Open Pilon Fracture Postoperative Outcomes with Definitive Surgical Management Options: A Systematic Review and Meta-analysis



1 Faculty of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK

2 Department of Trauma and Orthopaedics, Cambridge University Hospital, Addenbrookes Major Trauma Centre, Cambridge, UK


Background: Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Different
techniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-
Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole,
very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgical
management options can influence postoperative complications, and if this can influence future management protocols.
Methods: We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications and
functional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD42020184213).
The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation,
osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was also
measured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions.
Results: The search yielded 309 results and a total of 18 studies consisting of 484 patients were included. All fractures
included were open, and consisted of 64 Gustilo-Anderson Type I, 148 Type II, 103 Type IIIa, 90 Type IIIb and 9 Type
IIIc. 60 Type III fractures could not be further separated and 12 were ungraded. Both ORIF and Ex-Fix were found to
have statistically similar AOFAS scores (P=0.682). For all included studies, the Ex-Fix group had significantly higher
rates of superficial infections (P=0.001), non-unions (P=0.001), osteoarthritis (P=0.001) and bone grafting (P=0.001).
The meta-analysis found no significant difference in non-union (pooled OR=0.25, 95% CI: 0.03 to 2.24, P=0.44) or deep
infection rates (pooled OR=1.35, 95% CI: 0.11 to 16.69, P=0.12) between the ORIF and Ex-fix groups.
Conclusion: Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to have
a significantly higher risk of postoperative complications which must be considered by surgeons when choosing
surgical management options. Further research, ideally in a randomised control trial format, is required to definitively
demonstrate ORIF superiority in the management of open pilon fractures.
Level of evidence: I


1. Tomás-Hernández J. High-energy pilon fractures
management: State of the art. EFORT open reviews.
2016; 1(10):354-61.
2. Mauffrey C, Vasario G, Battiston B, Lewis C, Beazley
J, Seligson D. Tibial pilon fractures: A review of
incidence, diagnosis, treatment, and complications.
Acta Orthopaedica Belgica. 2011; 77(4):432.
3. White TO, Guy P, Cooke CJ, Kennedy SA, Droll KP,
Blachut PA, et al. The results of early primary open
reduction and internal fixation for treatment of
OTA 43. C-type tibial pilon fractures: a cohort study.
Journal of orthopaedic trauma. 2010; 24(12):757-63.
4. Grose A, Gardner MJ, Hettrich C, Fishman F, Lorich DG,
Asprinio DE, et al. Open reduction and internal fixation
of tibial pilon fractures using a lateral approach.
Journal of orthopaedic trauma. 2007; 21(8):530-7.
5. Wang D, Xiang JP, Chen XH, Zhu QT. A meta-analysis 
for postoperative complications in tibial plafond
fracture: open reduction and internal fixation versus
limited internal fixation combined with external
fixator. The Journal of Foot and Ankle Surgery. 2015;
6. Marcus MS, Yoon RS, Langford J, Kubiak EN, Morris AJ,
Koval KJ, et al. Is there a role for intramedullary nails
in the treatment of simple pilon fractures? Rationale
and preliminary results. Injury. 2013; 44(8):1107-11.
7. Vidović D, Matejčić A, Ivica M, Jurišić D, Elabjer E,
Bakota B. Minimally-invasive plate osteosynthesis
in distal tibial fractures: results and complications.
Injury. 2015; 46:S96-9.
8. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche
PC, Ioannidis JP, et al. The PRISMA statement for
reporting systematic reviews and meta-analyses
of studies that evaluate health care interventions: 
explanation and elaboration. Journal of clinical
epidemiology. 2009; 62(10):e1-34.
9. Natasha Daniels, Jiang An Lim, Azeem Thahir.
Open pilon fracture postoperative outcomes with
different definitive surgical management options:
a systematic review and meta-analysis. PROSPERO
2020 CRD42020184213 Available from: https://
10. Hu C, Zhu W, Chahal K, Zhu N, Fang W, Jing J, et al.
Open reduction and internal fixation of Gustilo
type-I and type-II open pilon fractures using a lateral
approach. Journal of Orthopaedic Surgery. 2019;
11. Encinas-Ullán CA, Fernandez-Fernandez R, Rubio-
Suárez JC, Gil-Garay E. Medial versus lateral plating
in distal tibial fractures: a prospective study of 40
fractures. Revista Española de Cirugí􀆴a Ortopédica y
Traumatologí􀆴a (English Edition). 2013; 57(2):117-22.
12. Choi KY, Lee JY, Jang H, Kim YW. Result of Staged
Operation in Ruedi-Allgower Type II and III Open Tibia
Pilon Fractures with Severe Comminution. Journal of
Korean Foot and Ankle Society. 2019; 23(3):110-5.
13. Boraiah S, Kemp TJ, Erwteman A, Lucas PA, Asprinio
DE. Outcome following open reduction and internal
fixation of open pilon fractures. JBJS. 2010; 92(2):
14. Sirkin M, Sanders R, DiPasquale T, Herscovici Jr D.
A staged protocol for soft tissue management in
the treatment of complex pilon fractures. Journal of
orthopaedic trauma. 1999; 13(2):78-84.
15. Bone LA, Stegemann PH, McNamara KE, Seibel RO.
External fixation of severely comminuted and open
tibial pilon fractures. Clinical orthopaedics and
related research. 1993 (292):101-7.
16. Molina CS, Stinner DJ, Fras AR, Evans JM. Risk factors
of deep infection in operatively treated pilon fractures
(AO/OTA: 43). Journal of Orthopaedics. 2015;
12(Suppl 1):S7-13.
17. Gardner MJ, Mehta S, Barei DP, Nork SE. Treatment
protocol for open AO/OTA type C3 pilon fractures
with segmental bone loss. Journal of orthopaedic
trauma. 2008; 22(7):451-7.
18. Gehr J, Hilsenbeck F, Arnold T, Friedl W. Minimally
invasive management of distal metaphyseal tibial
fractures and pilon fractures. European Journal of
Trauma. 2004; 30(6):378-86.
19. Danoff JR, Saifi C, Goodspeed DC, Reid JS. Outcome of
28 open pilon fractures with injury severity-based
fixation. European Journal of Orthopaedic Surgery &
Traumatology. 2015; 25(3):569-75.
20. Silluzio N, De Santis V, Marzetti E, Piccioli A, Rosa
MA, Maccauro G. Clinical and radiographic outcomes
in patients operated for complex open tibial pilon
fractures. Injury. 2019; 50:S24-8.
21. Zeng XT, Pang GG, Ma BT, Mei XL, Sun X, Wang J,
et al. Surgical treatment of open pilon fractures.
Orthopaedic surgery. 2011; 3(1):45-51.
22. Conroy J, Agarwal M, Giannoudis PV, Matthews SJ.
Early internal fixation and soft tissue cover of severe
open tibial pilon fractures. International orthopaedics.
2003; 27(6):343-7.
23. Harris AM, Patterson BM, Sontich JK, Vallier HA.
Results and outcomes after operative treatment of
high-energy tibial plafond fractures. Foot & ankle
international. 2006; 27(4):256-65.
24. Kapukaya A, Subasi M, Arslan H, Tuzuner T. Nonreducible,
open tibial plafond fractures treated with
a circular external fixator (is the current classification
sufficient for identifying fractures in this area?).
Injury. 2005; 36(12):1480-7.
25. Yildiz C, Atesalp AS, Demiralp B, Gür E. High-velocity
gunshot wounds of the tibial plafond managed with
Ilizarov external fixation: a report of 13 cases. Journal
of orthopaedic trauma. 2003; 17(6):421-9.
26. Wyrsch B, McFerran MA, McAndrew M, Limbird TJ,
Harper MC, Johnson KD, et al. Operative treatment
of fractures of the tibial plafond. A randomized,
prospective study. JBJS. 1996; 78(11):1646-57.
27. Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS,
Boutron I, et al. RoB 2: a revised tool for assessing risk
of bias in randomised trials. bmj. 2019; 366.
28. Rüedi TP, Allgöwer M. Fractures of the lower end of
the tibia into the ankle-joint. Injury. 1969; 1(2):92-9.
29. Zelle BA, Dang KH, Ornell SS. High-energy tibial pilon
fractures: an instructional review. International
orthopaedics. 2019:1-2.
30. Bear J, Rollick N, Helfet D. Evolution in management
of tibial pilon fractures. Current reviews in
musculoskeletal medicine. 2018; 11(4):537-45.
31. Shah KN, Johnson JP, O’Donnell SW, Gil JA, Born
CT, Hayda RA. External Fixation in the Emergency
Department for Pilon and Unstable Ankle Fractures.
JAAOS-Journal of the American Academy of
Orthopaedic Surgeons. 2019; 27(12):e577-84.
32. Kottmeier SA, Madison RD, Divaris N. Pilon fracture:
preventing complications. JAAOS-Journal of the
American Academy of Orthopaedic Surgeons. 2018;
33. Jacob N, Amin A, Giotakis N, Narayan B, Nayagam S,
Trompeter AJ. Management of high-energy tibial
pilon fractures. Strategies in trauma and limb
reconstruction. 2015; 10(3):137-47.
34. Saad BN, Yingling JM, Liporace FA, Yoon RS. Pilon
Fractures: Challenges and Solutions. Orthopedic
Research and Reviews. 2019; 11:149.
35. Anderson DD, Marsh JL, Brown TD. The pathomechanical
etiology of post-traumatic osteoarthritis following
intraarticular fractures. The Iowa orthopaedic journal.
2011; 31:1.
36. Ewalefo SO, Dombrowski M, Hirase T, Rocha JL,
Weaver M, Kline A, et al. Management of posttraumatic
ankle arthritis: literature review. Current reviews in
musculoskeletal medicine. 2018; 11(4):546-57.
37. Rubio-Suarez JC, Carbonell-Escobar R, Rodriguez-
Merchan EC, Ibarzabal-Gil A, Gil-Garay E. Fractures of
the tibial pilon treated by open reduction and internal
fixation (locking compression plate-less invasive
stabilising system): Complications and sequelae.
Injury. 2018; 49:S60-4.
38. Finkemeier CG. Bone-grafting and bone-graft
substitutes. JBJS. 2002; 84(3):454-64. 
39. Cutillas-Ybarra MB, Lizaur-Utrilla A, Lopez-Prats FA.
Prognostic factors of health-related quality of life in
patients after tibial plafond fracture. A pilot study.
Injury. 2015; 46(11):2253-7.
40. Liporace FA, Yoon RS. Decisions and staging leading to
definitive open management of pilon fractures: where
have we come from and where are we now? Journal of
orthopaedic trauma. 2012; 26(8):488-98.