A systematic review of posterior pilon fractures

Abstract

Posterior pilon fractures (PPFs) are intra-articular ankle injuries of the posterior aspect of the distal tibia, often caused by high-energy mechanisms of trauma such as falling from high heights or motor vehicular accidents. However, the definition, mechanism, classification, and surgical approach for fractures have not been thoroughly investigated. This study aims to explore current literature to expand the understanding of this fracture to help physicians achieve better treatment outcomes. Keywords such as “posterior pilon,” “surgical approach,” “fracture,” etc., were used to find relevant literature on PubMed, MEDLINE, Embase, and the Web of Science. Inclusion criteria involved studies discussing PPFs and retrospective and prospective cohort studies. Exclusion criteria included non-English-published papers, anatomical or biomechanical studies, and studies not discussing PPFs. General demographics, complications, and the American Orthopaedic Foot and Ankle Society (AOFAS) functional outcome scores were collected. A total of 18 publications were selected for data collection, most of which were retrospective studies. The articles discussed 959 (Male: 430, Female: 529) patients. PPFs are defined as distal tibia fractures involving impaction of the articular surface and proximal displacement of talus and posterior malleolus fragments. This characteristic fracture is caused by high-energy rotational and axial load. Five studies in this review describe a classification system for ankle fractures that include studies from Klammer (2013), Bartoníček (2015), Mason (2017), Zhang (2018), and Wang (2020). The posterolateral (PL) approach was used in 34.9 % of cases, followed by the posteromedial (PM) in 7.9 %, modified PM in 20.7 %, and combined PM and PL approach in 6.9 % of cases. PPFs are breaks that occur in the posterior half of the articular surface of the distal tibia, typically affecting the weight-bearing area. These fractures result from a combination of rotational and axial loads, leading to intra-articular ankle fractures that often involve a sizeable posterior fragment. Five classification systems for PPFs identify characteristics observable in X-rays, CT scans, or through morphological analysis. The posterolateral (PL) approach was used more than the posteromedial approach. Common complications included malreduction, nerve injuries, and post-operative pain.

Level of Evidence: III.