JAAOS - 2026-07-09 - Journal Article
Predictors of Revision Surgery to Promote Bone Healing After Surgical Fixation of Pilon Fractures.
Wilson AL, Litten RM, Darnley JE, Patch DA, Boyd BO, McGwin G, Johnson MD, Spitler CA
Topics
Key Takeaway
Fracture-related infection (OR 11.17) and absence of medial column fixation (OR 0.41) are the strongest independent predictors of revision surgery to promote bone healing in 13.8% of surgically treated pilon fractures.
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Summary
This single-center retrospective cohort study identified predictors of revision surgery to promote bone healing (RPBH) in 349 adults undergoing surgical fixation of AO/OTA 43 pilon fractures from 2014–2019. RPBH was required in 48 patients (13.8%), with open fractures (50.0% vs. 24.6%), higher BMI (32.2 vs. 28.5 kg/m²), and absence of medial column fixation significantly associated on univariate analysis. On multivariate analysis, fracture-related infection was the dominant independent predictor (OR 11.17, 95% CI 4.33–28.81), while medial column fixation was independently protective (OR 0.41, 95% CI 0.19–0.89); plate-pin site overlap lost independent significance after controlling for FRI.
Key Limitation
Retrospective single-center design prevents determination of whether medial column fixation was omitted due to soft-tissue compromise or surgeon preference, making it impossible to establish whether its protective effect is causal or a surrogate for less severe injury.
Original Abstract
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/m2, 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.