Review Question - QID 219021

This patient has a 43C pilon fracture. The most appropriate treatment strategy for this patient to optimize her outcome and mitigate postoperative complications would be closed reduction and external fixation with delayed open reduction internal fixation (ORIF).

Tibial pilon fractures are severe injuries that occur secondary to a high-energy axial load through the ankle joint (whereas typical ankle fractures are secondary rotational forces). These fractures are relatively rare and constitute only 5% to 10% of all tibial fractures. Multiple treatment strategies have been described, and the superior method remains a topic of debate. Acute ORIF is fraught with complications in these injuries, including an infection rate as high as 55%. The two most commonly employed techniques utilized today are two-stage ORIF and limited internal fixation combined with external fixation (LIFEF). Two-stage ORIF typically involves acute closed reduction and application of an external fixator to re-establish length, dis-impact the articular surface, and facilitate soft tissue rest. Once the soft tissues are amenable, the patient is taken back for definitive ORIF, which is typically 10-14 days after injury. LIFEF involves acute minimally invasive fixation typically with percutaneous fixation techniques in addition to external fixator application. While studies have demonstrated that comparable results could be achieved by LIFEF while minimizing the infection and skin sloughing rates. However, more recent studies have demonstrated increased rates of superficial infection bone healing issues with this technique. The current literature suggests that the most appropriate treatment strategy for severe pilon fractures to optimize outcomes and mitigate postoperative complications is a two-stage ORIF.

Cui et al. performed a meta-analysis to quantitatively compare the postoperative complications between two-stage ORIF and LIFEF. They reported that two-stage ORIF had a significantly lower risk of superficial infection, nonunion, and bone healing problems than the LIFEF group. However, no significant differences in deep infection, delayed union, malunion, arthritis symptoms, or chronic osteomyelitis were found between the two. They concluded that two-stage ORIF was associated with a lower risk of postoperative complications with respect to superficial infection, nonunion, and bone healing problems than LIFEF for tibial Pilon fractures.

Patterson and Cole performed a retrospective study evaluating the use of a two-stage technique for the treatment of C3 pilon fractures. They reported twenty-one of the twenty-two fractures healed within an average of 4.2 months, and that subjective and objective measurements showed 77% good results, 14% fair results, and 9% poor results. They concluded that a two-staged approach offers acceptable results for the treatment of severe pilon fractures.

Sirkin et al. performed a retrospective study to determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol results in minimal surgical wound complications. They reported that the average time from external fixation to formal reconstruction was fourteen days (range 4 to 31 days) and that the complication rate was 10.5% (deep infection). They concluded that the two-stage technique appears to be effective in closed and open fractures alike.

Olson et al. performed a retrospective cohort study comparing the deep infection rates following immediate versus staged open reduction internal fixation (ORIF) for pilon fractures. Patients were grouped by time from presentation to surgery: acute ORIF and delayed ORIF. Note that patients with swelling and ecchymosis precluding surgical approach all underwent delayed ORIF. They reported that early surgery was not associated with increased risk of post-operative wound complication, and that high-energy trauma, smoking, male sex, and increasing age were independent predictors of deep infection.

Figure A demonstrates an AP and lateral radiograph of a 43C pilon fracture.

Incorrect Answers:
Answer 1: Definitive management in a splint would not be appropriate and this would not allow for appropriate restoration of length, alignment and rotation.
Answer 3: Severe swelling of the soft tissues is eminent with these fractures and acute fixation poses an extremely high risk for wound healing complications.
Answer 4: In the setting of swelling (as well as ecchymosis in area of planned approach), the current literature suggests that the most appropriate treatment strategy for severe pilon fractures to optimize outcomes and mitigate postoperative complications is a two-stage ORIF. Furthermore, it would be very difficult to obtain appropriate fixation of the patient’s distal tibia given the comminution of the metaphysis and diaphysis with acute limited internal fixation alone.
Answer 5: While definitive management with an external fixator would incur a decreased risk of wound necrosis and skin sloughing, this strategy is associated with high rates of pin site infection, malalignment and nonunion.