Comparison of clinical and functional outcomes of open reduction internal fixation and circular external fixation in the management high-energy tibial pilon fractures: a systematic review

K. Malik-Tabassum, K. Pillai, S. Bleibleh, Y. Hussain, T. Tosounidis

Background: In high-energy tibial pilon fractures, combination of articular impaction, metaphyseal comminution and soft-tissue injury often result in poor outcomes. We conducted a systematic review of the literature to compare clinical and functional outcomes of open reduction internal fixation(ORIF) and circular external fixation(CEF) for treatment of high-energy tibial pilon fractures.

Methods: A comprehensive search of PubMed, MEDLINE, Embase, Scopus and Cochrane library was undertaken. Identified studies were peer-reviewed and screened against a strict eligibility criteria. Studies published in English, comparing ORIF with CEF for treatment of AO/OTA Type 43B and 43C fractures were included.

Results: 195 studies were identified, of which 4 studies met the inclusion criteria. Danoff et al. demonstrated comparable clinical and functional outcomes in open pilon fractures treated with ORIF or CEF. Bacon et al. showed no significant difference in time to union, rates of union, malunion, non-union, post-operative infections, or iatrogenic nerve injuries between the treatment groups. Harris et al. found lower post-operative complication rates and higher functional outcome scores in the ORIF group, though the authors acknowledged that 88% of patients treated with CEF sustained Type 43-C3 fractures. Watson et al. showed no statistically significant difference in the Modified Mazur score between both groups, but higher rates of non-union, infections and secondary procedures in the ORIF group.

Conclusion: This systematic review demonstrates that high-energy tibial pilon fractures remain a therapeutic challenge, and highlights lack of high-quality evidence in the literature. Conflicting results in the literature may be due to variation in study methodologies and outcome reporting. Therefore, recommendations for the best fixation method of these complex injuries cannot be made. In order to generate high-quality evidence regarding best treatment modality for high-energy tibial pilon fractures, UK Major Trauma Networks need to work collaboratively to undertake well-designed large multi-centred prospective studies.