Posterior Plating versus Anterior to Posterior Screws in Fixation of Posterior Column in Pilon Fractures

Objectives: To compare the results of anterior to posterior screws (AP screws) versus posterior buttress plating in the fixation of posterior columns fractures in pilon injuries, regarding the 1) functional and 2) radiological outcomes and 3) the incidence of complications. Methods: Design: Prospective, randomized clinical trial. Setting: Single Center, Level 1 trauma Center. Patient Selection criteria: All patients with two, three and four column fracture according to the four-column classification (OTA/AO 43-C1 and 43-C2) during the study period were eligible for inclusion. Patients were randomized into two groups: direct reduction and fixation by posterior buttress plating (group A) and indirect reduction with fixation by AP screws (group B). Exclusion criteria included pediatric age group with open physis, pathological fractures, open fractures and fractures with neurovascular injuries. The minimum follow up period was 24 months. Outcome Measures and Comparisons: The primary outcome was the quality of reduction as evaluated using postoperative plain radiographs and computed tomography (CT). Secondary outcomes included the functional American Orthopaedic Foot and Ankle Society (AOFAS) score and the incidence of complications. Results: 30 patients were included, 15 patients were randomized to group A (mean age 42.3 (range 19-65) and 15 patients in group B (mean age 38.0 in group B (range 23-58). The mean follow up was 32 months (24-45 months). Anatomical reduction was achieved in 80% and 26.7% of group A and group B respectively. AOFAS score was significantly higher in group A compared to group B (p=0.03). There was no statistically significant difference between the two groups regarding the time to union and the complication rates (p>0.05). Conclusions: A higher percentage of anatomical reduction was associated with direct reduction and posterior buttress plating compared to indirect reduction and anterior to posterior screws. This was reflected by a significantly higher AOFAS score.