with no evidence of malignancy, allowing for fracture fixation to proceed. Direct anatomic reduction of the articular surface was achieved at the fracture apex. An anti-glide buttress plate was applied for stabilization, supplemented by interfragmentary compression using lag screws.

Postoperative protocol:   Postoperatively, the patient was advised to maintain non-weight bearing status for 6 weeks, followed by progressive weight bearing as tolerated. Range of motion exercises were initiated early to prevent joint stiffness.

Follow up:   Not specified.

Orthopaedic implants used:   Anti-glide buttress plate, interfragmentary lag screws.

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