Pilon fractures of the distal tibia are associated with several complications. Late presentations are also not uncommon and together they present many challenges in the management. This review article looks at many of the problems they may present with, and the options available in their treatment with illustrative cases that we have treated over a number of years.

Purpose and context: Pilon fractures typically result from traumatic incidents involving significant axial and rotational forces. The primary focus is on anatomical bone injuries and significant damage to soft tissues. The treatment has difficulties in avoiding soft tissue problems following a stage of surgery due to the complexity of surgical methods. Several surgical exposures can be used for the distal tibia and the ankle joint visualization, including anteromedial, anterolateral, medial, posteromedial and its modification, and posterolateral approaches. Each approach has individual advantages and constraints. The choice between single or combination approaches depends on factors such as the characteristics of the fracture, the planned reduction and fixation, and the state of soft tissue management. This review article presents an analysis of the development of surgical exposures, including their indications, benefits, drawbacks, and techniques. There is a current trend indicating that wound problems are not associated with recent surgical incisions published in the past decade. This is attributed to the careful treatment of soft tissues and preservation of angiosomes.

Tibial pilon fractures remain a challenge for surgeons. The majority of these fractures are treated with anterior approaches. Select complex fractures require (typically additional) posterior approaches to obtain appropriate reduction and stabilization of the articular surface. Posterior approaches may be undertaken with the patient in the prone or semilateral position. The semilateral position may allow for simultaneous treatment and easy adjustment of reduction or fixation without repositioning the patient. The posterolateral approach has been commonly used by surgeons, often in conjunction with fixation of the fibula. Posteromedial approaches have been used less frequently but appear to offer significant versatility and greater access to more of the posterior column than posterolateral approaches.

Aim and background: Pilon fractures are usually the result of a high-energy mechanism and are widely considered more of a soft tissue injury secondary to the high rates of soft tissue complications that arise from them. The majority of pilon fractures have an associated fibular fracture in which minimally invasive intramedullary fixation has been utilized to minimize soft tissue complications. In this manuscript, we present three different cases that highlight different intramedullary fixation techniques. Technique: Cut flexible guidewire, standard cortical screw, intramedullary fibular nail. Conclusion: Intramedullary fixation for associated fibular fractures in the setting of pilon fractures has been shown to be a viable technique for successful outcomes. There are a variety of options for intramedullary fixation that can be utilized, and guidewire, cortical screw, and intramedullary fibular nail techniques are demonstrated in our case examples with tips to help produce good outcomes. Clinical significance: Using minimally invasive intramedullary fibular fixation can help mitigate risk of wound complications in high-risk pilon fractures. Level of evidence: V (expert opinion).

Pilon fracture is usually a high-energy trauma involving the soft tissue and bone. Operative treatment of complex intraarticular fractures of the distal tibia was historically fraught with difficulty and high complications rates. The importance of adequate soft tissue management when dealing with these high-energy injuries has became well-recognized as a crucial factor in determining the success of such surgeries. Arthroscopic assisted reduction of the fracture is attractive as it is a minimally invasive approach with less surgical trauma to the soft tissue and provides direct visualization of the articular surfaces, assessment of reduction of the articular fragments and detection of associated chondral injury. However, it is also time-consuming, technically demanding and requires a long learning curve. Its role in the management of pilon fractures appears limited and requires further study.

Aims and background: A bullet foreign body, especially if embedded in joint space, can cause multiple complications. Although there is still no standard treatment for retained bullet foreign bodies, we found in some literature that bullet removal is the best treatment option for intra-articular involvement. Achieving ankle stability is considered a priority after foreign body removal. Case description: We present a 48-year-old male with swelling and pain in his right ankle after falling from a parked motorcycle. The drop-foot gait pattern was also found. We later found from an X-ray examination that the patient had an untreated bullet foreign body embedded in his right ankle from an incident 20 years ago. Foreign body removal and tibiotalocalcaneal arthrodesis (TTCA) using retrograde intramedullary nail were performed to achieve ankle stability. Conclusion: Tibiotalocalcaneal arthrodesis (TTCA) using retrograde intramedullary nail performed in this particular case showed good clinical outcomes and a good return-to-work rate. Clinical significance: This case report revealed that bullet removal in the tibiotalar joint is a great treatment option for patients experiencing abnormal gait pattern and chronic pain. The utilization of retrograde intramedullary nail along with bone graft can be a promising option in cases with avascular necrosis of the talus to achieve a stable ankle fusion.

Aim and background: The management of chronic extensor hallucis longus (EHL) tendon ruptures presents a challenge. While primary suturing is feasible in acute cases, the challenge lies in treating chronic ruptures, as the gap between torn edges widens due to tendon contracture, rendering direct end-to-end repair unviable. Despite the variety of reconstruction methodologies available, a definitive consensus on the optimal technique remains elusive. The innovative approach to minimally invasive percutaneous tendon transfer of the extensor digitorum longus (EDL) from the second toe to the EHL for chronic traumatic EHL rupture holds promise as an alternative solution. Technique: The goal of surgical treatment was to restore normal gait by realigning the hallux and restoring its capacity to actively extend. For a minimally invasive approach, in this case, four small incisions of size 1 cm were made for the tendinous transfer of the EDL of the second toe to the EHL, making use of a Pulvertaft technique. Conclusion: By providing a less invasive alternative to traditional reconstructive approaches, this method addresses the limitations of functional compromise associated with common graft or transfer procedures. The described approach not only overcomes the challenges posed by tendon retraction and degeneration but also decreases the risks of donor site morbidity and disease transmission. Clinical significance: As the field continues to explore advanced surgical techniques, the minimally invasive percutaneous tendon transfer stands out as a valuable addition to the armamentarium of treatments for chronic EHL ruptures.

Aim and background: Ligamentous Lisfranc injuries are challenging to detect, with 20–40% of them remaining undiagnosed or misdiagnosed at initial presentation. While direct visualization in the operation room is the gold standard for detecting Lisfranc instability, it is also the most invasive. Other techniques currently available for assessment are unstandardized and nonreproducible. We aimed to introduce a novel reproducible intraoperative mechanical testing method (Listract test) for isolated Lisfranc instability assessment. Technique: The Lisfranc ligament between the first cuneiform (C1) and second metatarsus (M2) in eight lower leg cadaveric specimens was dissected to replicate C1-M2 Lisfranc instability. Intraoperative radiographs were used for measuring C1-M2 diastasis and area in two states, “stable” and “unstable.” A 50N distraction force was applied in the direction of the C1-M2 ligament through two K-wires for “unstable” conditions. Three methods of fixation—flexible fixation, metal screw, and bio-integrative screw were alternatively used to stabilize the joint, and the Listract test was applied again in a “stable” condition. Receiver operating characteristic (ROC) analysis for the Listract test was performed using Statistical Package for the Social Sciences (SPSS). The sensitivity and specificity of the Listract test for detection of ruptured ligament instability using C1-M2 diastasis (cutoff taken as 3 mm) were 100 and 77.8%. Similarly, the instability of ruptured ligament measured using C1-M2 area (cutoff taken as 26.1 mm) was 85 and 100%. The intraclass correlation coefficient (ICC) for C1-M2 diastasis and area measurements was 0.84 and 0.92, respectively. Conclusion and clinical significance: The Listract test is a simple, standardizable, and replicable intraoperative method for evaluating the Lisfranc joint for instability. Developing a device with this mechanism can be clinically significant to accurately assess the severity of instability intraoperatively and provide appropriate treatment.

I read the article “multifocal tubercular osteomyelitis of metatarsal and ulna: a case report,” published in your esteemed journal on 7^th October 2022, issue with great interest, especially when tuberculosis (TB) is still so prevalent in this country. However, I would like to highlight certain important issues.