Session X1I - Foot and Ankle
Outcomes of Treatment of Open Pilon Fractures: A Series of 68 Fractures Treated at a Level One Trauma Center
Background: Open pilon fractures remain among the most challenging injuries the traumatologist will encounter. There is a surprising paucity of literature evaluating the outcomes of these injuries treated in an era of modern soft-tissue coverage and staged fixation techniques. The purpose of this study is to retrospectively review a large, consecutive series of open fractures of the tibial pilon treated with contemporary techniques to learn more about the results and complications of treatment.
Methods: Between January 1996 and February 2004, 68 patients were treated at our level 1 trauma center for an open pilon fracture. There were 47 males and 21 females with a mean age of 44 years and a mean ISS of 13. Fractures were classified as OTA type 43A in 2 patients, 43B in 9, and 43C in 57. Traumatic wounds were Gustilo grade 1 in 6 patients, 21 grade 2, 20 grade 3A, 20 grade 3B, and 1 grade 3C. Twelve patients were lost to follow-up before 3 months, and one underwent immediate amputation, leaving 55 available for review with a mean follow-up of 24 months. All patients were treated with emergent irrigation and debridement and intravenous antibiotics. Initial bony stabilization was performed using a spanning external fixator in 56 patients (45 of whom had immediate fibular open reduction and internal fixation [ORIF]). Nine patients had acute plating and 2 patients, both with relatively stable fractures, were stabilized temporarily with a plaster splint. Of the 58 patients treated with a staged approach, 47 subsequently had ORIF, and 11 were managed definitively with external fixation. Outcomes were analyzed with specific attention to wound complications, deep infection, need for secondary surgeries, timing of soft-tissue coverage, and type of fixation strategy used. Wound complications were classified as minor (local wound care) or major (requiring operative debridement, hardware removal for infection, or late flap coverage).
Results: For the group as a whole, there were 20 major wound complications in 67 patients (30%). Of the 58 patients treated with a staged approach, 18 (31%) developed infection. Two of the 9 fractures treated with acute plating (22%) developed infection. 21 patients required flap coverage for their traumatic wounds (14 free flaps and 9 local flaps). 12 patients had flaps placed more than 3 days after plating due to scheduling difficulties with plastic surgery; of these, 10 (83%) developed infection. Nine 9 flaps were performed within 3 days, 3 developed infection. 47 patients did not require soft-tissue coverage for their traumatic wounds; of these, 10 (21%) ultimately developed infection. Infections by fracture type were 2 of 2 type 43A, 3 of 9 type 43B, and 15 of the 57 type 43C; by Gustilo grade, infections were 1 of 6 grade 1, 2 of 21 grade 2, 6 of 20 grade 3A, and 11 of the 20 grade 3B.
Conclusions/Significance: Although a staged protocol using temporary external fixation and delayed ORIF has been proven relatively safe for closed fractures, to date no study has exclusively evaluated a large series of open pilon fractures treated by Fellowship-trained traumatologists at a single level 1 trauma center with this strategy. When such a staged protocol was undertaken, 30% of patients developed infection. Patients should be counseled and surgeons cognizant of the high rate of complications even in the best of circumstances. When a flap will be necessary for coverage of the traumatic wound, careful coordination of timing with plastic surgery is recommended.