SLR - November 2015 - Hima Patel

Optimal Management of High-Energy Pilon Fractures

Reference: Chan R, Taylor BC, Gentile J. Optimal Management of High-Energy Pilon Fractures. Orthopedics. 2015 Aug 1; 38(8):e708–e714.

Scientific Literature Review

Reviewed by: Hima Patel, DPM
Residency Program: Hoboken University Medical Center

Podiatric Relevance: Pilon fractures occur at the distal tibial epiphysis and pose many challenges due to the complex nature of the injury. The main determinants that influence the outcomes of these fractures include mechanical axis alignment, articular surface restoration, fracture stabilization, and soft tissue management. A multitude of treatment strategies have been utilized in an attempt to achieve a successful outcome. Such surgical modalities include delayed single-stage approaches, external fixation only, external fixation with limited articular reduction and fixation, and two-stage reconstruction. Studies have portrayed complication rates related to each of these approaches, which then lead to the development of staged protocols. There still, however, exists a controversy regarding the fixation of fibular fractures associated with these high-energy pilon fractures. Thus, the aim of this study was to establish whether presence or timing of fibular fixation can impact outcomes.

Methods: This is a retrospective study that involved 83 patients with 85 pilon fractures. The patients were treated by one of six orthopaedic trauma surgeons at a Level 1 trauma center. Eight-two percent of pilon fractures were treated with initial external fixation, whereas the remaining patients were treated with an initial period of splint immobilization, followed by definitive fixation once the soft tissue was optimized. Patients with associated distal fibular fractures underwent intramedullary pin or plate-and-screw fixations either at the time of external fixation (temporization phase) or during the definitive fixation phase of the pilon fracture. The average follow-up was 18.7 months. Patients were divided into two groups: Group A consisted of 25 patients who did not undergo fibular fixation and Group B consisted of 60 patients who did. Group B was then subdivided into two more groups (C and D), depending on the timing of the fibular fixation. Group C consisted of 15 patients who went distal fibular fixation along with external fixation during the initial temporization phase. Group D, on the other hand, consisted of 45 patients who underwent distal fibular fixation during the definitive fixation stage of the pilon fracture.

Radiographic union was characterized by the presence of a bridging callus on three or more cortices using a minimum of two orthogonal views. Clinical union was characterized by the absence of pain and the ability to bear full weight on the ipsilateral extremity without pain. Coronal plane malalignment was defined as angulation of 5 degrees or greater. Sagittal plane malalignment was classified as angulation of 10 degrees or greater. Other post-operative variables, such as presence of wound dehiscence, deep or superficial infection, and tibial and fibular hardware failure were also taken into consideration throughout the follow-up period.

Results: When comparing Group A (no fibular fixation) with Group B (fibular fixation), they were similar in all demographic areas, with the exception of increased tobacco use in Group A. The only significant difference between the two groups was an increase in operative time (29 minutes) in the fibular fixation group, as expected. Moreover, all post-operative variables between the two groups were also similar.

When comparing Group A (no fibular fixation) with Group C (early fibular fixation), all intra-operative variables were similar, except for increased operative time in Group C.  The operative time for definitive fixation was similar between both groups. Furthermore, there was no statistically significant difference in the post-operative variables for both groups. There was, however, a higher rate of tibial implant removal in Group C. Group A (no fibular fixation) and Group D (late fibular fixation) were both similar in demographic, intra-operative and post-operative variables. The only difference between the two groups was the expected increase in operative time during definitive fixation in Group D. When comparing Group C (early fibular fixation) with Group D (late fibular fixation), there was a longer operative time during temporization in Group C. However, all other intra-operative and post-operative variables remained similar.

Based on their findings, the authors have concluded that fibular fixation during any phase of pilon fracture treatment had no effect on the alignment, healing of the fracture, or the complication rate. Fibular fixation did, however, increase operative time. Furthermore, the overall healing rates were similar regardless of the presence or absence of fibular fixation. The authors also found that early fibular fixation did not influence alignment, healing or complication rates when compared to late fibular fixation. Early fibular fixation also did not significantly decrease operative time during definitive fixation of pilon fractures. Thus, neither the presence nor the timing of fibular fixation significantly changes the radiographic outcomes or complication rates of high-energy pilon fractures. Given these findings, it can be gathered that whether early, late, or no fibular fixation is done, successful outcomes can be achieved as long as general fracture treatment principles are implemented.

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