Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach

Published:November 11, 2022DOI:


      • The current study has introduced a way to intra-operatively evaluate the reduction status of the distal tibial facet and the fibular notch during the entire reduction process for posterior pilon factures with direct visual confirmation.
      • The current study is the first research that compared the reduction accuracy of posterior pilon fractures between the posterior approach (PA) and the transfibular approach (TFA).
      • The current study is one of the largest studies to debate on the results of ORIF for posterior pilon fractures with detailed information.
      • Promising clinical improvement may be expected for certain kinds of posterior pilon fractures with transfibular approach (TFA).



      For posterior pilon fractures, the posterior approach (PA) is widely used but has its limitations. The transfibular approach (TFA) has been adopted to treat posterior malleolar fractures for the advantage of direct visual confirmation of the reduction status intraoperatively, yet the report of its application on posterior pilon fractures is rare. This study aims to compare TFA with PA in terms of their corresponding reduction quality.


      Clinical data of 85 posterior pilon fracture patients treated via PA (n = 62) or TFA (n = 23) were retrospectively reviewed. Radiographic and clinical assessments, including articular step-off or gap, syndesmosis reduction quality, signs of ankle arthritis, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), ankle stability, and the active range of motion (ROM) of the ankle, were all evaluated by two readers independently.


      The total incidence of step-off or gap ≥ 1 mm was significantly higher in the PA group (35.5%) than in the TFA group (8.7%, p = 0.015). In all the patients, step-off ≥ 1 mm was identified as an independent risk factor for the development of arthritis and a lower AOFAS score (p < 0.001). No significant difference was found in ROM and complication incidence between the two groups. Ankle instability was found in neither group during the follow-up.


      TFA could offer a way to intraoperatively evaluate the reduction status with direct visual confirmation and, thereby, might improve the results of reduction for posterior pilon fractures.

      Level of evidence

      Level III


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