Surgical Fixation of Pilon Injuries: A Comparison of the Anterolateral and Posterolateral Approach

SLR - November 2019 - Alexa Ray Santomero

Residency Program: Cooper University Hospital - Camden, NJ

Podiatric Relevance: Pilon fractures were first described in 1911 and to this day are one of the most challenging fracture types to treat. Although their incidence in lower extremity fractures is less than 1 percent, they are nevertheless notorious for high complication rates, poor outcomes, and potentially devastating long-term effects on patients’ ability to ambulate functionally and without pain. The challenging nature of this fracture type pushes physicians to refine their skills and to remain continually educated in order to choose the most appropriate procedure for each patient, for the best possible outcome. This study seeks to compare operative, post operative, and patient reported outcomes between Pilon fractures operated on using an anterolateral approach versus a posterolateral approach.

Methods: This was a therapeutic level IV study in which 135 charts of patients who were surgically treated for Pilon fractures were retrospectively reviewed. 44 patients treated by 10 orthopedic surgeons with average follow-up of 3.7 years were included in the study. Anterolateral approach was utilized for 32 (72.7 percent) patients, and posterolateral approach was utilized for 12 (27.3 percent) patients. 65.9 percent of patients were greater than 40 years of age, and 63.6 percent were male. Operative outcomes reviewed included tourniquet time, OR time, and estimated blood loss. Recorded patient outcomes were NRS pain scores, Focus on Therapeutic Outcome (FOTO) scores, range of motion, and postoperative opioid medication use. Patient demographics, fracture description, surgical intervention timeline, operative and patient outcomes, and complication rates were recorded. Data analysis methods included simple descriptive statistics, Mann–Whitney rank sums test, and the chi-square test.

Results: There was a statistically similar amount of time between the occurrence of injury and surgical treatment between the anterolateral approach group and the posterolateral approach group. The two groups also had a statistically similar length of hospital stay. There was no statistical difference in tourniquet time, OR time, or estimated blood loss. Patients within the two groups showed a statistically similar decrease in NRS pain score, and statistically similar change in FOTO scores. During the follow up period, they showed a statistically similar active range of motion and inversion/eversion axis. There was no statistically significant difference in complication rates. There was, however, a statistically significant difference in the amount of opioid pain medication used between the two groups: the posterolateral approach group used significantly more post-operative opioid pain medication (average = 6758.0 milimorphine equivalents) than the anterolateral approach group (average = 6612.3 milimorphine equivalents).

Conclusions: The study shows that both anterolateral and posterolateral approach for Pilon fracture fixation can be successfully utilized with no statistically significant difference in operating room course, patient outcomes, and complication rates. The study theorizes that the significant difference in medication use between the two groups is due to the more complicated nature of a posterolateral approach. Study limitations include small sample size, demographics biased towards a male population greater than 40 years of age, lack of consistency in the documentation of standardized outcome scores, as well as the retrospective nature of a study utilizing chart review for data.