Judicious Use of Early Fixation of Closed, Complete Articular Pilon Fractures Is Not Associated With an Increased Risk of Deep Infection or Wound Complications
Authors: Olson Jeffrey J. , Anand Krishna , von Keudell Arvind , Esposito John G. , Rodriguez Edward K. , Smith R. Malcolm , Weaver Michael J. 
Published: November 2020

Objectives:
To compare the deep infection rates after immediate versus staged open reduction internal fixation (ORIF) for pilon fractures.

Design:
Retrospective cohort study.

Setting:
Three academic Level I trauma centers.

Patients:
Four hundred one patients with closed OTA/AO type 43C distal tibia fractures treated with ORIF. Sixty-six percent were men, and the mean age was 45.6 years. The median (interquartile range) follow-up was 1.7 (1.0–3.7) years.

Intervention:
Acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours).

Main Outcome Measurement:
Deep infection or wound complication as defined by return to operating room for surgical irrigation and debridement.

Results:
Patients were grouped by time from presentation to surgery: acute ORIF (n = 99) and delayed ORIF (n = 302). Acute ORIF was more frequent in patients with OTA/AO type 43C1 fractures, low-energy mechanisms (ie, fall from standing), younger and female patients. Patients who demonstrated severe swelling (242, 80%), swelling and fracture blisters (26, 9%), swelling and ecchymosis precluding planned surgical approach (4, 1%), polytrauma requiring resuscitation (20, 6%), who were transferred from an outside facility with external fixator in place (6, 2%), who had evolving compartment syndrome (2, 1%), and who required medical clearance (2, 1%) underwent staged, delayed fixation. There were significantly more 43C1 fractures in the acute fixation group (31% vs. 7%, P < 0.001) and significantly more 43C3 fractures in the delayed group (63% vs. 37%, P < 0.001). The overall deep infection rate was 17%. Early surgery was not associated with an increased risk of postoperative wound complication (early 12% vs. delayed 18%, P = 0.235). Multivariate analysis adjusted for timing of surgery found high-energy trauma [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.1–13.8], smoking (OR 2.4, CI 1.3–4.6), male sex (OR 2.1, CI 1.0–4.1), and increasing age (OR 1.02, CI 1.00–1.04, P = 0.040) to be independent predictors of deep infection. Diabetes demonstrated a nonstatistically significant increased risk (OR 2.6, 95% CI 0.9–7.3, P = 0.063).

Conclusions:
This study confirms the high risk of infection after the fixation of tibial plafond fractures. If early definitive fixation is considered, extreme care should be taken to carefully evaluate the soft tissue envelope and assess for other risk factors (such as age, male sex, smokers, diabetics, and those with higher-energy fracture patterns) that may predispose the patient to a postoperative soft tissue infection. Our study has shown that the judicious use of early definitive fixation in closed pilon fractures, in the appropriate patient, and with careful evaluation of the soft tissue envelope, is likely safe and does not seem to increase the risk of wound complications and deep infection in the hands of experienced fracture surgeons.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.