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Predictors of Revision Surgery to Promote Bone Healing After Surgical Fixation of Pilon Fractures
Anthony L Wilson1, Robin M Litten, James E Darnley
1From the Department of Orthopaedic Surgery (Wilson, Litten, Patch, McGwin, Johnson, Spitler), University of Alabama at Birmingham, Birmingham, AL, the Department of Orthopaedic Surgery (Darnley), Summa Health, Akron, OH, and the Department of Orthopaedic Surgery (Boyd), Montefiore Medical Center-Albert Einstein College of Medicine, Bronx, NY.
Insights
Revision surgery to promote bone healing (RPBH) is needed for one in seven pilon fracture patients. Fracture-related infection is the strongest predictor of RPBH, while medial column fixation reduces the need for revision surgery.
Area of Science:
- Orthopedic surgery
- Trauma surgery
- Bone healing research
Background:
- Pilon fractures are severe injuries with significant soft-tissue damage.
- Impaired bone healing often necessitates revision surgery to promote bone healing (RPBH).
Purpose of the Study:
- To identify factors associated with RPBH after surgical fixation of pilon fractures.
Main Methods:
- Retrospective cohort study of 349 adult patients with pilon fractures (AO/OTA 43).
- Compared demographic, injury, surgical, and postoperative characteristics between patients with and without RPBH.
- Statistical significance defined as P < 0.05.
Main Results:
- 13.8% of patients required RPBH.
- Open fractures and higher BMI were more common in the RPBH group.
- Fracture-related infection (FRI) was the strongest predictor of RPBH (OR = 11.17).
- Medial column fixation was associated with reduced odds of RPBH (OR = 0.41).
Conclusions:
- One in seven patients needed RPBH after pilon fracture fixation.
- Minimizing infection risk and optimizing medial stability may improve healing outcomes.
- FRI is the strongest predictor of RPBH, while medial column fixation reduces RPBH odds.
Introduction:
Pilon fractures are high-energy injuries with substantial soft-tissue compromise and risk of impaired healing, sometimes necessitating revision surgery to promote bone healing (RPBH). The aim of this study was to identify factors associated with RPBH after surgical fixation of pilon fractures.
Methods:
A retrospective cohort study was conducted at a single Level I trauma center (2014 to 2019). Adult patients who underwent surgical fixation of pilon fractures (AO/OTA 43) were included; those with less than 6 months of follow-up or amputation before definitive fixation were excluded. Demographic, injury, surgical, and postoperative characteristics were compared between patients with and without RPBH. Statistical significance was defined as P < 0.05.
Results:
Of 349 patients included, 48 (13.8%) required RPBH. The mean age was 46.0 years, and 54.4% were male. Patients requiring RPBH more frequently sustained open fractures (50.0% vs. 24.6%, P = 0.001) and had higher BMI (32.2 vs. 28.5 kg/m 2 , P = 0.005). Bone grafting (25.0% vs. 4.7%), skin grafting (14.6% vs. 4.7%), and flap coverage (12.5% vs. 2.3%) were more common among patients with RPBH (all P < 0.001). Plate fixation overlapping external fixator pin sites occurred more frequently in the RPBH group (35.4% vs. 18.3%, P < 0.001), whereas medial column fixation was less common (43.8% vs. 69.1%, P < 0.001). Fracture-related infection (FRI) was the strongest independent predictor of RPBH (OR = 11.17, 95% CI 4.33 to 28.81, P < 0.001), while medial column fixation was associated with reduced odds (OR = 0.41, 95% CI 0.19 to 0.89, P = 0.024).
Conclusion:
One in seven patients required revision surgery to promote bone healing after pilon fracture fixation. FRI emerged as the strongest independent predictor of RPBH, while medial column fixation as part of the overall fixation construct was associated with reduced odds of RPBH. Although plate-pin site overlap was more common among patients with RPBH, it was not independently associated after controlling for FRI. Strategies to optimize medial stability and minimize infection risk may improve healing outcomes.
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