Foot & Ankle International - June 2017 - 650

695348

FAIXXX10.1177/1071100717695348Foot & Ankle InternationalBusel et al

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Article
Foot & Ankle International®
2017, Vol. 38(6) 650-655
© The Author(s) 2017
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https://doi.org/10.1177/1071100717695348
DOI: 10.1177/1071100717695348
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Evaluation of Fibular Fracture
Type vs Location of Tibial
Fixation of Pilon Fractures

Gennadiy A. Busel, MD1, J. Tracy Watson, MD1, and Heidi Israel, PhD1

Abstract
Background: Comminuted fibular fractures can occur with pilon fractures as a result of valgus stress. Transverse fibular
fractures can occur with varus deformation. No definitive guide for determining the proper location of tibial fixation exists.
The purpose of this study was to identify optimal plate location for fixation of pilon fractures based on the orientation of
the fibular fracture.
Methods: One hundred two patients with 103 pilon fractures were identified who were definitively treated at our
institution from 2004 to 2013. Pilon fractures were classified using the AO/OTA classification and included 43-A through
43-C fractures. Inclusion criteria were age of at least 18 years, associated fibular fracture, and definitive tibial plating.
Patients were grouped based on the fibular component fracture type (comminuted vs transverse), and the location of plate
fixation (medial vs lateral) was noted. Radiographic outcomes were assessed for mechanical failures.
Results: Forty fractures were a result of varus force as evidenced by transverse fracture of the fibula and 63 were due
to valgus force with a comminuted fibula. For the transverse fibula group, 14.3% mechanical complications were noted for
medially placed plate vs 80% for lateral plating (P = .006). For the comminuted fibular group, 36.4% of medially placed plates
demonstrated mechanical complications vs 16.7% for laterally based plates (P = .156). Time to weight bearing as tolerated
was also noted to be significant between groups plated medially and laterally for the comminuted group (P = .013).
Conclusions: Correctly assessing the fibular component for pilon fractures provides valuable information regarding
deforming forces. To limit mechanical complications, tibial plates should be applied in such a way as to resist the original
deforming forces.
Level of Evidence: Level III, comparative study.
Keywords: pilon, distal tibia, fracture pattern, distal tibia plate

Introduction
Pilon fractures occur as a result of high-energy axial loading in which the talus impacts the distal part of the tibia.
These fractures account for less than 10% of all fractures of
the lower extremity.1,9 Over the last 100 years, the management of this complex fracture has changed drastically. From
Ruedi and Allgower introducing the classification system
and basic treatment principles to Sirkin and Peterson stressing the importance of soft tissues in fracture healing, the
success rates have slowly improved.17,18,20 Nonetheless,
decades later, outcomes after open reduction internal fixation (ORIF) continues to be average at best, with only 25%
to 66% of patients experiencing good results after highenergy trauma.7,10,16,21
Better understanding of the role of soft tissues in fracture healing has led to numerous technological advancements. Evaluation of the soft tissue envelope became one
of the major determinants for an operative approach,

together with fracture pattern and surgeon's preference.1
Although some studies are encouraging, we continue to see
high rates of complications associated with fixation of this
complex fracture.3,4,11,13,15 We propose standardization of
treatment based on the evaluation of the fibular component
as a major determinant for location of plate placement during operative fixation.
The importance of fibular evaluation is well documented
in treatment of pilon fractures and makes up one of the basic
treatment principles discussed by Ruedi and Algower.18
Comminuted fibular fractures are known to occur as a result
1

Department of Orthopaedic Surgery, Saint Louis University School of
Medicine, Saint Louis, MO, USA
Corresponding Author:
Gennadiy A. Busel, MD, Department of Orthopaedic Surgery, Saint
Louis University School of Medicine, 3635 Vista Avenue, 7th Floor
Desloge Towers, St Louis, MO 63110, USA.
Email: gbusel@slu.edu

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