A Novel Strategy for Accurate Posterior Fragment Reduction in Posterior Pilon Fracture

A Novel Strategy for Accurate Posterior Fragment Reduction in Posterior Pilon Fracture | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Novel Strategy for Accurate Posterior Fragment Reduction in Posterior Pilon Fracture Zhenhui Sun, Hecheng Zhou, Xiangliang Ge, Dehang Liu, Jinxi Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6674240/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Reducing the posterior fragment in posterior pilon fractures presents a significant surgical challenge due to its complex anatomy and limited exposure. In recent years, the transfibular approach has gained attention for enhancing reduction accuracy and improving American Orthopaedic Foot & Ankle Society (AOFAS) scores. However, the outcomes associated with the transfibular approach remain suboptimal in many cases. This study aims to introduce a novel reduction strategy specifically targeting the posterior fragment in posterior pilon fractures and overcome the limitations observed with current methods. Methods: Clinical data were collected from 14 patients diagnosed with posterior pilon fractures who underwent surgical treatment between October 2023 and October 2024. All patients were treated using our proposed reduction strategy, which combined a transfibular approach with a posteromedial approach to improve fragment visualization and fixation. Postoperative recovery was assessed using the AOFAS score, the Visual Analog Scale (VAS) for pain, and the Kellgren–Lawrence grading system to evaluate the degree of post-traumatic osteoarthritis. Results: 11 female and 3 male were included with a mean age of 45.2 (23–67) years. The mean follow-up duration was 13.1 months (6-19 months). The mean AOFAS score was 89 (78-100). All patients reported a VAS score of ≤1 during rest and active range of motion; however, VAS scores varied during weight-bearing ambulation. Radiographic evaluation showed that all patients had a Kellgren–Lawrence grade of 0 or 1, suggesting minimal or no radiographic evidence of post-traumatic osteoarthritis. Conclusions: We propose a novel and effective for accurate reduction of the posterior fragment in posterior pilon fracture. It improves the AOFAS score and decreases posttraumatic osteoarthritis after surgery. Posterior Pilon fracture Ankle Joint Fracture Reduction Internal Fixation Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Posterior pilon fracture is a distinct subtype of ankle fracture involving the posterior portion of the tibial plafond. It typically results from high-energy trauma, such as axial loading or a forceful impact of the talus against the distal tibia, and is associated with considerable risk for long-term complications and functional impairment if not adequately treated[ 1 , 2 ]. Unlike posterior malleolar avulsion fractures, which are commonly caused by tension forces exerted by the posterior inferior tibiofibular ligament, posterior pilon fractures are primarily the result of direct impact from the talus, often producing larger and more displaced fragments[ 3 ]. Open reduction and internal fixation (ORIF) remains the gold standard for the management of posterior pilon fractures. This approach prioritizes the anatomical reconstruction of the articular surface of the distal tibia, which is essential for promoting fracture union, preserving joint function, and minimizing the risk of post-traumatic arthritis[ 4 ]. Posterior approaches, including the posteromedial and posterolateral techniques, are commonly employed in the surgical treatment of posterior pilon fractures[ 3 , 5 , 6 ]. However, achieving anatomical reduction and restoring joint congruence through these approaches remains challenging. This difficulty largely stems from the limited direct visualization of the articular surface during surgery. Surgeons often rely on metaphyseal fracture lines and intraoperative fluoroscopy for guidance, but these methods are not sufficiently reliable for detecting subtle, millimeter-scale incongruities of the tibial plafond [ 7 , 8 ]. Notably, previous studies have reported that up to 26.7% of posterior Pilon fracture cases exhibit residual articular step-offs greater than 1 mm postoperatively, highlighting a persistent challenge in achieving precise reduction[ 9 ]. Such residual incongruence is associated with a heightened risk of developing post-traumatic ankle osteoarthritis in the near future[ 10 ]. Recently, the transfibular approach has been introduced as an alternative technique for managing posterior Pilon fractures, offering direct visualization of the posterior tibial plafond[ 11 , 12 ]. This improved exposure facilitates more accurate reduction of the articular surface and enhances fixation. Compared to traditional posterior approaches, the transfibular technique has been associated with a lower rate of malreduction and significantly improved clinical outcomes. Specifically, studies have demonstrated higher American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores at 12 months postoperatively in patients treated with the transfibular approach[ 9 , 13 ]. However, challenges persist in the treatment of complex posterior Pilon fractures, even when using the transfibular approach. Difficulties such as accurately restoring the fragment’s height, managing separation, and correcting rotational deformities remain significant obstacles to achieving optimal outcomes. In this study, we propose a novel reduction strategy utilizing the transfibular approach to address these specific challenges. We retrospectively analyze the clinical outcomes of patients treated with this technique and share key intraoperative tips and technical considerations that may enhance surgical precision and improve patient recovery. Methods Patient population Between October 2023 and October 2024, a total of 18 patients met the initial inclusion criteria for this study; however, 4 patients were lost to follow-up, leaving 14 patients eligible for final analysis. All included patients underwent surgery for posterior Pilon fractures using our novel reduction strategy via a transfibular approach. This study was conducted retrospectively and approved by the institutional Ethics Committee. Informed consent was obtained from all patients. The inclusion criteria were as follows: (1) A confirmed diagnosis of posterior Pilon fracture. (2) Completion of preoperative imaging, including X-ray and three-dimensional computed tomography (CT) reconstruction. (3) Surgical treatment using the transfibular approach in combination with the proposed novel reduction strategy. Exclusion criteria included: (1) Pathological fractures or open fractures. (2) Patients with severe comorbidities rendering them unsuitable for surgery. (3) A follow-up period of less than six months. Surgical procedure Before surgery, all patients underwent routine ankle X-rays and a CT scan with three-dimensional reconstruction to assess the fracture type and the extent of involvement (Fig. 1 ). The fractures were classified using the Lauge-Hansen and Klammer ankle fracture classification systems. In preparation for surgery, the patient was positioned supine on a fracture table, and a tourniquet was applied to the proximal thigh to control bleeding during the procedure. The ankle fracture was exposed through a combined posteromedial and lateral transfibular approach. Initially, hematoma and osteochondral fragments within the ankle joint were thoroughly debrided. To facilitate exposure of the tibial plafond, the distal fibula was laterally rotated using a K-wire as a lever (Fig. 2 A). If the fibula could not be rotated sufficiently to visualize the entire tibial plafond, the anterior talofibular ligament (ATFL) was transected from its distal attachment on the fibula. After soft tissue release and hematoma removal, a 2.0 mm K-wire was inserted into the tibial Tillaux tuberosity, and another K-wire was placed into the neck of the talus. These wires were then distracted with a distractor to fully expose the tibial plafond (Fig. 2 B). The medial and lateral malleoli were reduced anatomically and temporarily fixed using K-wires in sequence (Fig. 2 C). The posterior malleolus was then reduced anatomically and temporarily fixed using a posterior malleolus reduction forceps through the posteromedial incision. After removing the fixation of the lateral malleolus, the posterior malleolus was reduced under direct visualization, often assisted by a towel clip applied to the posterior tibiofibular ligament for distraction (Fig. 2 D, E). The posterior fragments were then secured with one or two screws, placed from the anterior Tillaux tuberosity to the posterior Volkmann fragment. Following this, the lateral and medial malleoli were anatomically reduced and stabilized with screws or plates. The distal tibiofibular syndesmosis was repaired using either a screw or Endobuttons. The resected ATFL was repaired with an anchor screw inserted into the distal fibula. Finally, the quality of fracture reduction and the position of the internal fixation were confirmed using fluoroscopy in the ankle's anteroposterior, mortise, and lateral views, or, if necessary, with an intraoperative CT scan. Postoperative management All patients followed the same postoperative management and follow-up protocol. The decision to apply plaster immobilization was made based on the intraoperative situation. Casts were removed two weeks post-surgery to allow for functional rehabilitation exercises. For patients who did not receive a postoperative cast, active and passive range of motion exercises were initiated on the second postoperative day. Partial weight-bearing was allowed, starting at 30 kg with the use of bilateral crutches for support. Full weight-bearing was permitted after eight weeks post-surgery, contingent on the healing progress and radiographic assessment. Follow up Patients were reviewed at regular intervals following surgery, with follow-up visits scheduled immediately postoperatively, at 1 month, 3 months, 6 months, 12 months, and 18 months. These visits allowed for monitoring of recovery, assessment of functional outcomes, and early identification of potential complications. Results A total of 14 patients were included in the study, comprising 11 females and 3 males, with a mean age of 45.2 years (range: 23–67 years). Based on the Klammer classification, 2 patients were classified as Type 1, 3 as Type 2, and 9 as Type 3. According to the Lauge-Hansen classification, 8 patients were classified as PER4, 2 as SER4, and 4 were classified as not applicable. The mean follow-up duration was 13.1 months (range: 6–19 months). The mean AOFAS score was 89 (range: 78–100), indicating generally favorable functional outcomes. Among the patients, 1 had a concomitant Maisonneuve fracture, 1 had an old fracture with malunion, and 3 patients had diabetes. Regarding pain levels, 1 patient (a 64-year-old male) reported a VAS score of 1 at rest, while all other patients reported a score of 0 at rest. During active movement, the 64-year-old male patient reported a VAS score of 4, 7 patients reported a score of 1, and 6 patients reported a score of 0. Four patients reported a VAS score of 0 during weight-bearing walking, while the remaining patients had varying pain scores. Radiographically, only 1 patient (a 67-year-old female) was found to have a Kellgren-Lawrence grade of 1, indicating mild osteoarthritis. The remaining patients had a Kellgren-Lawrence grade of 0, indicating no radiographic evidence of osteoarthritis. All surgical incisions healed without complications, and there were no cases of deep infection or osteomyelitis. None of the patients experienced vascular damage, peroneal nerve sensory abnormalities, or compartment syndrome. (Fig. 3, 4) (Table 1) Table 1 Summary of included patients Age Gender Side BMI Injury Lauge-Hansen Classification Klammer type Time to full weight bearing (week) Final follow-up (month) AOFAS VAS (rest） VAS (active movement） VAS (weight-bearing walking） Kellgren-Lawrence degree Note 44 female left 33.2 traffic NA 2 13 8 90 0 0 0~1 0 combined with Maisonneuve fracture 47 female right 26.8 traffic NA 2 13 6 78 0 1 3~8 0 malunion revision 67 female left 22.9 twist PER4 3 13 18 89 0 1 1 1 38 female right 19.6 twist PER4 3 13 18 90 1 1 3~4 0 39 female left 31.2 twist PER4 3 13 6 90 0 1 2 0 51 female right 27.3 twist SER4 3 10 18 98 0 0 0 0 38 female right 19.8 twist SER4 3 13 12 85 0 1 3 0 26 male left 26 twist PER4 3 8 13 90 0 0 0 0 64 male right 26.9 fall on flat road NA 3 13 12 80 1 4 6 0 diabetes 34 male left 20.8 fall from height NA 1 14 11 88 0 0 0-2 0 61 female right 28.4 twist PER4 2 26 19 80 0 1 3~5 0 diabetes 46 female right 22.7 twist PER4 1 8 17 88 0 1 1~5 0 23 female left 22.3 twist PER4 3 13 12 100 0 0 0 0 55 female right 21.5 twist PER4 3 8 13 100 0 0 0 0 diabetes Discussion This study introduces a novel strategy for the reduction of posterior Pilon fractures, which has shown promising results compared to previous approaches. Our method demonstrated improvements in the AOFAS scores and a reduction in the incidence of post-traumatic osteoarthritis following surgery. An important aspect of our technique is the sequence in which the fractures are reduced. We observed that in certain cases, reducing the lateral malleolus was challenging, particularly when there was significant displacement of both the medial and lateral malleoli. Based on these observations, we recommend that the medial and lateral malleoli be reduced primarily before proceeding to the reduction of the posterior malleolus. This sequence helps to achieve more stable fixation and provides better exposure, facilitating a more accurate reduction of the posterior fragment. Achieving excellent reduction is crucial for optimal outcomes in patients with tibial plafond fractures. In addition to good fracture reduction, factors such as a lower BMI, OTA/AO 43-B (partial articular) fracture classification, and closed fractures are also associated with better functional results[ 14 , 15 ]. Without a satisfactory reduction, post-traumatic arthritis of the ankle joint becomes a significant challenge, often requiring additional surgical intervention[ 16 ]. Therefore, achieving anatomical reduction and stable fixation is vital in the treatment of posterior Pilon fractures [ 17 ]. Our proposed strategy offers a simplified approach to the reduction procedure. However, it remains challenging to anatomically reduce the tibial plafond without direct visualization, a limitation inherent to the posterior approach. The Klammer classification system, introduced in 2013, has been widely adopted to classify posterior Pilon fractures and guide treatment[ 18 ]. In the present study, the mean postoperative AOFAS score was 82, with a mean follow-up of 22.7 months (range: 15–30 months), and 18% of patients developed post-traumatic osteoarthritis by the final follow-up. A similar study, utilizing a combined posterolateral and anterior extensile approach in 2022, reported an average AOFAS score of 81.9 one year after surgery[ 19 ]. Another study in 2019, using the posterolateral approach, reported an average AOFAS score of 82.3 (range: 44–97) one year post-surgery[ 8 ]. These findings indicate that while our strategy improves clinical outcomes, the rates of post-traumatic osteoarthritis remain a significant concern, and further refinements in surgical technique may be needed to optimize long-term results. The transfibular approach has been previously utilized in various procedures, including tibiotalar arthrodesis, tibiotalocalcaneal arthrodesis, total ankle replacement, and distal tibial tumor excision surgeries[ 20 ]. Recently, it has been applied in the reduction of posterior Pilon fractures, offering the advantage of direct visualization of the tibial plafond. Liang et al. reported an average AOFAS score of 89.6 ± 7.2 points and 61.3 ± 3.9 degrees of ankle range of motion (ROM) in patients who underwent surgery using the transfibular approach, with a mean follow-up of 21 months (12–35 months). In comparison, the posterolateral approach group had a lower AOFAS score (86.6 ± 7.1) and ankle ROM (58.4 ± 2.8 degrees), suggesting better functional outcomes with the transfibular approach[ 21 ]. Gan et al. also demonstrated the advantages of the transfibular approach, reporting an AOFAS score of 88.6 (75–100) in the transfibular group versus 85.5 (75.3–90) in the posterior approach group. Additionally, the Kellgren-Lawrence degree was lower in the transfibular group, indicating a reduced incidence of post-traumatic osteoarthritis following surgery with this approach. The mean follow-up in their study was 40 months (13–71 months)[ 9 ]. Similarly, Jiang et al. reported an AOFAS score of 86.6 ± 7.1 in the transfibular approach group versus 82.7 ± 6.9 in the posterior approach group at the final follow-up[ 13 ]. Our strategy incorporates the transfibular approach with additional refinements. The average AOFAS score of our patients, who were followed up for 6 to 18 months post-surgery, supports the efficacy of our approach in improving functional outcomes and reducing complications associated with posterior Pilon fractures. With our proposed strategy, the mean AOFAS score was 89 (78–100), which is comparable to the AOFAS scores reported in other studies using the transfibular approach[ 9 , 13 , 21 ]. Among the 14 patients included in our study, 3 patients had an AOFAS score of less than 80. Notably, one patient (44female) with an old malunion of a posterior Pilon fracture had an AOFAS score of 78, 6 months after revision surgery. Additionally, two diabetic patients (64male and 61female) had AOFAS scores of 80. In contrast, the AOFAS scores of two other patients (23female and 55female) were 100, and another (51female) had a score of 98. The AOFAS scores for the remaining 8 patients ranged between 85 and 90. We observed that mild pain, particularly between 6 and 18 months postoperatively, was quite common, which may account for some reductions in AOFAS scores. Regarding post-operative radiographic findings, only one patient (67female) showed a Kellgren-Lawrence grade of 1 (7%), while the remaining 13 patients (93%) had a grade of 0. In a previous study utilizing the transfibular approach, 60.9% of patients had a Kellgren-Lawrence grade of 0, 34.8% had grade 1, and 4.3% had grade 2, 2 years after surgery. In contrast, a study using the posterior approach reported a lower proportion of grade 0 (38.7%) and a higher proportion of grade 1 (38.7%), along with 19.4% grade 2, and even 1.6% for grades 3 and 4, 2 years after surgery[ 9 ]. Earlier research on one or two-column Pilon fractures found that 6.9% of patients had modified Kellgren-Lawrence grade 3 or 4 at 3 years post-surgery, with significantly higher rates (61.54%) in three or four-column fractures[ 22 ]. This further emphasizes the need for careful reduction and fixation in complex fractures to reduce the risk of long-term complications such as post-traumatic arthritis. In summary, our strategy further confirms the benefits of the transfibular approach for posterior Pilon fractures. It led to improved AOFAS scores, averaging around 90, compared to the traditional posterior approach, one year after surgery. Additionally, our approach significantly reduced the risk of post-traumatic osteoarthritis following posterior Pilon fractures, offering a promising solution for better long-term outcomes. This study has several limitations. First, its retrospective design and uneven follow-up periods present significant potential sources of bias. Second, the sample size was relatively small, which limits the generalizability of the findings. Future studies with larger sample sizes are needed to validate these results. Third, the follow-up period in this study was less than two years; therefore, longer follow-up studies are required to more comprehensively assess the long-term effectiveness of our strategy. Conclusion We propose a novel strategy for the accurate reduction of posterior fragments in posterior Pilon fractures. This approach enhances the AOFAS score and reduces the incidence of post-traumatic osteoarthritis following surgery. Declarations Ethics declarations Ethics approval and consent to participate This study has been approved by the appropriate ethical review committee and strictly complies with all the provisions of the Declaration of Helsinki. All participants were fully informed of the nature of the study prior to the start of the study and signed informed consent forms. This study was approved by the Medical Ethics Review Committee of The First Hospital of Hebei Medical University: No. 2025(S00790). Consent for publication Participants provided written consent permitting the publication of their clinical or personal details, including any identifying images associated with the study. Funding This study was supported by Hebei Provincial Health and Family Planning Commission, 20241338. Acknowledgements We would like to appreciate all individuals who contributed to this study. Authors' information Authors and Affiliations Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China Zhenhui Sun Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China Hecheng Zhou Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China Xiangliang Ge Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China Dehang Liu Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China Jinxi Hu Contributions Z.S. provided fund, completed the most surgeries, wrote the manuscript. H.Z. wrote the manuscript, collected data and follow-up. X.G. follow-up and photograph. D.L. follow-up and photograph. J.H. revised the manuscript, completed part of surgeries. Corresponding author Correspondence to Jinxi Hu ( [email protected] ). Competing interests The authors declare no competing interests. Clinical trial number Not applicable. References Rüedi TP, Allgöwer M: The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res 1979 : 105-110. Boesel J, DiGiacomo D, Hoffman B, Liu J: A systematic review of posterior pilon fractures. J Orthop 2025, 68: 34-39. Amorosa LF, Brown GD, Greisberg J: A surgical approach to posterior pilon fractures. J Orthop Trauma 2010, 24: 188-193. Lassiter EM, Brown KJ, Patel D, Sparks A, Liu J, Elattar O: A systematic review of posterior pilon variant fractures. J Orthop 2024, 53: 73-81. Sukur E, Akman YE, Gokcen HB, Ozyurek EC, Senel A, Ozturkmen Y: Open reduction in pilon variant posterior malleolar fractures: Radiological and clinical evaluation. Orthop Traumatol Surg Res 2017, 103: 703-707. Yang Y, He W, Zhou H, Xia J, Li B, Yu T: Combined Posteromedial and Posterolateral Approaches for 2-Part Posterior Malleolar Fracture Fixation. Foot Ankle Int 2020, 41: 1234-1239. Chaparro F, Ahumada X, Urbina C, Lagos L, Vargas F, Pellegrini M, Barahona M, Bastias C: Posterior pilon fracture: Epidemiology and surgical technique. Injury 2019, 50: 2312-2317. Gao M, Liu N, Cheng Y, Shi W, Yang H: Treatment outcomes of the posterolateral approach of plate fixation for posterior pilon fractures. Exp Ther Med 2019, 17: 4267-4272. Gan TJ, Li YX, Chen Y, Liu X, Zhang H: Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach. Injury 2023, 54: 751-760. Verhage SM, Krijnen P, Schipper IB, Hoogendoorn JM: Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures. Arch Orthop Trauma Surg 2019, 139: 323-329. Warner WC, Farber LA: Trimalleolar fractures. South Med J 1965, 58: 1292-1295. Weber M, Ganz R: Malunion following trimalleolar fracture with posterolateral subluxation of the talus--reconstruction including the posterior malleolus. Foot Ankle Int 2003, 24: 338-344. Jiang Z, Zhang C, Qin JJ, Wang GD, Wang HS: Posterior pilon fracture treated by opening the fibula fracture gap. J Orthop Surg Res 2022, 17: 214. Wheelwright JC, Christensen GV, Cizik AM, Zhang C, Marchand LS: Significant Factors of High Performance Outcomes for Tibial Plafond Fractures. Foot Ankle Int 2022, 43: 1261-1268. Myers DM, Kelley JA, Taylor BC, Umbel B, Buchan J, Melaragno A: The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance. J Foot Ankle Surg 2022, 61: 1060-1064. Liu X, An J, Zhang H, Li Y, Chen Y, Zhang W: Autologous Osteochondral Graft for Early Posttraumatic Arthritis of Tibiotalar Joints After Comminuted Pilon Fractures in Young Patients. Foot Ankle Int 2020, 41: 69-78. Chen DW, Li B, Aubeeluck A, Yang YF, Zhou JQ, Yu GR: Open reduction and internal fixation of posterior pilon fractures with buttress plate. Acta Ortop Bras 2014, 22: 48-53. Klammer G, Kadakia AR, Joos DA, Seybold JD, Espinosa N: Posterior pilon fractures: a retrospective case series and proposed classification system. Foot Ankle Int 2013, 34: 189-199. Huang M, Wang Q, Guan J, Liu K, Chen Y, Wang L: Tips and Tricks in surgical reduction of the posterior column of AO/OTA C3 pilon fractures. BMC Musculoskelet Disord 2022, 23: 2. Hess MC, Abyar E, McKissack HM, Strom S, Johnson MD: Applications of the transfibular approach to the hindfoot: A systematic review and description of a preferred technique. Foot Ankle Surg 2021, 27: 1-9. Liang W, Zhou M, Jiang Z, Mao X, Zhou X: Treatment outcomes of posterior pilon fractures using a simple single lateral approach via stretching fibular fracture line. Front Surg 2023, 10: 1141606. Lou Z, Wang Z, Liu C, Tang X: Outcomes of tibial pilon fracture fixation based on four-column theory. Injury 2023, 54 Suppl 2: S36-s42. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6674240","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485161303,"identity":"f65a5156-8e88-4c35-930a-163a12739386","order_by":0,"name":"Zhenhui Sun","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China,","correspondingAuthor":false,"prefix":"","firstName":"Zhenhui","middleName":"","lastName":"Sun","suffix":""},{"id":485161305,"identity":"b5a099a7-afe6-4cd7-8ed7-80df252f5550","order_by":1,"name":"Hecheng Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYDACCQYGZiCVAOGx2UAYCQXEa0lLYGADcQ2I13IYooUBjxb52c3HpAsq7PL4pduvbvhQdj6PX7478cMDAwZ5frEDWLUwzjmWJj3jTHKx5JwzZTdnnLtdLNnGu1kC6DDDmbMTsGphlsgxk+ZtO5C44UZO2m3ettuJG47xbgBpSTC4jV0LG1jLvwOJ+0Fa/radA2nZ/AOfFh6wlgagLRLpx24zgqw7xrsNry0SEmnJ1jzHkhNn3Mhhu9lzLjlxZlvuNosEAwmcfpGfkXzwNk+NXWL/jPRnN36UARnMZzff/FFhI88vjV0LshtR4kKCkHIQYH9AjKpRMApGwSgYgQAATKdiZgcXkzMAAAAASUVORK5CYII=","orcid":"","institution":"Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China,","correspondingAuthor":true,"prefix":"","firstName":"Hecheng","middleName":"","lastName":"Zhou","suffix":""},{"id":485161311,"identity":"0ef971ef-e54f-44c3-b745-1283f83797cf","order_by":2,"name":"Xiangliang Ge","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China,","correspondingAuthor":false,"prefix":"","firstName":"Xiangliang","middleName":"","lastName":"Ge","suffix":""},{"id":485161314,"identity":"248db5da-b8db-481f-a77b-5e25fd9ae5c0","order_by":3,"name":"Dehang Liu","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China,","correspondingAuthor":false,"prefix":"","firstName":"Dehang","middleName":"","lastName":"Liu","suffix":""},{"id":485161315,"identity":"da7aa69c-f461-4ced-a576-03b583e4b969","order_by":4,"name":"Jinxi Hu","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China,","correspondingAuthor":false,"prefix":"","firstName":"Jinxi","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2025-05-15 15:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6674240/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6674240/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86830406,"identity":"8f2f743d-2738-410f-b7d8-9bb731d64fa2","added_by":"auto","created_at":"2025-07-16 05:55:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":572017,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative digital radiographs and MRI images of patients with posterior pilon fracture.\u003c/p\u003e\n\u003cp\u003eA. anterior-to-posterior radiograph of 55female, B. lateral radiograph of 55female, C. T2 fat suppressed image of 55female. D. anterior-to-posterior radiograph of 23female, E. lateral radiograph of 23female, F. T2 fat suppressed image of 23female.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6674240/v1/f3ae873c71be3ef56e7c35c6.jpg"},{"id":86830400,"identity":"75304423-50fd-49ac-917b-cc063f6c5bf8","added_by":"auto","created_at":"2025-07-16 05:55:21","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":972129,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical procedure.\u003c/p\u003e\n\u003cp\u003eA. distal fibula rotated laterally with a K-wire (right ankle). B. tibia and talus ditracted by a ditractor (left ankle). C. temporarily fixed medial and lateral malleolus (left ankle). D. posterior malleolus reduced anatomically with direct visualization (left ankle). E. distraction on the posterior tibiofibular ligament (left ankle).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6674240/v1/78d6a8a515ea3a42f8290bc9.jpg"},{"id":86830401,"identity":"0cc9eb73-64f5-4fca-9a0b-41bbe509c37c","added_by":"auto","created_at":"2025-07-16 05:55:21","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":593739,"visible":true,"origin":"","legend":"\u003cp\u003ePre- and post-operation radiographs of 51female.\u003c/p\u003e\n\u003cp\u003eA. preoperative anterior-to-posterior radiograph, B. preoperative lateral radiograph, C. preoperative CT sagittal plane, D. preoperativeT2 fat suppressed image, E. postoperative anterior-to-posterior radiograph, F. postoperative lateral radiograph, G. postoperative CT sagittal plane\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6674240/v1/d47f6064fc0df969066171c0.jpg"},{"id":86830404,"identity":"de89b802-d522-4769-903e-7e1d3757012d","added_by":"auto","created_at":"2025-07-16 05:55:21","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":822288,"visible":true,"origin":"","legend":"\u003cp\u003ePre- and post-operation radiographs of 67female.\u003c/p\u003e\n\u003cp\u003eA. preoperative anterior-to-posterior radiograph, B. preoperative lateral radiograph, C. preoperative CT axial and sagittal plane, D. preoperative CT coronal plane, E. preoperativeT2 fat suppressed image, F. postoperative anterior-to-posterior radiograph, G. postoperative lateral radiograph, H. postoperative CT axial and sagittal plane, I. postoperative CT coronal plane.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6674240/v1/3a7595ac4835d1401e60bdaa.jpg"},{"id":88408195,"identity":"b1bc3aa1-978e-42cb-9a5a-eb19c9a4902e","added_by":"auto","created_at":"2025-08-06 08:10:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4257397,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6674240/v1/45637a50-37b5-4379-936b-6aaf544363f3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Novel Strategy for Accurate Posterior Fragment Reduction in Posterior Pilon Fracture","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePosterior pilon fracture is a distinct subtype of ankle fracture involving the posterior portion of the tibial plafond. It typically results from high-energy trauma, such as axial loading or a forceful impact of the talus against the distal tibia, and is associated with considerable risk for long-term complications and functional impairment if not adequately treated[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Unlike posterior malleolar avulsion fractures, which are commonly caused by tension forces exerted by the posterior inferior tibiofibular ligament, posterior pilon fractures are primarily the result of direct impact from the talus, often producing larger and more displaced fragments[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Open reduction and internal fixation (ORIF) remains the gold standard for the management of posterior pilon fractures. This approach prioritizes the anatomical reconstruction of the articular surface of the distal tibia, which is essential for promoting fracture union, preserving joint function, and minimizing the risk of post-traumatic arthritis[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePosterior approaches, including the posteromedial and posterolateral techniques, are commonly employed in the surgical treatment of posterior pilon fractures[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, achieving anatomical reduction and restoring joint congruence through these approaches remains challenging. This difficulty largely stems from the limited direct visualization of the articular surface during surgery. Surgeons often rely on metaphyseal fracture lines and intraoperative fluoroscopy for guidance, but these methods are not sufficiently reliable for detecting subtle, millimeter-scale incongruities of the tibial plafond [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Notably, previous studies have reported that up to 26.7% of posterior Pilon fracture cases exhibit residual articular step-offs greater than 1 mm postoperatively, highlighting a persistent challenge in achieving precise reduction[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Such residual incongruence is associated with a heightened risk of developing post-traumatic ankle osteoarthritis in the near future[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecently, the transfibular approach has been introduced as an alternative technique for managing posterior Pilon fractures, offering direct visualization of the posterior tibial plafond[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This improved exposure facilitates more accurate reduction of the articular surface and enhances fixation. Compared to traditional posterior approaches, the transfibular technique has been associated with a lower rate of malreduction and significantly improved clinical outcomes. Specifically, studies have demonstrated higher American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores at 12 months postoperatively in patients treated with the transfibular approach[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, challenges persist in the treatment of complex posterior Pilon fractures, even when using the transfibular approach. Difficulties such as accurately restoring the fragment\u0026rsquo;s height, managing separation, and correcting rotational deformities remain significant obstacles to achieving optimal outcomes. In this study, we propose a novel reduction strategy utilizing the transfibular approach to address these specific challenges. We retrospectively analyze the clinical outcomes of patients treated with this technique and share key intraoperative tips and technical considerations that may enhance surgical precision and improve patient recovery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient population\u003c/h2\u003e\n \u003cp\u003eBetween October 2023 and October 2024, a total of 18 patients met the initial inclusion criteria for this study; however, 4 patients were lost to follow-up, leaving 14 patients eligible for final analysis. All included patients underwent surgery for posterior Pilon fractures using our novel reduction strategy via a transfibular approach. This study was conducted retrospectively and approved by the institutional Ethics Committee. Informed consent was obtained from all patients. The inclusion criteria were as follows: (1) A confirmed diagnosis of posterior Pilon fracture. (2) Completion of preoperative imaging, including X-ray and three-dimensional computed tomography (CT) reconstruction. (3) Surgical treatment using the transfibular approach in combination with the proposed novel reduction strategy. Exclusion criteria included: (1) Pathological fractures or open fractures. (2) Patients with severe comorbidities rendering them unsuitable for surgery. (3) A follow-up period of less than six months.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSurgical procedure\u003c/h3\u003e\n\u003cp\u003eBefore surgery, all patients underwent routine ankle X-rays and a CT scan with three-dimensional reconstruction to assess the fracture type and the extent of involvement (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The fractures were classified using the Lauge-Hansen and Klammer ankle fracture classification systems.\u003c/p\u003e\n\u003cp\u003eIn preparation for surgery, the patient was positioned supine on a fracture table, and a tourniquet was applied to the proximal thigh to control bleeding during the procedure.\u003c/p\u003e\n\u003cp\u003eThe ankle fracture was exposed through a combined posteromedial and lateral transfibular approach. Initially, hematoma and osteochondral fragments within the ankle joint were thoroughly debrided. To facilitate exposure of the tibial plafond, the distal fibula was laterally rotated using a K-wire as a lever (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA). If the fibula could not be rotated sufficiently to visualize the entire tibial plafond, the anterior talofibular ligament (ATFL) was transected from its distal attachment on the fibula.\u003c/p\u003e\n\u003cp\u003eAfter soft tissue release and hematoma removal, a 2.0 mm K-wire was inserted into the tibial Tillaux tuberosity, and another K-wire was placed into the neck of the talus. These wires were then distracted with a distractor to fully expose the tibial plafond (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB). The medial and lateral malleoli were reduced anatomically and temporarily fixed using K-wires in sequence (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eC).\u003c/p\u003e\n\u003cp\u003eThe posterior malleolus was then reduced anatomically and temporarily fixed using a posterior malleolus reduction forceps through the posteromedial incision. After removing the fixation of the lateral malleolus, the posterior malleolus was reduced under direct visualization, often assisted by a towel clip applied to the posterior tibiofibular ligament for distraction (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eD, E). The posterior fragments were then secured with one or two screws, placed from the anterior Tillaux tuberosity to the posterior Volkmann fragment. Following this, the lateral and medial malleoli were anatomically reduced and stabilized with screws or plates. The distal tibiofibular syndesmosis was repaired using either a screw or Endobuttons. The resected ATFL was repaired with an anchor screw inserted into the distal fibula. Finally, the quality of fracture reduction and the position of the internal fixation were confirmed using fluoroscopy in the ankle\u0026apos;s anteroposterior, mortise, and lateral views, or, if necessary, with an intraoperative CT scan.\u003c/p\u003e\n\u003ch3\u003ePostoperative management\u003c/h3\u003e\n\u003cp\u003eAll patients followed the same postoperative management and follow-up protocol. The decision to apply plaster immobilization was made based on the intraoperative situation. Casts were removed two weeks post-surgery to allow for functional rehabilitation exercises. For patients who did not receive a postoperative cast, active and passive range of motion exercises were initiated on the second postoperative day. Partial weight-bearing was allowed, starting at 30 kg with the use of bilateral crutches for support. Full weight-bearing was permitted after eight weeks post-surgery, contingent on the healing progress and radiographic assessment.\u003c/p\u003e\n\u003ch3\u003eFollow up\u003c/h3\u003e\n\u003cp\u003ePatients were reviewed at regular intervals following surgery, with follow-up visits scheduled immediately postoperatively, at 1 month, 3 months, 6 months, 12 months, and 18 months. These visits allowed for monitoring of recovery, assessment of functional outcomes, and early identification of potential complications.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 14 patients were included in the study, comprising 11 females and 3 males, with a mean age of 45.2 years (range: 23\u0026ndash;67 years). Based on the Klammer classification, 2 patients were classified as Type 1, 3 as Type 2, and 9 as Type 3. According to the Lauge-Hansen classification, 8 patients were classified as PER4, 2 as SER4, and 4 were classified as not applicable. The mean follow-up duration was 13.1 months (range: 6\u0026ndash;19 months). The mean AOFAS score was 89 (range: 78\u0026ndash;100), indicating generally favorable functional outcomes. Among the patients, 1 had a concomitant Maisonneuve fracture, 1 had an old fracture with malunion, and 3 patients had diabetes. Regarding pain levels, 1 patient (a 64-year-old male) reported a VAS score of 1 at rest, while all other patients reported a score of 0 at rest. During active movement, the 64-year-old male patient reported a VAS score of 4, 7 patients reported a score of 1, and 6 patients reported a score of 0. Four patients reported a VAS score of 0 during weight-bearing walking, while the remaining patients had varying pain scores. Radiographically, only 1 patient (a 67-year-old female) was found to have a Kellgren-Lawrence grade of 1, indicating mild osteoarthritis. The remaining patients had a Kellgren-Lawrence grade of 0, indicating no radiographic evidence of osteoarthritis. All surgical incisions healed without complications, and there were no cases of deep infection or osteomyelitis. None of the patients experienced vascular damage, peroneal nerve sensory abnormalities, or compartment syndrome. \u0026nbsp;(Fig. 3, 4) (Table 1)\u003c/p\u003e\n\u003cp\u003eTable 1 \u0026nbsp;Summary of included patients\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1045\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eSide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003eInjury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eLauge-Hansen Classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003eKlammer type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eTime to full weight bearing (week)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003eFinal follow-up (month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eAOFAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eVAS (rest）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(active movement）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eVAS (weight-bearing walking）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eKellgren-Lawrence degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eNote\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e33.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etraffic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0~1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ecombined with Maisonneuve fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e26.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etraffic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e3~8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003emalunion revision\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e22.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e3~4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e31.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003eSER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003eSER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003efall on flat road\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ediabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003efall from height\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e3~5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ediabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1~5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e22.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003etwist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePER4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003ediabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study introduces a novel strategy for the reduction of posterior Pilon fractures, which has shown promising results compared to previous approaches. Our method demonstrated improvements in the AOFAS scores and a reduction in the incidence of post-traumatic osteoarthritis following surgery. An important aspect of our technique is the sequence in which the fractures are reduced. We observed that in certain cases, reducing the lateral malleolus was challenging, particularly when there was significant displacement of both the medial and lateral malleoli. Based on these observations, we recommend that the medial and lateral malleoli be reduced primarily before proceeding to the reduction of the posterior malleolus. This sequence helps to achieve more stable fixation and provides better exposure, facilitating a more accurate reduction of the posterior fragment.\u003c/p\u003e\u003cp\u003eAchieving excellent reduction is crucial for optimal outcomes in patients with tibial plafond fractures. In addition to good fracture reduction, factors such as a lower BMI, OTA/AO 43-B (partial articular) fracture classification, and closed fractures are also associated with better functional results[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Without a satisfactory reduction, post-traumatic arthritis of the ankle joint becomes a significant challenge, often requiring additional surgical intervention[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, achieving anatomical reduction and stable fixation is vital in the treatment of posterior Pilon fractures [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Our proposed strategy offers a simplified approach to the reduction procedure. However, it remains challenging to anatomically reduce the tibial plafond without direct visualization, a limitation inherent to the posterior approach. The Klammer classification system, introduced in 2013, has been widely adopted to classify posterior Pilon fractures and guide treatment[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the present study, the mean postoperative AOFAS score was 82, with a mean follow-up of 22.7 months (range: 15\u0026ndash;30 months), and 18% of patients developed post-traumatic osteoarthritis by the final follow-up. A similar study, utilizing a combined posterolateral and anterior extensile approach in 2022, reported an average AOFAS score of 81.9 one year after surgery[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another study in 2019, using the posterolateral approach, reported an average AOFAS score of 82.3 (range: 44\u0026ndash;97) one year post-surgery[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These findings indicate that while our strategy improves clinical outcomes, the rates of post-traumatic osteoarthritis remain a significant concern, and further refinements in surgical technique may be needed to optimize long-term results.\u003c/p\u003e\u003cp\u003eThe transfibular approach has been previously utilized in various procedures, including tibiotalar arthrodesis, tibiotalocalcaneal arthrodesis, total ankle replacement, and distal tibial tumor excision surgeries[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Recently, it has been applied in the reduction of posterior Pilon fractures, offering the advantage of direct visualization of the tibial plafond. Liang et al. reported an average AOFAS score of 89.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 points and 61.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 degrees of ankle range of motion (ROM) in patients who underwent surgery using the transfibular approach, with a mean follow-up of 21 months (12\u0026ndash;35 months). In comparison, the posterolateral approach group had a lower AOFAS score (86.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1) and ankle ROM (58.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 degrees), suggesting better functional outcomes with the transfibular approach[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Gan et al. also demonstrated the advantages of the transfibular approach, reporting an AOFAS score of 88.6 (75\u0026ndash;100) in the transfibular group versus 85.5 (75.3\u0026ndash;90) in the posterior approach group. Additionally, the Kellgren-Lawrence degree was lower in the transfibular group, indicating a reduced incidence of post-traumatic osteoarthritis following surgery with this approach. The mean follow-up in their study was 40 months (13\u0026ndash;71 months)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Similarly, Jiang et al. reported an AOFAS score of 86.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 in the transfibular approach group versus 82.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9 in the posterior approach group at the final follow-up[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our strategy incorporates the transfibular approach with additional refinements. The average AOFAS score of our patients, who were followed up for 6 to 18 months post-surgery, supports the efficacy of our approach in improving functional outcomes and reducing complications associated with posterior Pilon fractures.\u003c/p\u003e\u003cp\u003eWith our proposed strategy, the mean AOFAS score was 89 (78\u0026ndash;100), which is comparable to the AOFAS scores reported in other studies using the transfibular approach[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Among the 14 patients included in our study, 3 patients had an AOFAS score of less than 80. Notably, one patient (44female) with an old malunion of a posterior Pilon fracture had an AOFAS score of 78, 6 months after revision surgery. Additionally, two diabetic patients (64male and 61female) had AOFAS scores of 80. In contrast, the AOFAS scores of two other patients (23female and 55female) were 100, and another (51female) had a score of 98. The AOFAS scores for the remaining 8 patients ranged between 85 and 90. We observed that mild pain, particularly between 6 and 18 months postoperatively, was quite common, which may account for some reductions in AOFAS scores. Regarding post-operative radiographic findings, only one patient (67female) showed a Kellgren-Lawrence grade of 1 (7%), while the remaining 13 patients (93%) had a grade of 0. In a previous study utilizing the transfibular approach, 60.9% of patients had a Kellgren-Lawrence grade of 0, 34.8% had grade 1, and 4.3% had grade 2, 2 years after surgery. In contrast, a study using the posterior approach reported a lower proportion of grade 0 (38.7%) and a higher proportion of grade 1 (38.7%), along with 19.4% grade 2, and even 1.6% for grades 3 and 4, 2 years after surgery[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Earlier research on one or two-column Pilon fractures found that 6.9% of patients had modified Kellgren-Lawrence grade 3 or 4 at 3 years post-surgery, with significantly higher rates (61.54%) in three or four-column fractures[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This further emphasizes the need for careful reduction and fixation in complex fractures to reduce the risk of long-term complications such as post-traumatic arthritis.\u003c/p\u003e\u003cp\u003eIn summary, our strategy further confirms the benefits of the transfibular approach for posterior Pilon fractures. It led to improved AOFAS scores, averaging around 90, compared to the traditional posterior approach, one year after surgery. Additionally, our approach significantly reduced the risk of post-traumatic osteoarthritis following posterior Pilon fractures, offering a promising solution for better long-term outcomes.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, its retrospective design and uneven follow-up periods present significant potential sources of bias. Second, the sample size was relatively small, which limits the generalizability of the findings. Future studies with larger sample sizes are needed to validate these results. Third, the follow-up period in this study was less than two years; therefore, longer follow-up studies are required to more comprehensively assess the long-term effectiveness of our strategy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe propose a novel strategy for the accurate reduction of posterior fragments in posterior Pilon fractures. This approach enhances the AOFAS score and reduces the incidence of post-traumatic osteoarthritis following surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics declarations\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the appropriate ethical review committee and strictly complies with all the provisions of the Declaration of Helsinki. All participants were fully informed of the nature of the study prior to the start of the study and signed informed consent forms. This study was approved by the Medical Ethics Review Committee of The First Hospital of Hebei Medical University: No. 2025(S00790).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eParticipants provided written consent permitting the publication of their clinical or personal details, including any identifying images associated with the study.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by Hebei Provincial Health and Family Planning Commission, 20241338.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;We would like to appreciate all individuals who contributed to this study.\u003c/p\u003e\n\u003cp\u003eAuthors' information\u003c/p\u003e\n\u003cp\u003eAuthors and Affiliations\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China\u003c/p\u003e\n\u003cp\u003eZhenhui Sun\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China\u003c/p\u003e\n\u003cp\u003eHecheng Zhou\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China\u003c/p\u003e\n\u003cp\u003eXiangliang Ge\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China\u003c/p\u003e\n\u003cp\u003eDehang Liu\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopaedic Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China\u003c/p\u003e\n\u003cp\u003eJinxi Hu\u003c/p\u003e\n\u003cp\u003eContributions\u003c/p\u003e\n\u003cp\u003eZ.S. provided fund, completed the most surgeries, wrote the manuscript. H.Z. wrote the manuscript, collected data and follow-up. X.G. follow-up and photograph. D.L. follow-up and photograph. J.H. revised the manuscript, completed part of surgeries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCorresponding author\u003c/p\u003e\n\u003cp\u003eCorrespondence to Jinxi Hu ([email protected]).\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eR\u0026uuml;edi TP, Allg\u0026ouml;wer M: \u003cstrong\u003eThe operative treatment of intra-articular fractures of the lower end of the tibia.\u003c/strong\u003e \u003cem\u003eClin Orthop Relat Res\u0026nbsp;\u003c/em\u003e1979\u003cstrong\u003e:\u003c/strong\u003e105-110.\u003c/li\u003e\n \u003cli\u003eBoesel J, DiGiacomo D, Hoffman B, Liu J: \u003cstrong\u003eA systematic review of posterior pilon fractures.\u003c/strong\u003e \u003cem\u003eJ Orthop\u0026nbsp;\u003c/em\u003e2025, 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classification system.\u003c/strong\u003e \u003cem\u003eFoot Ankle Int\u0026nbsp;\u003c/em\u003e2013, \u003cstrong\u003e34:\u003c/strong\u003e189-199.\u003c/li\u003e\n \u003cli\u003eHuang M, Wang Q, Guan J, Liu K, Chen Y, Wang L: \u003cstrong\u003eTips and Tricks in surgical reduction of the posterior column of AO/OTA C3 pilon fractures.\u003c/strong\u003e \u003cem\u003eBMC Musculoskelet Disord\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e23:\u003c/strong\u003e2.\u003c/li\u003e\n \u003cli\u003eHess MC, Abyar E, McKissack HM, Strom S, Johnson MD: \u003cstrong\u003eApplications of the transfibular approach to the hindfoot: A systematic review and description of a preferred technique.\u003c/strong\u003e \u003cem\u003eFoot Ankle Surg\u0026nbsp;\u003c/em\u003e2021, \u003cstrong\u003e27:\u003c/strong\u003e1-9.\u003c/li\u003e\n \u003cli\u003eLiang W, Zhou M, Jiang Z, Mao X, Zhou X: \u003cstrong\u003eTreatment outcomes of posterior pilon fractures using a simple single lateral approach via stretching fibular fracture line.\u003c/strong\u003e \u003cem\u003eFront Surg\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e10:\u003c/strong\u003e1141606.\u003c/li\u003e\n \u003cli\u003eLou Z, Wang Z, Liu C, Tang X: \u003cstrong\u003eOutcomes of tibial pilon fracture fixation based on four-column theory.\u003c/strong\u003e \u003cem\u003eInjury\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e54 Suppl 2:\u003c/strong\u003eS36-s42.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Posterior Pilon fracture, Ankle Joint, Fracture Reduction, Internal Fixation","lastPublishedDoi":"10.21203/rs.3.rs-6674240/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6674240/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Reducing the posterior fragment in posterior pilon fractures presents a significant surgical challenge due to its complex anatomy and limited exposure. In recent years, the transfibular approach has gained attention for enhancing reduction accuracy and improving American Orthopaedic Foot \u0026amp; Ankle Society (AOFAS) scores. However, the outcomes associated with the transfibular approach remain suboptimal in many cases. This study aims to introduce a novel reduction strategy specifically targeting the posterior fragment in posterior pilon fractures and overcome the limitations observed with current methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Clinical data were collected from 14 patients diagnosed with posterior pilon fractures who underwent surgical treatment between October 2023 and October 2024. All patients were treated using our proposed reduction strategy, which combined a transfibular approach with a posteromedial approach to improve fragment visualization and fixation. Postoperative recovery was assessed using the AOFAS score, the Visual Analog Scale (VAS) for pain, and the Kellgren–Lawrence grading system to evaluate the degree of post-traumatic osteoarthritis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 11 female and 3 male were included with a mean age of 45.2 (23–67) years. The mean follow-up duration was 13.1 months (6-19 months). The mean AOFAS score was 89 (78-100). All patients reported a VAS score of ≤1 during rest and active range of motion; however, VAS scores varied during weight-bearing ambulation. Radiographic evaluation showed that all patients had a Kellgren–Lawrence grade of 0 or 1, suggesting minimal or no radiographic evidence of post-traumatic osteoarthritis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e We propose a novel and effective for accurate reduction of the posterior fragment in posterior pilon fracture. It improves the AOFAS score and decreases posttraumatic osteoarthritis after surgery.\u003c/p\u003e","manuscriptTitle":"A Novel Strategy for Accurate Posterior Fragment Reduction in Posterior Pilon Fracture","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-16 05:55:17","doi":"10.21203/rs.3.rs-6674240/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5969d4e1-9974-4355-8fb0-ad81f593643a","owner":[],"postedDate":"July 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-06T08:09:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-16 05:55:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6674240","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6674240","identity":"rs-6674240","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}