Foot & Ankle International - June 2017 - 651

Busel et al
of valgus stresses, whereas transverse fractures of the fibula
are seen with varus angulation.1,19 Although multiple force
vectors act at the time of injury, resulting in a diverse group
of fractures, the 2 most common plate locations used to
resist those forces are medial and anterolateral. Even though
the location of plating has been debated, no definitive protocol exists. In a review paper, Sirkin briefly mentions
assessment of the fibular fracture for location of tibial plate
placement to resist forces originally seen at the time of
injury; however, no research supports this claim.19 Yenna
et al performed a biomechanical study with the use of sawbones to evaluate the strongest plate construct and concluded no difference between medial vs lateral plating.23
The main limitations of their biomechanical study were the
use of sawbone tibiae and absence of the fibular and soft
tissue components, which we believe play a crucial role in
stabilization of the fracture. Although several papers
describe use of a specific operative approach,6 we were not
able to find any research evaluating differences between
medial vs lateral plating of the pilon fracture based on the
fibular component other than that mentioned above. Our
current study attempts to answer whether plate fixation on
the lateral side for valgus fractures and on the medial side
for varus mechanisms of fracture would demonstrate better
results, including fewer mechanical complications and
hardware failures.

Methods
This was a retrospective case study undertaken at a single
tertiary referral center with multiple, trauma-trained surgeons. After obtaining institutional review board approval,
we identified 407 patients with distal tibial fractures who
were seen primarily or referred to our tertiary care center
from July 2004 to June 2013. Patients were initially identified based on CPT codes for pilon fractures and distal onethird tibial shaft fractures to minimize loss of patients based
on coding error. We defined tibial pilon fractures according
to AO/OTA classification and included 43-A through 43-C
fracture patterns. Inclusion criteria were age of 18 years or
older, associated fibular fracture, and definitive treatment
with a plate. We excluded patients whose presenting radiographs were outside of the parameters of the AO/OTA classification as discussed above, those with isolated tibial
fractures without a fibular component, patients with less
than 6 months' follow-up, dual plating, or patients requiring
amputation prior to definitive fixation. After application of
exclusion criteria, the final data set included 103 fractures
in 102 patients (51men and 51 women) with >6 months'
follow-up, of which 80 patients (42 men and 38 women)
with 81 fractures had >1 year's follow-up. The fibula was
fixed in 87 patients, with 58 patients (92.1%) having the
fibula fixed in the valgus group and 29 patients (72.5%)
having the fibula fixed in the varus group.

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Medical records and radiographs were reviewed to determine the patient's age, sex, weight, mode of injury, fibular
fracture type at the level of the joint only (comminuted or
transverse) and tibial fracture orientation, plate location
(medial or lateral), fixation of the fibula (if any), location of
open wound (if any), time to definitive fixation, smoking
status, time to full weight bearing as decided by the treating
surgeon, total follow-up, and complications. We chose to
separate complications into 2 categories, mechanical and
wound related. Mechanical complications were defined as
hardware failure, nonunion, delayed union, and malunion.
Nonunion was defined as lack of bony bridging more than 9
months after definitive fixation with failure of callus progression on subsequent radiographs for 3 consecutive
months. This was confirmed by radiographs, computed
tomographic (CT) scan, or both if concerns for union persisted. Delayed union was defined as failure of cortical
bridging of at least 75% of the cortical diameter but with
progressive increase in callus on subsequent radiographs,
CT scan, or both past 6 months after fixation. Patients with
routine healing were not subject to CT scans. Wound complications consisted of wound dehiscence, persistent drainage, and deep infections. Wound-related complications
were grouped together whether or not they required secondary unplanned surgery or treated with local wound care and
antibiotics. Superficial cellulitis was not included as a
complication.
After data gathering was completed, patients were separated into 2 groups based on duration of follow-up. Group A
with >1 year of follow-up (n = 81) and group B with >6
months but <1 year of follow-up (n = 22).

Data Analysis
Fracture types were separated based on the fibular component into transverse (varus deforming force) and comminuted (valgus deforming force). To properly analyze the
data, the 2 groups were further subdivided based on the
location of the plate. Transverse fractures were divided into
transverse-medial plating and transverse-lateral plating
groups. Similarly, comminuted fractures were divided into
comminuted-medial plating and comminuted-lateral plating
groups. Clinical outcomes were compared for group A independently, as well as both groups (A and B) together using
a Fisher exact test for nominal data and t test for continuous
variables. P values <.05 were considered significant.

Results
In the transverse fracture group (varus) (n = 40), 35 were
plated medially (87.5%) and 5 were plated laterally (12.5%).
Mechanical complications were seen in 9 patients (22.5%).
Five of 35 patients (14.3%) who were plated medially
(Figure 1) presented with mechanical complications;

Table of Contents for the Digital Edition of Foot & Ankle International - June 2017