Outcomes of tibial pilon fracture fixation based on four-column theory



      To assess the medium-term functional and radiological outcomes, as well as injury mechanisms, fracture patterns and demographics of typical pilon fractures and pilon variant fractures treated based on the four-column theory in adults.


      A retrospective comparative study was performed. Demographics of typical pilon and pilon variant fractures, injury mechanisms, OTA/AO classification, Rüedi-Allgöwer and the four-column classification were analyzed for the cohort. Radiographic ankle arthrosis (modified Kellgren-Lawrence 3/4), Burwell Charnley Score, and AOFAS score were also analyzed.


      There were 142 pilon fractures met the inclusion and exclusion criteria for this study, of which 77(54.23%) were females and 65 (45.77%) were males, with an average of 48 (range, 18-86)years. One hundred twenty-five posterior columns fractured in 142 pilon fractures, and the posterior columns were most prone to fractures. Ninety cases of posterior pilon fractures in 142 pilon fractures were single posterior column fractures with or without medial or lateral malleolar fractures. The average age (51, range, 18-86 years) of low-energy pilon fractures was older than the average age (42, range, 19-66 years) of high-energy pilon fractures significantly. The average time (5, range, 0-17 days) from injury to definitive internal fixation of the low-energy group was shorter than the average time (9, range, 0-21 days) from injury to definitive internal fixation of the high-energy group significantly. The average of AOFAS (87, range, 56-100) of the low-energy group is higher than the average of AOFAS (82, range, 47-100) of the high-energy group significantly. There were more male patients and more die-punch or intercalary fractures in high energy groups significantly. There were more medial and lateral malleolar fractures in low-energy groups. Compared with the non-multiple column group, the multiple-column group had more Rüedi-Allgöwer type III cases, more modified Kellgren-Lawrence 3/4 cases and lower AOFAS score significantly. However, the numbers of Burwell Charnley Score type 1 and 2 cases were not significantly different between the two groups.


      Kinds of pilon variants should be recognized. Outcomes of high-energy pilon fractures were worse than low-energy pilon fractures. The four-column theory can be applied to typical pilon fracture and pilon variants in adults.



      MIPPO (minimally invasive percutaneous plate osteosynthesis), AOFAS (American Orthopaedic Foot and Ankle Society)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Destot E.A.J.
        Traumatismes du pied et rayons x: Malléoles, astragale, calcanéum, avant-pied.
        Masson, 1911
        • Krettek C.
        • Bachmann S.
        Pilon fractures. Part 1: diagnostics, treatment strategies and approaches.
        Der Chir Z Alle Geb Oper Medizen. 2015; 86 (quiz 2): 87-101
        • Haller J.M.
        • Ross H.
        • Jacobson K.
        • Ou Z.
        • Rothberg D.
        • Githens M.
        Supination adduction ankle fractures: ankle fracture or pilon variant?.
        Injury. 2020; 51: 759-763
        • Tang X.
        • Tang P.F.
        • Wang M.Y.
        • et al.
        Pilon fractures: a new classification and therapeutic strategies.
        Chin Med J (Engl). 2012; 125: 2487-2492
        • Chaparro F.
        • Ahumada X.
        • Urbina C.
        • et al.
        Posterior pilon fracture: epidemiology and surgical technique.
        Injury. 2019; 50: 2312-2317
        • Wang J.
        • Wang X.
        • Xie L.
        • Zheng W.
        • Chen H.
        • Cai L.
        Comparison of radiographs and CT features between posterior Pilon fracture and posterior malleolus fracture: a retrospective cohort study.
        Br J Radiol. 2020; 9320191030
        • Rammelt S.
        • Bartoníček J.
        • Schepers T.
        • Kroker L.
        Fixation of anterolateral distal tibial fractures: the anterior malleolus.
        Oper Orthop Traumatol. 2021; : 1-13
        • Zhang Y.W.
        • Rui Y.F.
        A systematic review of the “Logsplitter” injury: how much do we know?.
        Injury. 2020;
        • Heim U.
        Morphological features for evaluation and classification of pilon tibial fractures. Major Fractures of the Pilon, the Talus, and the Calcaneus.
        Springer, 1993: 29-41
        • Bible J.E.
        • Sivasubramaniam P.G.
        • Jahangir A.A.
        • Evans J.M.
        • Mir H.R.
        High-energy transsyndesmotic ankle fracture dislocation—the “Logsplitter” injury.
        J Orthop Trauma. 2014; 28: 200-204
        • Meinberg E.G.
        • Agel J.
        • Roberts C.S.
        • Karam M.D.
        • Kellam JF.
        Fracture and dislocation classification compendium—2018.
        J Orthop Trauma. 2018; 32: S1-S10
        • Yde J.
        The Lauge Hansen classification of malleolar fractures.
        Acta Orthop Scand. 1980; 51: 181-192
        • Warner S.J.
        • Garner M.R.
        • Hinds R.M.
        • Helfet D.L.
        • Lorich D.G.
        Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures.
        J Orthop Trauma. 2015; 29: 574-578
        • Hinds R.M.
        • Schottel P.C.
        • Berkes M.B.
        • Little M.T.
        • Helfet D.L.
        • Lorich D.G.
        Evaluation of Lauge-Hansen designation of Weber C fractures.
        J Foot Ankle Surg. 2014; 53: 434-439
        • Lauge-Hansen N.
        Fractures of the ankle: IV. Clinical use of genetic roentgen diagnosis and genetic reduction.
        AMA Arch Surg. 1952; 64: 488-500
        • Lauge-Hansen N.
        Fractures of the ankle: V. Pronation-dorsiflexion fracture.
        AMA Arch Surg. 1953; 67: 813-820
        • Gustilo R.
        • Anderson J.
        Prevention of infection in the treatment of one thousand and twenty-five open fractures.
        J Bone Jt Surg (Am). 1975; : 453-472
        • Pankovich A.M.
        • Shivaram MS.
        Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament: II. Clinical studies.
        Acta Orthop Scand. 1979; 50: 225-236
        • Rydberg E.M.
        • Zorko T.
        • Sundfeldt M.
        • Möller M.
        • Wennergren D.
        Classification and treatment of lateral malleolar fractures-a single-center analysis of 439 ankle fractures using the Swedish Fracture Register.
        BMC Musculoskelet Disord. 2020; 21: 1-9
        • Burwell H.N.
        • Charnley A.D.
        The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement.
        J Bone Jt Surg Brit. 1965; 47 (Volume): 634-660
        • Holzer N.
        • Salvo D.
        • Marijnissen A.C.A.
        • et al.
        Radiographic evaluation of posttraumatic osteoarthritis of the ankle: the Kellgren–Lawrence scale is reliable and correlates with clinical symptoms.
        Osteoarthr Cartil. 2015; 23: 363-369
        • Madeley N.J.
        • Wing K.J.
        • Topliss C.
        • Penner M.J.
        • Glazebrook M.A.
        • Younger A.S.
        Responsiveness and validity of the SF-36, Ankle Osteoarthritis Scale, AOFAS Ankle Hindfoot Score, and Foot Function Index in end stage ankle arthritis.
        Foot Ankle Int. 2012; 33: 57-63
        • Mündermann A.
        • Dyrby C.O.
        • Andriacchi T.P.
        Secondary gait changes in patients with medial compartment knee osteoarthritis: increased load at the ankle, knee, and hip during walking.
        Arthritis Rheumatism. 2005; 52: 2835-2844
        • Bardou P.
        • Mariette J.
        • Escudié F.
        • Djemiel C.
        • Klopp C.
        jvenn: an interactive Venn diagram viewer.
        BMC Bioinf. 2014; 15: 293
      1. Orthopaedic Surgeon; Central Middlesex Hospital. 5½ × 8¾ in. Pp. 412 + xvi, with 399 illustrations. 1950. London: William Heinemann (Medical Books) Ltd. 63s.
        BJS (Br J Surg). 1951; 38: 535
        • Thordarson D.B.
        Complications after treatment of tibial pilon fractures: prevention and management strategies.
        J Am Acad Orthop Surg. 2000; 8: 253-265
        • Letournel E.
        • Tile M.
        • Isler B.
        • Helfet D.
        • Nazarian S.
        Orthopedic Trauma Association committee for coding and classification: fracture and dislocation compendium.
        J Orthop Trauma. 1996; 10: 66
        • Chohan M.B.Y.
        • Del Balso C.
        • Ching M.
        • Schemitsch E.
        • Lawendy A.R.
        • Sanders D.W.
        Impaction fractures of the anterior tibial plafond: Outcomes after fractures around the ankle: Is the anterior impaction plafond fracture a problem?.
        OTA Int. 2020; 3: e076
        • Kwon J.Y.
        • Gitajn I.L.
        • Walton P.
        • Miller T.J.
        • Appleton P.
        • Rodriguez E.K.
        A cadaver study revisiting the original methodology of Lauge-Hansen and a commentary on modern usage.
        JBJS. 2015; 97: 604-609
        • Benedick A.
        • Kavanagh M.
        • Audet M.
        • Simske N.M.
        • Vallier H.A.
        Supination adduction ankle fractures are associated with arthritis and poor outcomes.
        J Orthop Trauma. 2021; 35: e195-e201
        • Lauge-Hansen N.
        Fractures of the ankle: II. Combined experimental-surgical and experimental-roentgenologic investigations.
        Arch Surg. 1950; 60: 957-985
        • Githens M.F.
        • DeBaun M.R.
        • Jacobsen K.A.
        • Ross H.
        • Firoozabadi R.
        • Haller J.
        Plafond malreduction and talar dome impaction accelerates arthrosis after supination-adduction ankle fracture.
        Foot Ankle Int. 2021; 10711007211006032
        • Rammelt S.
        • Bartonícek J.
        • Kroker L.
        • Neumann A.P.
        Surgical fixation of quadrimalleolar fractures of the ankle.
        J Orthop Trauma. 2021; 35: e216-ee22
        • Chen H.
        • Cui X.
        • Ma B.
        • Rui Y.
        • Li H.
        Staged procedure protocol based on the four-column concept in the treatment of AO/OTA type 43-C3. 3 pilon fractures.
        J Int Med Res. 2019; 47: 2045-2055
        • Fair L.R.
        • Donatelli N.S.
        • Somes J.
        Accurate triage and specialized assessment needs of the geriatric trauma patient who experiences low-energy trauma.
        J Emerg Nurs. 2012; 38: 378-380
        • Rüedi T.
        • Allgöwer M.
        Fractures of the lower end of the tibia into the ankle-joint.
        Injury. 1969; 1: 92-99
        • Rüedi T.P.
        • Allgöwer M.
        The operative treatment of intra-articular fractures of the lower end of the tibia.
        Clin Orthop Relat Res. 1979; : 105-110
        • Dibbern K.
        • Kempton L.B.
        • Higgins T.F.
        • et al.
        Fractures of the tibial plateau involve similar energies as the tibial pilon but greater articular surface involvement.
        J Orthop Res. 2017; 35: 618-624
        • Tarkin I.S.
        • Clare M.P.
        • Marcantonio A.
        • Pape H.C.
        An update on the management of high-energy pilon fractures.
        Injury. 2008; 39: 142-154
        • Topliss C.
        • Jackson M.
        • Atkins R.
        Anatomy of pilon fractures of the distal tibia.
        J Bone Jt Surg Br. 2005; 87 (volume): 692-697
        • Han S.M.
        • Wu T.H.
        • Wen J.X.
        • et al.
        Radiographic analysis of adult ankle fractures using combined Danis-Weber and Lauge-Hansen classification systems.
        Sci Rep. 2020; 10: 1-9
        • Kurylo J.C.
        • Datta N.
        • Iskander K.N.
        • Tornetta 3rd, P.
        Does the fibula need to be fixed in complex pilon fractures?.
        J Orthop Trauma. 2015; 29: 424-427
        • DeCoster T.
        • Willis M.
        • Marsh J.
        • et al.
        Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome?.
        Foot Ankle Int. 1999; 20: 44-49