SLR - August 2016 - Benjamin Elgamil

Does the Fibula Need to Be Fixed in Complex Pilon Fractures?

Reference: Kurylo JC, Datta N, Iskander KN, Tornetta P. Does the Fibula Need to be Fixed in Complex Pilon Fractures? (2015). Journal of Orthopaedic Trauma, 29(9), 424–427.

Scientific Literature Review

Reviewed By: Benjamin Elgamil, DPM
Residency Program: Aria Health System

Podiatric Relevance: Classic dogma in pilon fracture management recommends staged reconstruction. The first stage is performed just after the time of injury to restore and stabilize the ankle joint congruency with external fixation. When the soft-tissue envelope allows for definitive fixation, the choice for open reduction, internal fixation (ORIF) is made to restore the anatomic figure of the tibia and fibula. This study investigated if radiographic parameters and clinical outcomes improved with fixation of the fibula in nonrotational pilon fractures.

Methods: A retrospective case-control study was performed on 93 patients with metadiaphyseal, nonrotational pilon fractures after undergoing tibial ORIF. These patients concomitantly received one of three subsequent treatment strategies: (1) 26 patients had fibula ORIF; (2) 37 patients did not have fibula ORIF but was reduced with prolonged external fixation; (3) 30 patients were a control where the fibula was not fractured. There was no statistical difference comparing the degree of comminution or fracture location within each group. Prereduction, immediate postoperative and last follow-up radiographs were compared to analyze the tibial ankle surface angle. Categorical data also compiled for patient complications in each group.

Results: The majority of patients suffering a nonrotational metadiaphyseal pilon fracture went into valgus at presentation (30 patients) compared to those with a varus position (23 patients). There was no statistical difference in the postoperative reduction between those patients receiving fibula ORIF versus definitive treatment with external fixation. Only one patient receiving fibula ORIF had a loss of alignment >5 degrees while no patients receiving only external fixation. The complications seen in the patients receiving fibula ORIF (11/26) were higher than those who did not receive fibula ORIF (3/37). The most notable of which was having to remove hardware in 5 of the 26 patients in that group.

Conclusions: Through this study, the authors were able to justify their hypothesis that fibula ORIF is not imperative after a patient suffers a metadiaphyseal, nonrotational pilon fracture. This study was not without limitations, which further investigations should examine patient function and satisfaction. Additionally, the majority of pilon fractures presenting to this institution were rotational in nature, and the authors still recommend fibula ORIF in that patient population. 

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