Poor Outcomes After Anterior Impaction Pilon Fractures

Sally Jo, MD; Justin Tilan, MD; Christopher McAndrew, MD, MSc; Anna N. Miller, MD, FACS

Disclosures

J Am Acad Orthop Surg. 2022;30(1):19-26. 

In This Article

Abstract and Introduction

Abstract

Introduction: Pilon fractures occur through high-energy axial-loading trauma and are frequently associated with complications. The goal of this study was to assess whether anterior impaction (AI) tibial pilon fractures are associated with increased rates of posttraumatic osteoarthritis (PTOA), secondary surgeries, and lower patient-reported outcomes compared with patients with non-AI pilon fractures.

Methods: In this retrospective cohort study, 52 pilon fractures in 50 patients were included. The average follow-up was 25 months (range, 12 to 62 in non-AI and 12 to 66 in AI). The Kellgren and Lawrence (KL) score for PTOA, tibiotalar ratio for anterior-posterior talar subluxation, coronal tibiotalar angle, Patient-Reported Outcomes Measurement Information System score, and rates of secondary surgeries and infection were assessed.

Results: The AI group showed radiographic evidence of more advanced PTOA at the final follow-up (KL score 3.1 vs. 2.5, P = 0.021) and a higher rate of implant removal for pain (39% vs. 13%, P = 0.030). AI also had greater anterior talar subluxation on preoperative (P < 0.001) and final follow-up radiographs (P = 0.026). A higher KL score was associated with greater anterior talar displacement on preoperative (r = −0.421, P = 0.003) and final follow-up radiographs (r = −0.359, P < 0.009). No differences were seen in 1-year Patient-Reported Outcomes Measurement Information System scores.

Discussion: AI pilon fractures are associated with recurrent anterior talar subluxation, more severe PTOA, and a higher rate of implant removal for pain compared with non-AI fractures.

Introduction

Pilon fractures comprise approximately 3 to 7% of tibial fractures and less than 1% of all lower extremity fractures.[1–3] These fractures occur through high-energy axial-loading trauma, such as motor vehicle crashes and falls that lead to impaction of the distal tibial articular surface and disruption of the soft-tissue envelope. Given these injury characteristics, patients with pilon fractures are at a high risk of developing posttraumatic osteoarthritis (PTOA), nonunion, malunion, soft-tissue infection, and osteomyelitis,[1,4–6] leading to a high rate of secondary surgeries and poor long-term outcomes.[5]

The pattern of pilon fractures varies depending on the foot position and direction of impact. Fractures with impaction to the anterior plafond are produced through axial loading on a dorsiflexed foot. In a study assessing the injury mechanism of pilon fractures, anterior split-type fractures were caused by falls from a greater height than posterior split-type fractures, suggesting that the former fracture pattern occurs through a mechanism involving greater "energy transfer."[7] However, there are no previous studies that investigate the outcomes of patients with anterior impaction (AI) pilon fractures.

This study aimed to examine whether AI pilon fractures affect patients' outcomes and recovery. We hypothesized that patients with AI pilon fractures (AO/OTA 43 B and C) have increased rates of PTOA, secondary surgeries, and lower patient-reported outcomes compared with patients with non-AI pilon fractures.

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