Foot and Ankle International - 2026-09-16 - Journal Article
Outcomes of AO/OTA 43C Pilon Fractures Treated With Open Reduction Internal Fixation or Tibiotalocalcaneal Nailing.
Litten RM, Sankey MT, Harris CS, McIlwain RN, Spitler CA, Johnson JP, Johnson MD
Topics
Key Takeaway
After 1:1 matching by open fracture status, TTC nailing and ORIF for AO/OTA 43C pilon fractures showed no significant difference in FRI (25.7% vs 13.7% unmatched, equalized post-match), reoperation, nonunion, or amputation rates despite TTC patients carrying higher ISS (15.8 vs 11.4) and polytrauma burden (42.9% vs 20.0%).
Summary Depth
Choose how much analysis to show on this article page.
Summary
This single-center retrospective cohort compared outcomes of AO/OTA 43C pilon fractures treated with TTC nailing versus ORIF, matching 70 TTC to 70 ORIF patients by open fracture status and Gustilo-Anderson grade. In the unmatched cohort, TTC patients had significantly higher FRI (25.7% vs 13.7%), longer LOS (13.0 vs 9.4 days), and more ICU admissions, reflecting greater injury severity (ISS 15.8 vs 11.3). After matching, no significant differences were detected in FRI, reoperation, nonunion, or amputation, though TTC patients retained higher ISS, polytrauma rates, and transfusion requirements.
Key Limitation
Residual selection bias persists after matching because TTC patients retained significantly higher ISS and polytrauma rates, meaning the two groups were not truly equivalent and the study may be underpowered to detect real differences in complication rates.
Original Abstract
BACKGROUND
AO/OTA 43C pilon fractures are severe intra-articular distal tibia injuries associated with high complication rates. Although open reduction internal fixation (ORIF) remains the standard treatment, tibiotalocalcaneal (TTC) nailing has been used in select patients; this study compared characteristics and outcomes of patients treated with ORIF or TTC nailing.
METHODS
A retrospective cohort study was performed of adult patients (≥18 years) with AO/OTA 43C pilon fractures and ≥90 days of follow-up treated operatively at a single level 1 trauma center between 2020 and 2025. Patients treated with TTC nailing were matched 1:1 to patients treated with ORIF based on open vs closed fracture status, with open fractures further matched by Gustilo-Anderson classification. Primary outcomes included fracture-related infection (FRI), reoperation, fracture nonunion, amputation, and hospital length of stay (LOS).
RESULTS
In the unmatched cohort (n = 436), TTC patients had higher rates of open fractures (58.6% vs 38.8%, P = .002), higher Injury Severity Scores (ISSs) (15.8 vs 11.3, P = .001), and higher rates of polytrauma (42.9% vs 22.4%, P < .001). TTC nailing was associated with higher rates of FRI (25.7% vs 13.7%, P = .011), longer hospital LOS (13.0 vs 9.4 days, P = .004), and more frequent intensive care unit (ICU) admission (31.4% vs 20.2%, P = .038). After matching, the cohort included 70 TTC and 70 ORIF patients. TTC patients continued to have higher ISS (15.8 vs 11.4, P = .009), higher polytrauma rates (42.9% vs 20.0%, P = .004), more blood transfusions (48.6% vs 17.1%, P < .001), and more frequent ICU admission (31.4% vs 17.1%, P = .049). However, rates of FRI, reoperation, fracture nonunion, and amputation were similar between groups.
CONCLUSION
With the numbers available, rates of postoperative complications showed no significant difference that could be detected between TTC nailing and ORIF after matching, supporting its use as a viable limb salvage strategy in patients with pilon fractures characterized by severe articular comminution, poor bone quality, or compromised soft tissues limiting conventional reconstruction.
LEVEL OF EVIDENCE
Level III, retrospective cohort study.