Abstract
BackgroundComminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes. This study reviewed [1] treatment, complications, and clinical outcomes in studies of complex comminuted tibial pilon fractures (type AO43-C3); and [2] primary ankle arthrodesis as a management option for these types of complex injuries.MethodsA systematic literature search was performed on PubMed from 1990 to 2020 to determine complications and outcomes after staged fracture fixation and primary ankle joint arthrodesis for comminuted C3-type tibial pilon fractures.The search was conducted in compliance with the PRISMA guidelines, using the following MeSH terms: “tibial pilon”/“pilon fracture”/“plafond fracture”/“distal tibial”/“43-C3”/“ankle fracture”/“ankle fusion”/“primary ankle arthrodesis”/“pilon fracture staged”/“pilon external fixation” and “pilon open reduction internal fixation.” Inclusion criteria were restricted to original articles in English language on adult patients ≥18 years of age. Eligibility criteria for retrieved publications were determined using a “PICO” approach (population, intervention/exposure, comparison, outcomes). Weighted analysis was used to compare treatment groups on time to definitive treatment, follow-up time, range of motion, fracture classification, and complications.ResultsThe systematic literature review using the defined MeSH terms yielded 72 original articles. Of these, 13 articles met the eligibility criteria based on the PICO statements, of which 8 publications investigated the outcomes of a staged fixation approach in 308 cumulative patients, and 5 articles focused on primary ankle arthrodesis in 69 cumulative patients. For staged treatment, the mean wound complication rate was 14.6%, and the malunion/nonunion rate was 9.9%. For primary arthrodesis, the mean wound complication rate was 2.9%, and the malunion/nonunion rate was 2.9%. After risk stratification for fracture type and severity, the small cumulative cohort of patients included in the primary arthrodesis publications did not provide sufficient power to determine a clinically relevant difference in complications and long-term patient outcomes compared to the staged surgical fixation group.ConclusionsAt present, there is insufficient evidence in the published literature to provide guidance towards consideration of ankle arthrodesis for complex comminuted C3-type tibial pilon fractures, compared to the standard treatment by staged surgical fracture fixation.
Highlights
Comminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes
The goal of treatment is to stabilize the fracture and reduce the joint anatomically, but to preserve the soft tissue envelope [1,2,3, 8]. This concept has led to recommendations of a staged procedure especially for high-energy AO 43-C2 and AO 43-C3 injuries; initial external fixation to allow soft tissue resting followed by open reduction and internal fixation (ORIF) 10 to 14 days later [10,11,12,13,14,15]
The authors searched the PubMed database for articles from January 1990 through June 2020 containing any of the following MeSH terms or combinations thereof: “tibial pilon,” “pilon fracture,” “plafond fracture,” “distal tibial,” “43-C3,” “ankle fracture,” “ankle fusion,” “primary ankle arthrodesis,” “pilon fracture staged,” “pilon external fixation,” and “pilon open reduction internal fixation.”
Summary
Comminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes. Type AO 43-C3 fractures, which have a high degree of comminution and extensive intra-articular involvement, are the most challenging because of the severe disruption to the articular surface and the associated soft tissue injury [3, 8,9,10,11]. The goal of treatment is to stabilize the fracture and reduce the joint anatomically, but to preserve the soft tissue envelope [1,2,3, 8] This concept has led to recommendations of a staged procedure especially for high-energy AO 43-C2 and AO 43-C3 injuries; initial external fixation (with or without internal fixation of the fibula) to allow soft tissue resting followed by open reduction and internal fixation (ORIF) 10 to 14 days later [10,11,12,13,14,15]
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