Comparison of radiographs and CT features between posterior Pilon fracture and posterior malleolus fracture: a retrospective cohort study

A systematic review of posterior pilon variant fractures

Posterior pilon variant ankle fractures (PPVF) are a unique subtype of posterior malleolar fractures which have been a source of controversy and confusion in recent years. There has not been a thorough literature review previously written on the topic. Database searches of PubMed and Embase were conducted from inception until June 2023. The key words included "pilon variant," "posterior pilon variant," and "posterior pilon" fractures. Outcomes were evaluated by union time, rates of delayed union, nonunion, malunion, and complication. A total of 15 articles relevant to surgical repair of pilon variant fractures were included in the literature review. The unique mechanism of injury has been reported to involve both rotational and axial forces, leading to involvement of the posterior and medial aspects of the distal tibia. Pilon variant fractures can be suspected by several characteristics on radiographs and have a high confirmation rate via CT images. Multiple systems have been proposed to classify this fracture pattern, but there is no consensus on the ideal classification system. Surgically, direct fixation has shown better short-term clinical outcomes versus indirect fixation or no fixation. PPVF have a distinct fracture pattern involving the posterior and medial columns of the distal tibial plafond, and results from a mechanism intermediate to rotational and axial forces. These fractures are more severe than tri-malleolar fractures due to increased rates of articular impaction and incongruity. Future classification systems should focus on joint surface area and the tibial pilon column involved to avoid confusion with less severe posterior malleolar fractures.

Computed tomography changes diagnosis, management and surgical planning of ankle fractures

PURPOSE

To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation.

MATERIALS AND METHODS

A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning.

RESULTS

The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75).

CONCLUSIONS

The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care.

LEVEL OF EVIDENCE III

Retrospective Comparative Study.

Classifications of posterior malleolar fractures: a systematic literature review

INTRODUCTION

Complex ankle fractures frequently involve the posterior malleolus. Many classifications describing posterior malleolar fractures (PMF) exist. The aim of this study was to provide a systematic literature review to outline existing PMF classifications and estimate their accuracy.

METHODS

The databases PubMed and Scopus were searched without time limits. Only specific PMF classifications were included; general ankle and/or pilon fracture classifications were excluded. Selection and data extraction was performed by three independent observers. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score.

RESULTS

A total of 110 studies with a total of 12.614 patients were included. Four main classifications were identified: Those describing the size of the posterior malleolar fracture (n = 66), Haraguchi (n = 44), Bartoníček/Rammelt (n = 21) and Mason (n = 12). The quality of the studies was moderate to good with a median Coleman-score of 43.5 (14-79) and a weighted median Coleman-score of 42.5 points. All classifications achieved a substantial to perfect score regarding the inter- and intraobserver reliability, with Mason scoring the lowest in comparison.

CONCLUSIONS

None of the reviewed PMF classifications has been able to establish itself decisively in the literature. Most of the classifications are insufficient in terms of a derivable treatment algorithm or a prognosis with regard to outcome. However, as the Bartoníček/Rammelt classification has the greatest potential due to its treatment algorithm, its reliability in combination with consistent predictive values, its usage in clinical practice and research appears advisable.

Outcomes of tibial pilon fracture fixation based on four-column theory

OBJECTIVES

To assess the medium-term functional and radiological outcomes, as well as injury mechanisms, fracture patterns and demographics of typical pilon fractures and pilon variant fractures treated based on the four-column theory in adults.

METHODS

A retrospective comparative study was performed. Demographics of typical pilon and pilon variant fractures, injury mechanisms, OTA/AO classification, Rüedi-Allgöwer and the four-column classification were analyzed for the cohort. Radiographic ankle arthrosis (modified Kellgren-Lawrence 3/4), Burwell Charnley Score, and AOFAS score were also analyzed.

RESULTS

There were 142 pilon fractures met the inclusion and exclusion criteria for this study, of which 77(54.23%) were females and 65 (45.77%) were males, with an average of 48 (range, 18-86)years. One hundred twenty-five posterior columns fractured in 142 pilon fractures, and the posterior columns were most prone to fractures. Ninety cases of posterior pilon fractures in 142 pilon fractures were single posterior column fractures with or without medial or lateral malleolar fractures. The average age (51, range, 18-86 years) of low-energy pilon fractures was older than the average age (42, range, 19-66 years) of high-energy pilon fractures significantly. The average time (5, range, 0-17 days) from injury to definitive internal fixation of the low-energy group was shorter than the average time (9, range, 0-21 days) from injury to definitive internal fixation of the high-energy group significantly. The average of AOFAS (87, range, 56-100) of the low-energy group is higher than the average of AOFAS (82, range, 47-100) of the high-energy group significantly. There were more male patients and more die-punch or intercalary fractures in high energy groups significantly. There were more medial and lateral malleolar fractures in low-energy groups. Compared with the non-multiple column group, the multiple-column group had more Rüedi-Allgöwer type III cases, more modified Kellgren-Lawrence 3/4 cases and lower AOFAS score significantly. However, the numbers of Burwell Charnley Score type 1 and 2 cases were not significantly different between the two groups.

CONCLUSIONS

Kinds of pilon variants should be recognized. Outcomes of high-energy pilon fractures were worse than low-energy pilon fractures. The four-column theory can be applied to typical pilon fracture and pilon variants in adults.

A Current Concepts Update in Pilon Fracture Management

A review of the existing literature, related to treatment options and management principles of pilon fractures, was performed, and its results are presented. Pilon fractures have a very diverse pattern, but there are general characteristics to help diagnose and plan therapy. The choice of therapy is highly dependent on the surrounding soft-tissue environment. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopedic surgeon can face. This review focuses on the general aspects of the pilon fracture management as well as its complications and possible solutions.

Posterior pilon fracture treated by opening the fibula fracture gap

Background

Posterior pilon fracture is a relatively common clinical fracture involving the posterior articular surface of the distal tibia. Currently, this form of fracture is receiving increasing attention. The surgical approach and technique for the treatment of posterior pilon fractures are still controversial. The purpose of this retrospective study was to compare the clinical and imaging outcomes of pilon fractures after treatment with the open fibula fracture line (OFFL) surgical technique versus the traditional posterolateral approach (TPL).

Methods

A retrospective analysis of patients with posterior pilon fractures treated using the open fibula fracture line technique and the traditional posterolateral approach between January 2015 and March 2020. Thirty-one cases were included in the open fibula fracture line technique group and twenty-eight cases were included in the traditional posterolateral approach group. We used the Burwell-Charnley scale to assess the effectiveness of surgical repositioning. The clinical outcomes were evaluated using American Orthopaedic Foot & Ankle Society ankle-hind foot score (AOFAS) and visual analog score (VAS).

Results

The overall anatomic reduction rate was slightly better in the open fibula fracture line group than in the conventional posterolateral group (81% vs. 71%, p = 0.406), but there was no statistically significant difference between the two groups. There were no statistically significant differences between the two groups in terms of fracture healing time and time to full weight bearing (p > 0.05). At the final follow-up, the AOFAS functional score of the open fibula fracture line group was statistically superior to that of the conventional posterolateral group (p < 0.05). However, there was no statistical difference between the two groups in VAS pain scores at rest, during activity, and under weight bearing (p > 0.05).

Conclusion

The trans-fibular fracture approach provides a better surgical option for specific types of posterior pilon fractures with a high rate of anatomic repositioning and a good near-term outcome.

Trial registration: Retrospective registration.