To evaluate the incidence of nonunion and wound complications following open, complete articular pilon fractures. Second, to study the effect that both timing of fixation and timing of flap coverage have on deep infection rates.
Retrospective case series.
Three Academic Level One Trauma Centers.
161 patients with open AO/OTA type 43C distal tibia fractures treated with open reduction internal fixation (ORIF) between 2002-2018. Mean (SD) age of 46 (14) years, 70% male, with median (IQR) follow up of 2.1 (1.3-5.0) years (minimum 1 year). There were 133 (83%) type 3A and 28 (17%) type 3B open fractures.
Fracture fixation: Acute, primary (24 hours). Soft tissue coverage: rotational or free flap.
Primary outcomes included deep infection and nonunion. Secondary outcomes included rates of soft tissue coverage and reoperation.
Acute fixation (<24 hours) was performed in 36 (22%) patients; 125 (78%) underwent delayed, staged fixation. Deep infection occurred in 27% patients and was associated with males (33% vs. 16%, p=0.029), smoking (38% vs. 23%, p=0.047), type 3B fractures (39% vs. 25%, p=0.046). Acute fixation of type 3A fractures demonstrated higher rate of infection (38% vs. 20% p=0.036) than delayed, staged fixation. In type 3B fractures, early flap coverage (< 1 week) demonstrated lower rate of infection (18% vs. 53%, p=0.066) and 20% (vs. 43%) with a single-staged "fix and flap" procedure (p=0.408). Nonunion occurred in 36 (22%) and was associated with deep infection (43% vs. 15%, p<0.001). Fifteen (42%) were septic nonunions. Twenty-nine of the 36 (81%) nonunions achieved radiographic union after median (IQR) 27 (20-41) weeks and median (range) 1 (1-3) revision ORIF procedures. There was no difference in rate of secondary union between septic and aseptic nonunions (85% vs 86%, p=1.00). There was a high rate of secondary procedures (47%): revision ORIF (17%), I&D, (15%), and removal hardware (11%).
Complete articular, open pilon fractures are associated with high rate of complications following ORIF. Early fixation carries a high risk of deep infection, however early flap coverage for 3B fractures appears to play a protective role. We advocate for aggressive management including urgent surgical debridement and very early soft tissue cover combined with definitive fixation during single procedure if possible.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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