Clinical Outcomes for Pilon Variant Posterior Malleolar Fractures: A Multicenter Retrospective Analysis.

ABSTRACT

Currently, there is no consensus on surgical approach for posterior malleolar fracture fragments with significant posteromedial involvement. The Bartonicek type III/Haraguchi type II posterior malleolar morphologies typically involve large posteromedial fragments, behaving like a pilon injury and have been reported as pilon variant fractures. We performed a retrospective chart review at 2 large healthcare institutions, evaluating patients that underwent surgical management of pilon variant posterior malleolar fractures and determining clinical outcomes including time to union, union rates, soft tissue complications, infection and time to weight bearing. A total of 68 patients were included (51 females, 17 males). A total of 51 direct (19 posterolateral, 31 posteromedial), 6 indirect, and 11 no-fixation approaches were identified. Significantly different time-to-union was found between direct fixation (mean = 85.1 days), indirect fixation (mean = 74 days) and no-fixation (mean = 174.3 days) (p < .001). A posteromedial approach (mean = 63.0 days, SD = 16.6) was associated with significantly shorter time to union when compared to a posterolateral approach (mean = 124.8 days, SD = 59.4; p < .001). Fixation (direct or indirect) was associated with significantly increased likelihood of union of the overall ankle fracture pattern (52/57 = 91%) when compared to no fixation of the posterior malleolar component (9/14 = 64%), p = .01. Patients who underwent direct fixation had significantly lower incidence of neurovascular damage (6%) when compared to patients who underwent indirect fixation (33%) or no-fixation (29%) (p = .02). There was no significant difference between the groups in terms of tendon damage (p = .54), infection rates (p = .45) and time to weight bearing (p = .66). The authors suggest that surgical management and specifically direct approaches have better outcomes in the short-term follow up.