Classifications in Brief: Rüedi-Allgöwer Classification of Tibial Plafond Fractures

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According to Michelson et al. [17], the French word for pestle, “pilon,” was first used by Étienne Destot in 1911 as a metaphor for the mechanical function of the distal tibia on the talus. Subsequent descriptions of fractures of the tibial plafond adopted the term “pilon” to describe the explosive nature and axial compression mechanism of these injuries, in which the tibia acts as a pestle and is driven vertically into the talus [10, 21, 22]. Fractures of the tibial plafond commonly result from high-energy trauma with axial load, sometimes leading to severe bone loss and soft tissue injury [3, 5, 15]. They are relatively rare, accounting for 1% to 10% of lower leg or tibial fractures, but are substantial injuries that can result in persistent disability if not fixed properly. Many of these fractures leave the patient with persistent pain, limitations in ROM, and residual disability, especially when the fracture patterns involve severe articular comminution [18, 26, 30]. Complications after surgical treatment and inconsistency in achieving fracture union during the early half of the last century led many physicians to consider these fractures as “not amenable to surgery” [22]. As a result, patients had to live with the persistent disability.
One of the first pivotal shifts in the approach to treating pilon fractures came from the proposed techniques and results published by Rüedi and Allgöwer in 1968 [23]. They noted from previous studies that nonoperative treatment was likely to result in secondary joint displacement and worse outcomes. Rüedi and Allgöwer postulated that by adhering to strict aseptic technique and applying four operative stages, internal fixation of pilon fractures would result in the best-possible anatomic reconstruction. This staged principle was applied in a series of 84 comminuted pilon fractures in 82 patients [21]. Rüedi and Allgöwer's first step calls for restoration of the length of the fibula to assist in fracture reduction of the tibia. They noted that 60% of all cases involved a concomitant transverse or oblique fracture of the fibula. An initial approach to the tibia was possible in the remaining 40% of cases. The second step involves anatomic restoration of the distal articular surface of the tibia. They commented on the “jigsaw puzzle” nature of severely comminuted fractures in half of all patients and recommended using the talus as a guide to reconstruct the tibia. Next, autologous bone graft can be used to fill the metaphyseal bone defect and support the articular surface to prevent collapse. Finally, buttress plate fixation can be applied to the medial side of the tibia to prevent late-onset varus deformity.
Although there are numerous modern techniques for pilon fixation, the concepts presented by Rüedi and Allgöwer still form the foundation of the surgical approach to these injuries [24, 30]. Furthermore, their contributions to the management of pilon fractures included not only surgical principles, but also the introduction of a classification system still widely used [26, 27].
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