• John Ketz and Roy Sanders.
• Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY 14642, USA. john_ketz@urmc.rochester.edu
• J Orthop Trauma. 2012 Jun 1;26(6):341-7.

ObjectiveObtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures.DesignProspective clinical cohort.SettingA Level I trauma and tertiary referral center.Patients/ParticipantsFrom January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months).InterventionAll patients were treated with open reduction and internal fixation for their pilon fractures.Main Outcome MeasurementsQuality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications.ResultsThere were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group.ConclusionsThe addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.

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