Fusion versus fixation in complex comminuted C3-type tibial pilon fractures: a systematic review

Yash P Chaudhry; Efstratios Papadelis; Hunter Hayes; Philip F Stahel; Erik A Hasenboehler

doi:10.1186/s13037-021-00298-2

Fusion versus fixation in complex comminuted C3-type tibial pilon fractures: a systematic review

Patient Saf Surg. 2021 Oct 18;15(1):35. doi: 10.1186/s13037-021-00298-2.

Authors

Yash P Chaudhry¹, Efstratios Papadelis¹, Hunter Hayes¹, Philip F Stahel², Erik A Hasenboehler³

Affiliations

¹ Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, 19131, USA.
² Department of Specialty Medicine, Rocky Vista University, College of Osteopathic Medicine, Parker, CO, 80134, USA.
³ Department of Orthopaedic Surgery, The Johns Hopkins University, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave. #A667, Baltimore, MD, 21224, USA. eahtrauma@icloud.com.

Abstract

Background: Comminuted 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.

Methods: A 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.

Results: The 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.

Conclusions: At 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.

Keywords: Complications; Patient outcomes; Post-traumatic osteoarthritis; Primary ankle arthrodesis; Staged surgical fixation; Tibial pilon fracture.