SLR - September 2023 - DiLeo
Title: Differences in Pilon Fractures According to Ipsilateral Fibular Injury Patterns: A Clinical Computed Tomography-Based Mapping StudyReference: Lim, Jae-Hwan & Lee, Jun-Young & Kim, Ba-Rom & Jo, Suenghwan & Cha, Dong-Hyuk & Lee, Hyo-Jun & Jung, Gu-Hee. (2023). Differences in Pilon Fractures According to Ipsilateral Fibular Injury Patterns: A Clinical Computed Tomography-Based Mapping Study. Clinics in Orthopedic Surgery. 15. 10.4055/cios22187.
Level of Evidence: Retrospective Study
Scientific Literature Review
Reviewed By: Anthony R. DiLeo, DPM, MBS
Residency Program: Our Lady of Lourdes Memorial Hospital, NY
Podiatric Relevance: As foot and ankle surgeons, we need to determine the optimal approach to repair pilon fractures. The preoperative strategy must consider the severity of the articular surface injury and metaphyseal communications when dealing with these fractures. Surgical options must consider management of the fracture to restore the original length of the rotation. Thus, clarifying which fixation is biomechanically optimal requires establishing whether the fibula fracture is a result of tension or compression fracture. Many ipsilateral fibular fractures present as comminuted, transverse, oblique and/or spiral fractures demonstrating the importance of this research in further understanding the treatment approach.
Methods: This retrospective study examined radiographs and medical records of 145 patients between August 2008 and March 2019 diagnosed with a distal tibia intra-articular fracture and meeting the definition of pilon fractures. Patients younger than 18 years or older than 75 years, those with an ipsilateral talus fracture and ankle joint deformity from the previous operation and trauma, or patients where fractures were not caused by axial impaction (high-energy injury) were all excluded. Thus, 96 patients with an average age of 47 years (range of 18-74 years) were enrolled in the study. The ipsilateral fibular injury patterns were divided into three groups: (1) intact fibula /no fracture, (2) simple fracture with two fragments of either transvers, oblique or spiral fractures, and (3) multifragment fracture with three fragments or more representing segmental, wedge, and comminuted.
Results: The study demonstrated no significant difference in the lateral tibiotalar angle (varus/valgus angulation) based on fibular injury patterns. It did demonstrate the thickest comminution zone was most often located in the anterolateral quadrant and indicates more fracture patterns that percentages stipulate. The researchers observed varus angulation and valgus angulation in 52 patients (54.2%) and 44 patients (45.8%), respectively. Further, C-type fractures were more frequently noted in simple and multifragment groups rather than the intact groups using the AO/OTA classification. Of note, the most severe comminution zones of the intact and simple fracture groups were placed two grids more central than those of the multifragment fracture group. Radiographic analysis established pilon fractures were more severe in the fractured fibula group than in the intact fibula group.
Conclusions: The severity of the articular surface injury could not be established in this study. However, details noted on the comminution zone according to fibular injury patterns is instrumental for preoperative strategy of plate fixation, medial vs. anterolateral plate fixation. As a foot and ankle surgeon, this study is beneficial in illustrating optimal approaches and definitive plate fixation. As such, understanding the comminuted zone of pilon fractures based on fibular injury patterns impacts the patient prognosis.