# Reduction and outcome of posterior pilon fractures with intercalary fragments: a retrospective cohort study comparing the transfibular and posteromedial approaches

## TL;DR

This study compares two surgical approaches for treating posterior pilon fractures and finds similar long-term outcomes but shorter surgery time with one method.

## Contribution

The study provides the first long-term outcome comparison of the transfibular and posteromedial approaches for posterior pilon fractures with intercalary fragments.

## Key findings

- The TFFR approach had shorter surgical duration compared to the posteromedial approach.
- Both approaches showed similar functional outcomes in terms of pain, quality of life, and activities of daily living.
- The TFFR approach may be preferred for fractures in the same plane due to reduced surgical time and single incision use.

## Abstract

The transfibular fracture region (TFFR) approach can be utilized for managing posterior pilon fractures associated with intercalary fragments. However, its long-term outcomes remain unreported. This study aimed to compare the long-term clinical outcomes of the TFFR approach and the posteromedial approach for posterior pilon fractures (Klammer type 2/3, Danis–Weber type B) associated with displaced intercalary fragments over an average 8 year follow-up.

From 2012 to 2018, a cohort of consecutive patients who underwent open reduction and internal fixation surgery via either the TFFR approach or the posteromedial approach for posterior pilon fracture associated with intercalary fragments were enrolled for this study. Clinical outcomes were evaluated over an average 8 year (range 5–12 years) follow-up. The surgical duration, number of intraoperative fluoroscopies, and postoperative complications were recorded. Functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), and Short Form-36 (SF-36) score at last follow-up.

Seventy-nine patients were included in the final analysis, including 43 in the TFFR group and 36 in the posteromedial group. No significant differences between the two groups were observed in the FAOS (p = 0.679) or its specific components for symptoms (p = 0.264), pain (p = 0.963), activities of daily living (ADL, p = 0.102), sports (p = 0.156), or quality of life (p = 0.859). There was also no significant difference between the two groups in the FAAM-ADL (p = 0.408), FAAM-Sport (p = 0.617), and SF-36 scores (p = 0.757). Nevertheless, the surgical duration was shorter in the TFFR group (p < 0.001).

The TFFR approach is not inferior to the posteromedial approach. For posterior pilon fractures with lateral malleolar fractures in the same plane, the TFFR approach may be preferred owing to its potential to reduce surgical time and the use of a single incision.

Level of Evidence Level III, retrospective cohort study.

The online version contains supplementary material available at 10.1186/s10195-025-00851-0.