Level III: Retrospective, comparative study.

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Objectives: The objective of this study was to describe the anatomic variations in the saphenous nerve and risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. Methods: Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1, 2, and 3 cm above the tibial plafond on 10 below-knee cadaver leg specimens. The distance and position of each button from the greater saphenous vein and saphenous nerve were evaluated. Results: The mean distance of the saphenous nerve to the suture buttons at 1, 2, and 3 cm were 7.1 ± 5.6, 6.5 ± 4.6, and 6.1 ± 4.2, respectively. Respective rate of nerve compression was as follows, 20% at 1 cm, 20% at 2 cm, and 10% at 3 cm. Mean distance of the greater saphenous vein from the suture buttons at 1, 2, and 3 cm was 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9 mm, respectively. Respective rate of vein compression was 20%, 10%, and 10%. A single nerve branch was identified in 7 specimens, and 2 branches were identified in 3 specimens. Conclusion: There was at least one case of injury to the saphenous vein and nerve at every level of button insertion at a rate of 10% to 20%. Neurovascular injury may occur despite vigilant use of fluoroscopy and adequate surgical technique. Further investigation into the use of direct medial visualization of these high-risk structures should be done to minimize the risk. Levels of Evidence: Therapeutic, Level II: Prospective, comparative study

Objectives: To determine if overlap of definitive plate fixation with external fixator pin sites is a risk factor for infection in pilon fractures. Design: Retrospective cohort. Setting: Level 1 trauma center. Patients: One hundred forty-six patients with pilon fractures treated between 2012 and 2018. Intervention: Staged treatment with ankle-spanning external fixation, followed by delayed open reduction and internal fixation. Main Outcome Measures: Demographic, radiographic, and operative data were reviewed, and the distance between the temporary external fixator pin sites and the definitive plate was measured. The primary outcome measure was the development of a deep postoperative infection. Results: Overall, 22 (15%) patients developed deep wound infections. Overlap of definitive plate and external fixation pin site occurred in 58 (40%) of ankles. Of these, 7 (12%) developed deep wound infection compared with 15 (17%) patients without overlap (P = 0.484). There was no significant difference in amount of overlap (P = 0.636) or distance from plate to pin site (P = 0.607) in patients with and without deep infection. Of the patients with deep infection, 11 (50%) occurred in patients with open fractures. Conclusions: Overlap of definitive plate fixation with primary spanning external fixator pin sites is not a risk factor for development of deep infection in a staged treatment of high-energy pilon fractures. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.