Abstract
Purpose
This study looks to compare patient outcomes in those with pilon fractures fixed with the anterolateral approach versus those with the posterolateral approach.
Methods
135 patient charts of those with surgically treated pilon fractures over a 7-year period were retrospectively reviewed, recording demographic information, fracture description, surgical intervention timeline, operative outcomes, patient outcomes, and complication rates.
Results
Of the 44 included patients (32 anterolateral and 12 posterolateral), most were older than 40 years of age (65.9%) and male (63.6%). There was no difference seen between anterolateral approach and posterolateral approach tourniquet times (p = 0.80), operating room time (p = 0.40), or estimated blood loss (p = 0.73). There was also no reported difference in decrease in Numerical Rating Scale pain scores (p = 0.38), FOTO (Focus on Therapeutic Outcomes) percent increase (p = 0.13), active flexion–extension axis range of motion (p = 0.35), or inversion–eversion axis (p = 0.25) range of motion after an anterolateral approach versus a posterolateral approach. Finally, statistically similar complication rates (p = 0.75) were seen between anterolateral and posterolateral approaches, but patients who underwent a posterolateral approach surgical fixation were trending towards significantly using more post-operative outpatient opioid medications for pain control compared to those who underwent surgical fixation with an anterolateral approach (p = 0.09).
Conclusions
Pilon injuries that lend themselves to anterolateral fixation have similar outcomes peri-operatively and post-operatively compared to injuries lending to posterolateral fixation. Both approaches can be used as dictated by the injury not fearing poorer outcomes or increased complication rates. However, surgeons must be wary of high complication rates associated with all pilon injury patterns.
Level of evidence
Therapeutic Level IV.
Similar content being viewed by others
References
Bonin JG (1950) Injuries to the Ankle. William Heinemann, London, pp 248–260
Destot EA (1911) Traumatismes du pied et rayons X: malleoles-astragale-calcaneum-avant-pied. Masson
Borrelli J, Catalano L (1999) Open reduction and internal fixation of pilon fractures. J Orthop Trauma 13(8):573–582
Rüedi TP, Allgöwer M (1969) Fractures of the lower end of the tibia into the ankle-joint. Injury 1(2):92–99
Kellam JF, Waddell JP (1979) Fractures of the distal tibial metaphysis with intra-articular extension-the distal tibial explosion fracture. J Trauma Acute Care Surg:593–601
Assal M, Ray A, Stern R (2015) Strategies for surgical approaches in open reduction internal fixation of pilon fractures. J Orthop Trauma 29(2):69–79
Borrelli J, Ellis E (2002) Pilon fractures: assessment and treatment. Orthop Clin North Am 33(1):231–245
Höntzsch D, Karnatz N, Jansen T (1990) One-or two-step management (with external fixator) of severe pilon-tibial fractures. Aktuelle Traumatologie 20(4):199–204
Liporace FA, Yoon RS (2012) Decisions and staging leading to definitive open management of pilon fractures: where have we come from and where are we now? J Orthop Trauma 26(8):488–498
Rüedi TP, Allgöwer M (1979) The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res 138:105–110
Miller ME, Allgower M, Schneider R, Willenegger H (1979) Manual of internal fixation. Springer, Berlin, pp 3–14
Makwana NK, Bhowal B, Harper WM, Hui AW (2001) Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. Bone Jt J 83(4):525–529
Patterson MJ, Cole JD (1999) Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma 13(2):85–91
Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr (1999) A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 13(2):78–84
Brumback RJ, McGarvey WC (1995) Fractures of the tibial plafond. Evolving treatment concepts for the pilon fracture. Orthop Clin North Am 26(2):273–285
El-Mowafi H, El-Hawary A, Kandil Y (2015) The management of tibial pilon fractures with the Ilizarov fixator: the role of ankle arthroscopy. Foot 25(4):238–243
Femino JE, Vaseenon T (2009) The direct lateral approach to the distal tibia and fibula: a single incision technique for distal tibial and pilon fractures. Iowa Orthop J 29:143
Carbonell-Escobar R, Rubio-Suarez JC, Ibarzabal-Gil A, Rodriguez-Merchan EC (2017) Analysis of the variables affecting outcome in fractures of the tibial pilon treated by open reduction and internal fixation. J Clin Orthop Trauma 8(4):332–338
Helfet DL, Koval K, Pappas J, Sanders RW, DiPasquale T (1994) Intraarticular” pilon” fracture of the tibia. Clin Orthop Relat Res 298:221–228
Blauth M, Bastian L, Krettek C, Knop C, Evans S (2001) Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma 15(3):153–160
Jia SH, Huang CL, Xu HW, Gong SL (2016) Surgical treatment for posterior Pilon fracture through posterolateral approach. Zhongguo Gu Shang 29(6):557–560
Bhattacharyya T, Crichlow R, Gobezie R, Kim E, Vrahas MS (2006) Complications associated with the posterolateral approach for pilon fractures. J Orthop Trauma 20(2):104–107
Ketz J, Sanders R (2012) Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures. J Orthop Trauma 26(6):341–347
Oken OF, Yildirim AO, Asilturk M (2017) Finite element analysis of the stability of AO/OTA 43-C1 type distal tibial fractures treated with distal tibia medial anatomic plate versus anterolateral anatomic plate. Acta Orthop Traumatol Turc 51(5):404–408
Kellam JF, Meinberg EG, Agel J, Karam MD, Roberts CS (2018) Introduction: fracture and dislocation classification compendium—2018 International Comprehensive Classification of Fractures and Dislocations Committee. J Orthop Trauma 32:S1–S0
Hak DJ (2012) Anterolateral approach for tibial pilon fractures. Orthop 35(2):131–133
Horisberger M, Valderrabano V, Hintermann B (2009) Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma 23(1):60–67
Harris AM, Patterson BM, Sontich JK, Vallier HA (2006) Results and outcomes after operative treatment of high-energy tibial plafond fractures. Foot Ankle Int 27(4):256–265
Pollak AN, McCarthy ML, Bess RS, Agel J, Swiontkowski MF (2003) Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg 85(10):1893–1900
Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C (1987) The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 7(5):290–299
Amorosa LF, Brown GD, Greisberg J (2010) A surgical approach to posterior pilon fractures. J Orthop Trauma 24(3):188–193
Chung F, Ritchie E, Su J (1997) Postoperative pain in ambulatory surgery. Anesth Analg 85(4):808–816
Kehlet H, Wilkinson RC, Fischer HB, Camu F, Prospect Working Group (2007) PROSPECT: evidence-based, procedure-specific postoperative pain management. Best Pract Res Clin Anaesthesiol 21(1):149–159
Kohring JM, Orgain NG (2017) Multimodal Analgesia in Foot and Ankle Surgery. Orthop Clin 48(4):495–505
Castillo RC, Raja SN, Frey KP, Vallier HA, Tornetta P III, Jaeblon T, Goff BJ, Gottschalk A, Scharfstein DO, O’Toole RV (2017) Improving pain management and long-term outcomes following high-energy orthopaedic trauma (Pain Study). J Orthop Trauma 31:S71–S77
McQuay HJ, Carroll D, Moore RA (1988) Postoperative orthopaedic pain—the effect of opiate premedication and local anaesthetic blocks. Pain 33(3):291–295
Sanders A, Gupta A, Jones M, Roberts M, Levine D, Drakos M, O’Malley M, Elliott A, Deland J, Ellis S, Kumar K (2017) Pain management after outpatient foot and ankle surgery. Foot Ankle Orthop 2(3):2473011417S000350
McFerran MA, Smith SW, Boulas HJ, Schwartz HS (1992) Complications encountered in the treatment of pilon fractures. J Orthop Trauma 6(2):195–200
Teeny SM, Wiss DA (1993) Open reduction and internal fixation of tibial plafond fractures: variables contributing to poor results and complications. Clin Orthop Rel Res 292:108–117
Xin T, Tang PF, Wang MY, LÜ DC, Liu MZ, Liu CJ, Yi L, Sun LZ, Huang LJ, Li Y, Zhao YG (2012) Pilon fractures: a new classification and therapeutic strategies. Chin Med J 125(14):2487–2492
Chen DW, Li B, Aubeeluck A, Yang YF, Zhou JQ, Yu GR (2014) Open reduction and internal fixation of posterior pilon fractures with buttress plate. Acta Orthop 22(1):48–53
Hasenboehler E, Rikli D, Babst R (2007) Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients. Injury 38(3):365–370
Szczęsny G, Janowicz J (2012) Minimally invasive osteosynthesis of ankle fractures. Pol Orthop Traumatol 77:145–150
Kritsaneephaiboon A, Vaseenon T, Tangtrakulwanich B (2013) Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report. Int Orthop 37(1):105–111
Vidović D, Matejčić A, Ivica M, Jurišić D, Elabjer E, Bakota B (2015) Minimally-invasive plate osteosynthesis in distal tibial fractures: results and complications. Injury 46:S96–S99
Acknowledgements
We would like to thank Aaron Leatherman, PA-C for his contributions to the data collection process that allowed us to complete this manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
IRB approval was obtained both from the St. Luke’s University Health Network IRB Committee and the Temple University School of Medicine IRB Committee. This article does not contain any studies with human participants or animals performed by any of the authors.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Malige, A., Yeazell, S. & Nwachuku, C. Surgical fixation of pilon injuries: a comparison of the anterolateral and posterolateral approach. Arch Orthop Trauma Surg 139, 1179–1185 (2019). https://doi.org/10.1007/s00402-019-03145-3
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-019-03145-3