- This multicenter, retrospective cohort study evaluated 401 patients who underwent open reduction and internal fixation for a type 43C pilon fracture, of whom 25% received definitive fixation within 24 hours and 75% underwent staged surgery
- The risk of deep infection was similar in the early fixation group (12%) and the delayed fixation group (18%; P=0.35)
- The greater the amount of comminution, a proxy for degree of soft tissue and overall energy of the injury, the higher the rate of deep infection
- Multivariable analysis identified male sex, smoking, high-energy injury and older age as independent predictors of deep infection regardless of timing of fixation
- Early definitive fixation may be reasonable even for patients with comminuted pilon fractures; if it is considered, patients should be assessed for the infection risk factors revealed here, and the soft tissue envelope should be examined carefully
Surgical management of pilon fractures (also called tibial plafond fractures) has come full circle. Early on, immediate management was associated with high rates of infection and wound complications, so staged treatment protocols were developed in which external fixation is placed to allow for soft tissue rest before definitive fixation.
Over the past few years, though, several studies have renewed interest in open reduction and internal fixation (ORIF) within the first 24–48 hours. Results suggest that, in carefully selected patients, it can lead to high union rates and good functional outcomes without high rates of wound complications.
Now, a large multicenter retrospective study has confirmed that, with judicious patient selection, early definitive fixation does not appear to increase the postoperative risk of deep infection. Jeffrey J. Olson, MD, orthopaedic surgery resident, John G. Esposito, MD, orthopedic trauma surgeon, R. Malcolm Smith, MD, chief of the Orthopedic Trauma Center, and colleagues in the Harvard Medical School Orthopedic Trauma Initiative, report the findings in the Journal of Orthopaedic Trauma.
The study subjects were 401 patients who underwent ORIF for a type 43C pilon fracture between 2002 and 2018 at one of three Harvard teaching hospital level 1 trauma centers. They were grouped according to the timing of surgery, which was at the surgeon's discretion:
- Early fixation: 99 patients (25%) patients received definitive fixation within 24 hours
- Delayed fixation: 302 patients (75%) underwent staged surgery
The primary outcome was deep infection, defined as an infection or wound complication at the surgical site that required surgical irrigation and debridement.
- Early group: 12% had deep infection
- Delayed group: 18% (P=0.35)
Patients with High-Energy Injury Mechanisms
- Early group: 15%
- Delayed group: 5% (P=0.24)
The greater the amount of comminution, the higher the rate of deep infection, but rates did not differ significantly with early versus delayed fixation.
Rates of superficial wound infection, delayed closure, need for skin grafting and need for flap coverage did not differ significantly between groups. Tourniquet and operative times were 15 and 31 minutes shorter, respectively, with early fixation (P<0.001 for both comparisons).
Independent predictors of deep infection, regardless of the timing of fixation, were:
- High-energy injuries (OR, 4.0)
- Smoking (OR, 2.4)
- Male sex (OR, 2.1)
- Increasing age (OR, 1.02)
Diabetes was associated with an increased risk of deep infection (OR, 2.6) but was not a statistically significant predictor.
Recommendations for Surgeons
Early definitive fixation may be reasonable even for patients with comminuted pilon fractures. If it is considered, patients should be assessed for the infection risk factors revealed here and the soft tissue envelope should be examined extremely carefully. Factors important to success include pliable skin with wrinkling, no blistering (serous or hemorrhagic) in the surgical field and a level of swelling that will not preclude tension-free wound closure.
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