The Direct Anterior Approach for AO/OTA43B and 43C Pilon Injuries

Background: Pilon fractures carry high rates of early wound healing, infectious complications, and late posttraumatic arthrosis. When reconstructive procedures are indicated, these patients are at further risk for early complications. Perhaps using the same direct anterior (DA) approach for initial repair and later reconstruction might mitigate these risks, but the DA approach has not been explored for initial repair. This study aimed to evaluate the performance of the DA approach for internal fixation of pilon fractures. We hypothesized that the reoperation rate for fractures treated with the DA approach would not differ from other surgical approaches in our series. Methods: A retrospective chart and radiographic review of operative Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 43B and C fractures from 2013 to 2022 were undertaken. Using Kaplan-Meier estimations, the likelihood of reoperation within 1 year of index surgery was analyzed. Reoperation risk factors were determined using multivariable logistic regression analyses created using a backward stepwise process. Results: A total of 135 fractures in 130 patients were eligible for review. The overall reoperation rate was 40.7%. There was no significant difference between DA and all other approaches for rate of reoperation for infection (2.3% vs 10%, P = .21), nonunion (15.9% vs 16.5%, P > .99), posttraumatic osteoarthritis (PTOA) (9.1% vs 7.8%, P > .99), and removal of symptomatic hardware (25% vs 36.3%, P = .27). In multivariate regression analysis, DA approach was associated with a lower rate of reoperation within 1 year (odds ratio 0.25, 95% CI 0.07-0.71, P = .015). Conclusion: The direct anterior approach can perform well for fixation of AO/OTA 43B and C fractures. Our retrospective series showed a favorable risk of reoperation at 1 year and a similar overall reoperation rate compared with all other combinations of approaches. Many factors determine the surgical approach to pilon fractures. This study has shown that the DA approach merits consideration as an option for open reduction and internal fixation.