Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters

Abstract

Objective: To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures. Design: Retrospective cohort study. Setting: 3 Level 1 tertiary academic trauma centers. Patients/Participants: The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures. Main Outcome Measurements: Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal. Results: The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate (P < 0.05), smoking with rate of nonunion (P < 0.05), and Charlson Comorbidity Index with loss of articular reduction (P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating. Conclusions: While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.