Tibial pilon fractures resulting from high-energy mechanisms typically involve substantial comminution and soft tissue injury. Over the years, several treatment methods have been used for the management of these fractures (30-32). Although there is no standardized method of fixation (33), most surgeons favor a staged approach to allow resolution of soft tissue swelling, which typically involves temporary ankle-bridging external fixation with or without fibular internal fixation followed by definitive ORIF (8, 10-15). The current study’s aim was to determine, on the basis of a review of the current literature, whether primary ankle arthrodesis is a reasonable alternative treatment choice to staged ORIF for AO43-C3 fractures. Although qualitative synthesis was performed and demonstrated no differences in any of the observed outcomes other than certain short-term complications (wound complications, infection, or hardware pain), there was insufficient evidence to allow for any definitive conclusion. The authors found that there are relatively few quality data reported in the literature regarding the management of AO 43-C3 fractures. None of the studies reviewed had complete data, there was a lack of homogeneity in outcomes reporting, and most studies did not adequately distinguish among fracture types or report complete data on complications. Additionally, data on primary ankle arthrodesis are limited compared with staged ORIF and with all of these articles reporting only relatively small numbers of cases.
PICO Question 1: Short-Term Complications
Using primary arthrodesis for severely comminuted pilon fractures is not a novel concept. Beckwitt et al examined the differences in patient outcomes between primary arthrodesis and primary ORIF in AO-43C3 pilon fractures and found that patients treated with the arthrodesis approach had a lower rate of nonunion (23). While this study was notable in that the average follow-up was 73.7 months, like the other studies included in this review, it did not have a treatment arm involving staged treatment (primary ORIF was the comparator group). Zelle et. al (22) assessed 20 patients who underwent blade plate ankle fusion of comminuted tibial plafond fractures, and with a two-year follow-up reported no wound complications and only one incidence of nonunion.
Bozic et al (8) treated 15 severely comminuted AO 43-C3 fractures with primary tibiotalar arthrodesis using a fixed-angle blade plate, achieving ankle fusion at an average of 15 weeks (range, 10-21). No patient required secondary procedures to obtain union. Similar results had previously been reported by Morgan et al (21) in a series of 6 patients, in which primary ankle fusion was obtained after a mean of 26 weeks (range, 20-34). In a retrospective study of 63 patients, Beaman and Gellman (20) reported on the outcomes of 13 patients treated over 2 years, whose highly comminuted tibial pilon fractures were treated with primary arthrodesis. The authors, who chose fusion based on clinical experience, theorized that primary ankle arthrodesis would expedite the patients’ recovery and return to regular activity and improve clinical outcomes without the need for multiple procedures and long recovery times, as required with a staged approach. In their series, they were able to support their assumption with a high healing rate and good overall American Orthopaedic Foot and Ankle Society (AOFAS) functional score of 83 (34).
These findings are compatible with the functional score seen after ankle arthrodesis for osteoarthritis. Similar results were published by Zelle et al (22), who retrospectively reviewed 20 patients, all with AO 43-C3 fractures treated over a period of 17 years with primary arthrodesis. Their results were comparable to those of other primary arthrodesis studies, with very low soft tissue complication and nonunion rates and acceptably good outcomes, with all patients able to ambulate without assistive devices. These latest findings complement the outcome published by Hendrickx et al (35) in 2011, who studied 66 ankle arthrodesis cases performed for various indications at a mean follow-up of 9 years. The authors found that 91% of their patients were satisfied with their achieved ankle condition, with an AOFAS score of 67 ± 12 and an improved mental health perception according to the SF-36 score (35). On the basis of their findings, they suggested that ankle arthrodesis improves the quality of life for patients with end stage ankle osteoarthritis.
PICO Question 2: Long-Term Complications
Poor outcomes of pilon fractures is associated with the extent of articular surface involvement and cartilage damage and quality of the anatomical reduction of the fracture fragments (3, 8, 33, 36-38). This point has been highlighted by Anderson et al(36) and Marsh et al(38) ,who emphasized the high incidence (up to 50%) of PTOA secondary to fractures of the distal tibial articular surface. Both studies reported a strict correlation (P<.01) between the development of PTOA and the high-energy injury and fracture pattern, with a 20-fold higher risk of developing osteoarthritis within 2 years after high-energy pilon fractures. Similarly, Horisberger et al (37) addressed the link between the development of PTOA and ankle fracture pattern with significantly shorter osteoarthritis latency time (P<.01) in highly comminuted pilon fractures. Such articles emphasize the importance of evaluating the degree of articular surface damage because it can indicate a probable poor outcome.
Unfortunately, much of the literature reviewed in this study lacks long-term data needed to assess for the development of these outcomes. Among cases involving a staged treatment protocol, the average follow-up period was 26 months (range, 9-36). This number was significantly greater in the primary arthrodesis cohort, with an average follow-up time of 60 months (range, 24-86). Follow-up length is especially important when considering outcomes like PTOA, secondary arthrodesis, and amputation because these developments are typically observed with medium- or long-term follow-up. Most of the staged approach studies reviewed focused on short- or medium-term outcomes and thus did not adequately address long-term outcomes, especially arthrosis development. On the basis of the review of staged procedure articles, with reported PTOA rates of 20% to 50%, the authors estimate the rate of secondary arthrodesis in patients with comminuted pilon fractures to be higher than the data reported in more recent series (8% to 20%) (3, 15, 26-29) as most of these studies had inadequate follow-up, an issue commonly seen in trauma populations (39). No PTOA is expected in the primary arthrodesis group, as this complication is avoided with the joint fusion procedure. Thus, on the basis of this review, no conclusions can be made regarding the comparison of PTOA long-term outcomes between arthrodesis and staged ORIF.