SLR - January 2020 - Lewis A. Kane
Reference: Chaparro F, Ahumada X, Urbina C, Lagos L, Vargas F, Pellegrini M, Barahona M, Bastias C. Posterior Pilon Fracture: Epidemiology and Surgical Technique Injury. 2019 Dec;50(12):2312-2317Scientific Literature Review
Reviewed By: Lewis A. Kane, DPM, MS
Residency Program: Kaiser SF Bay Area Foot & Ankle Surgery – Oakland, CA
Podiatric Relevance: Posterior pilon variant ankle fractures—those with medial extension of the posterior malleolar fragment—have recently garnered increased attention due to their associated poor prognosis. These fractures have increased involvement of the plafond, which necessitates anatomic reduction and stabilization. In this article, the authors document a consecutive series of patients suffering these injuries and offer a technical guide to the evaluation and treatment of these injuries. In addition, they report early outcomes and potential pitfalls associated with this particular fracture pattern.
Methods: This retrospective study reviewed 187 consecutive rotational ankle fractures receiving operative management. Of these, a subset of 25 posterior pilon variants was identified. Most were treated through a modified posteromedial approach following fibular fixation. Most patients (19/25) underwent immediate postoperative CT scanning to assess anatomic reduction (defined as less than 2 millimeter fracture displacement). All complications occurring within one year of follow up were documented. Descriptive statistics are reported.
Results: The 13.4 percent of ankle fractures undergoing open reduction with internal fixation during the study period had posteromedial fragments. Of this subset, the majority (68 percent) suffered supination-external rotation type injuries. Four of 19 fractures with postoperative CT imaging were not anatomically reduced; all cases were due to inadequate reduction of the posterolateral fragment. Nearly half (44 percent) of posterior pilon fractures required syndesmotic fixation. The short-term complication rate of the posterior pilon subset was 28 percent, including superficial infection, osteoarthritis and nonunion.
Conclusions: The authors offer few conclusions from their data but do note that these challenging fractures may be successfully treated with a modified posteromedial approach. They highlight the high incidence of residual syndesmotic instability despite fracture stabilization, and postulate that this may be due in part to inadequate reduction of the Volkmann fragment. The article serves as a valuable technique guide for treating the posterior pilon variant fracture, and it provides several surgical pearls to improve patient outcomes.