Comparison of Temporary External Fixation and Open Reduction with Internal Fixation for the Management of Pilon Fractures: A Short-Term Outcome Prospective Clinical Trial

Document Type : RESEARCH PAPER

Authors

Orthopedic Surgery Department, Cairo University, Cairo, Egypt

10.22038/abjs.2024.82445.3755

Abstract

Objectives: Pilon fractures are among the difficult injuries to treat in orthopedic surgery. We aim to 
evaluate the feasibility, advantages, and disadvantages of temporary external fixation for pilon fractures 
and compare its outcomes with cases managed with internal fixation and primary open reduction.
Methods: In a prospective trial, 30 patients were divided into two cohorts: a two-stage cohort with external fixation 
and secondary ORIF (15 patients) and a one-stage primary ORIF cohort (15 patients). We compared the two cohorts' 
rates of infection (deep or superficial infection), non-union, malunion, length of hospital stay, patient satisfaction with 
the American Orthopaedic Foot and Ankle Society (AOFAS) score, and pain level. 
Results: All assessed variables showed no significant variations between the two cohorts, except for hospital stay 
duration, which was substantially more prolonged in the two-stage cohort.
Conclusion: This study demonstrates that both temporary external fixation with secondary ORIF and primary ORIF 
are viable options for managing pilon fractures. While there were no significant differences in complications between 
the two treatment modalities, the two-stage approach was associated with a longer hospital stay. These findings 
suggest that primary ORIF may be preferable when aiming to reduce the duration of hospitalization without 
compromising clinical outcomes.
 Level of evidence: II

Keywords

Main Subjects


1. Galante VN, Vicenti G, Corina G, et al. Hybrid external fixation 
in the treatment of tibial pilon fractures: A retrospective 
analysis of 162 fractures. Injury. 2016; 47:S131-S137. doi: 
10.1016/j.injury.2016.07.045.
2. Flores M, Ciminero M, Kottmeier SA, Botros D, Zelle BA, 
Shearer DW. Pilon fractures: Consensus and controversy. OTA 
Int. 2023; 6(3 Suppl):e236. 
doi:10.1097/oi9.0000000000000236.
3. Jacob N, Amin A, Giotakis N, Narayan B, Nayagam S, Trompeter 
AJ. Management of high-energy tibial pilon fractures. 
Strategies Trauma Limb Reconstr. 2015; 10(3):137-47. 
doi:10.1007/s11751-015-0231-5.
4. Daghino W, Messina M, Filipponi M, Alessandro M. Temporary 
Stabilization with External Fixator in 'Tripolar' Configuration 
in Two Steps Treatment of Tibial Pilon Fractures. Open Orthop 
J. 2016; 10:49-55. doi:10.2174/1874325001610010049.
5. Rollo G, Filipponi M, Pichierri P, et al. Emergent and delayed 
hybrid external fixation management of tibial pilon fractures: 
A multicentric retrospective analysis of 80 patients. Journal of 
Acute Disease. 2017; 6(4):169-174. 
doi:10.12980/jad.6.20170404.
6. Elgawadi M, Radwan Y, Othman S, Barakat A, Sabry A, Ahmed 
A. Randomized Comparative STudy of Definitive External 
Fixation Versus Orif in Pilon Fractures: An Early Clinical 
Outcome Report. Georgian Med News. 2023 ;( 344):34-38. 
7. Ibrahim DA, Swenson A, Sassoon A, Fernando ND. 
Classifications in Brief: The Tscherne Classification of Soft 
Tissue Injury. Clin Orthop Relat Res. 2017; 475(2):560-564. 
doi:10.1007/s11999-016-4980-3.
8. Qiu XS, Li XG, Qi XY, Wang Z, Chen YX. What Is the Most Reliable 
Classification System to Assess Tibial Pilon Fractures? J Foot 
Ankle Surg. 2020; 59(1):48-52. 
doi:10.1053/j.jfas.2019.07.002.
9. Burwell HN, Charnley AD. The treatment of displaced fractures 
at the ankle by rigid internal fixation and early joint 
movement. J Bone Joint Surg Br. 1965; 47(4):634-660. 
10. Chan YH. Biostatistics 103: qualitative data - tests of 
independence. Singapore Med J. 2003; 44(10):498-503. 
11. Chan YH. Biostatistics 104: correlational analysis. Singapore 
Med J. 2003; 44(12):614-9. 
12. Luo TD, Pilson H,eds. Pilon Fracture. 1st ed. 
StatPearls.Treasure Island (FL): StatPearls Publishing; 2025. 
13. Minator Sajjadi M, Ebrahimpour A, Okhovatpour MA, Karimi A, 
Zandi R, Sharifzadeh A. The Outcomes of Pilon Fracture 
Treatment: Primary Open Reduction and Internal Fixation 
versus Two-stage Approach. Arch Bone Jt Surg. 2018; 
6(5):412-419. 
14. Guo Y, Tong L, Li S, Liu Z. External Fixation combined with 
Limited Internal Fixation versus Open Reduction Internal 
Fixation for Treating Ruedi-Allgower Type III Pilon Fractures. 
Med Sci Monit. 2015; 21:1662-7. doi:10.12659/msm.893289.
15. Esposito JG, van der Vliet QMJ, Heng M, et al. Does Surgical 
Approach Influence the Risk of Postoperative Infection After 
Surgical Treatment of Tibial Pilon Fractures? J Orthop Trauma. 
2020; 34(3):126-130. doi:10.1097/bot.0000000000001655.
16. Konrath GA, Hopkins G, 2nd. Posterolateral approach for tibial 
pilon fractures: a report of two cases. J Orthop Trauma. 1999; 
13(8):586-9. doi:10.1097/00005131-199911000-00013.
17. Erichsen JL, Andersen PI, Viberg B, Jensen C, Damborg F, Froberg L. A systematic review and meta-analysis of 
functional outcomes and complications following external 
fixation or open reduction internal fixation for distal intraarticular tibial fractures: an update. Eur J Orthop Surg 
Traumatol. 2019; 29(4):907-917. doi:10.1007/s00590-019-
02368-9.
18. Cui X, Chen H, Rui Y, Niu Y, Li H. Two-stage open reduction and 
internal fixation versus limited internal fixation combined 
with external fixation: a meta-analysis of postoperative 
complications in patients with severe Pilon fractures. J Int Med 
Res. 2018; 46(7):2525-2536. 
doi:10.1177/0300060518776099.
19. Richards JE, Magill M, Tressler MA, Shuler FD, Kregor PJ, 
Obremskey WT. External fixation versus ORIF for distal intraarticular tibia fractures. Orthopedics. 2012; 35(6):e862-7. 
doi:10.3928/01477447-20120525-25.
20. Harris AM, Patterson BM, Sontich JK, Vallier HA. Results and 
outcomes after operative treatment of high-energy tibial 
plafond fractures. Foot Ankle Int. 2006; 27(4):256-65. 
doi:10.1177/107110070602700406.