Clinical Outcomes for Pilon Variant Posterior Malleolar Fractures: A Multicenter Retrospective Analysis

Reduction and outcome of posterior pilon fractures with intercalary fragments: a retrospective cohort study comparing the transfibular and posteromedial approaches

BACKGROUND

The transfibular fracture region (TFFR) approach can be utilized for managing posterior pilon fractures associated with intercalary fragments. However, its long-term outcomes remain unreported. This study aimed to compare the long-term clinical outcomes of the TFFR approach and the posteromedial approach for posterior pilon fractures (Klammer type 2/3, Danis-Weber type B) associated with displaced intercalary fragments over an average 8 year follow-up.

METHOD

From 2012 to 2018, a cohort of consecutive patients who underwent open reduction and internal fixation surgery via either the TFFR approach or the posteromedial approach for posterior pilon fracture associated with intercalary fragments were enrolled for this study. Clinical outcomes were evaluated over an average 8 year (range 5-12 years) follow-up. The surgical duration, number of intraoperative fluoroscopies, and postoperative complications were recorded. Functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), and Short Form-36 (SF-36) score at last follow-up.

RESULTS

Seventy-nine patients were included in the final analysis, including 43 in the TFFR group and 36 in the posteromedial group. No significant differences between the two groups were observed in the FAOS (p = 0.679) or its specific components for symptoms (p = 0.264), pain (p = 0.963), activities of daily living (ADL, p = 0.102), sports (p = 0.156), or quality of life (p = 0.859). There was also no significant difference between the two groups in the FAAM-ADL (p = 0.408), FAAM-Sport (p = 0.617), and SF-36 scores (p = 0.757). Nevertheless, the surgical duration was shorter in the TFFR group (p < 0.001).

CONCLUSION

The TFFR approach is not inferior to the posteromedial approach. For posterior pilon fractures with lateral malleolar fractures in the same plane, the TFFR approach may be preferred owing to its potential to reduce surgical time and the use of a single incision. Level of Evidence Level III, retrospective cohort study.

Treatment of distal third tibial fractures with anterior soft tissue compromise through the posterolateral approach: Distal Third Tibial Fractures via the Posterolateral Approach

Distal third tibial fractures associated with anterior soft tissue compromise are a predictor of more complications and poor prognosis. The study aimed to introduce the treatment of such fractures through the posterolateral approach. From March 2020 and January 2022, 32 patients with distal third tibial fractures were plated through the posterolateral approach due to concurrent closed anterior soft tissue compromise. There were 30 male and 2 female patients with the mean age of 33 years (range, 20-53 years). The reduction quality of diaphyseal fractures was good (n=30) and acceptable (n=2). The reduction quality of articular fragments was anatomic (n=21), good (n=6), and fair (n=1). All anterior soft tissue injuries healed without surgical intervention. Follow-ups lasted 28 months (range, 25-34 months). The mean dorsiflexion of the injured and uninjured ankles were 17.8°±5.4° and 24.5°±6.6°, respectively (P<0.05). The mean plantar flexion of the ankles were 42°±8.8° and 46°±12.9°, respectively (P>0.05). The mean inversion of the injured and uninjured ankles were 15°±13.3° and 19°±12.4°, respectively (P<0.05). The mean eversion of the injured and uninjured ankles were 27.8°±16.9° and 32.9°±14.3°, respectively (P>0.05). The mean American Orthopaedic Foot and Ankle score was 90 (range, 68-100). Distal third tibial fractures with anterior soft tissue compromise can be plated through the posterolateral approach, resulting in good functional outcomes and minimum complications.

A systematic review of posterior pilon variant fractures

Posterior pilon variant ankle fractures (PPVF) are a unique subtype of posterior malleolar fractures which have been a source of controversy and confusion in recent years. There has not been a thorough literature review previously written on the topic. Database searches of PubMed and Embase were conducted from inception until June 2023. The key words included "pilon variant," "posterior pilon variant," and "posterior pilon" fractures. Outcomes were evaluated by union time, rates of delayed union, nonunion, malunion, and complication. A total of 15 articles relevant to surgical repair of pilon variant fractures were included in the literature review. The unique mechanism of injury has been reported to involve both rotational and axial forces, leading to involvement of the posterior and medial aspects of the distal tibia. Pilon variant fractures can be suspected by several characteristics on radiographs and have a high confirmation rate via CT images. Multiple systems have been proposed to classify this fracture pattern, but there is no consensus on the ideal classification system. Surgically, direct fixation has shown better short-term clinical outcomes versus indirect fixation or no fixation. PPVF have a distinct fracture pattern involving the posterior and medial columns of the distal tibial plafond, and results from a mechanism intermediate to rotational and axial forces. These fractures are more severe than tri-malleolar fractures due to increased rates of articular impaction and incongruity. Future classification systems should focus on joint surface area and the tibial pilon column involved to avoid confusion with less severe posterior malleolar fractures.

Treatment outcomes of posterior pilon fractures using a simple single lateral approach via stretching fibular fracture line

Purpose

The aim of this study was to explore the treatment outcomes of a novel single lateral approach via fibular fracture line for patients with posterior pilon fractures.

Patients and methods

From January 2020 to December 2021, a total of 41 patients with posterior pilon fractures who received surgical treatment in our hospital were retrospectively reviewed. Twenty patients (Group A) were treated with open reduction and internal fixation (ORIF) via posterolateral approach. Twenty-one patients (Group B) were treated with ORIF using a simple single lateral approach via stretching fibular fracture line. Clinical assessments, including operation time, intraoperative blood loss, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and the active range of motion (ROM) of the ankle at the final follow-up visit after surgery, were performed in all patients. Radiographic outcome was evaluated by using the criteria proposed by Burwell and Charnley.

Results

The mean follow-up time was 21 months (range 12-35). The average operation time and intraoperative blood loss in the Group B were significantly less than those in the Group A. Moreover, the AOFAS score and ankle ROM in the Group B were significantly higher than those in the Group A at the final follow-up visit. Eighteen cases (90%) in Group A and 19 cases (90.5%) in Group B achieved anatomical reduction of the fracture.

Conclusion

The single lateral approach via stretching fibular fracture line is a simple and effective technique for reduction and fixation of posterior pilon fractures.