Fractures of the Tibial Plafond: Does the Presence or Absence of a Fibular Fracture Predict Future Morbidity?

Abstract

Category: Trauma; Ankle Introduction/Purpose: Surgical management pilon fractures continue to be a challenge for orthopedic surgeons. Despite a staged protocol, anatomic reduction, and stable fixation, many patients will require secondary procedures including ankle arthrodesis to treat painful post-traumatic arthritis. Some investigators have correlated the absorbed energy at the time of the injury with the natural history of the pilon fracture despite the quality of the surgical reconstruction. We hypothesize that the presence of an intact fibula in association with an OTA Type C pilon fracture may be a marker for a strict axial compression mechanism resulting in more severe cartilage compression and a poor late outcome. No studies to date have correlated the presence of an intact fibula to pilon fracture outcomes. Methods: An IRB approved 7-year retrospective study was performed at three Level I Trauma Centers. Inclusion criteria included all adult patients (>=18) with isolated OTA type B or C pilon fractures from 2008 through 2014. All patients were treated in a staged fashion with initial external fixation by fellowship-trained orthopedic traumatologists. The primary outcome measurement was ankle arthrodesis. Secondary measurements included infection. Binary logistic regression models were used to evaluate the prognostic factors of arthrodesis and infection. Results: A total of 239 patients met inclusion criteria for analysis: 33-patients (13.81%) had open injuries, 155 (64.85%) had a C type pilon fracture and 157 fractures (65.69%) presented with an associated fibula fracture. Only 12 patients (5.02%) progressed to ankle arthrodesis. The incidence of fusion in the intact fibula group was 5 (6.10%) similar to that of 7 (4.46%) of patients with an associated fibula fracture. It was found that OTA Type C pilon fractures (OR (95% CI): 6.34 (0.80, 49.98), p=0.08), intact fibulas (OR (95% CI): 1.39 (0.43, 4.53), p=0.58), and open injuries (OR (95% CI): 2.19 (0.56, 8.55), p=0.26) were more likely to result in eventual arthrodesis compared to OTA Type B pilon fractures, fractured fibulas, and closed injuries, respectively. Conclusion: The results of this study suggest an adverse relationship for closed complex pilon fractures with an intact fibula. This was especially pronounced in C type injuries in comparison to type B injuries with a 6.34 odds ratio of subsequent fusion. The data approached statistical significance and may have clinical relevance in the decision making and patient counselling for managing these fractures. Pilon fractures historically have had poor outcomes and a higher rate of secondary surgeries which was surprisingly low in our current study. Further study needs to determine if this observation correlates with improved patient outcomes.