The injury characteristics of open pilon fractures predictive of complications

Published:January 13, 2022DOI:


      • Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications requiring return trips to the operating room.
      • The OTA open fracture classification is an additional tool to assist in stratifying and assessing the severity of an open pilon injury.
      • In our cohort, a patient was at risk for an early amputation if they presented with segmental bone loss (OTA-OFC bone loss grade 3).
      • Major wound complications occurred with: fall > 3 m, multifragmentary articular surface, segmental fibula fracture, or OTA-OFC contamination grade 3.



      Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C).


      Retrospective Case Series.


      Level I Trauma Center.


      A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria.


      The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required.

      Main outcome measurements

      Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications.


      Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from > 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication.


      Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment.

      Level of evidence

      Level III


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        • Ruedi T.
        • Allgöwer M.
        Fractures of the lower end of the tibia into the ankle-joint.
        Injury. 1969; 1: 92-99
        • Bourne R.B.
        • Rorabeck C.H.
        • Macnab J.
        Intra-articular fractures of the distal tibia: the pilon fracture.
        J Trauma. 1983; 23: 591-596
        • Bone L.
        Fractures of the tibial plafond. The pilon fracture.
        Orthop Clin North Am. 1987; 18: 95-104
        • Helfet D.
        • Koval K.
        • Pappas J.
        • Sanders R.
        • DiPasquale T.
        Intraarticular “ Pilon ” Fracture of the Tibia.
        Clin Orthop Relat Res. 1994; : 221-228
        • Borrelli J.J.
        • Catalano L.
        Open reduction and internal fixation of pilon fractures [ current controversies in orthopaedic trauma].
        J Orthop Trauma. 1999; 13: 573-582
        • Topliss C.J.
        • Jackson M.
        • Atkins R.M.
        Anatomy of pilon fractures of the distal tibia.
        J Bone Joint Surg Br. 2005; 87-B: 692-697
        • Gustilo R.B.
        • Anderson J.T.
        Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones.
        J Bone Jt Surg. 1976; 58: 453-458
        • Gustilo R.B.
        • Mendoza R.M.
        • Williams D.N.
        Problems in the management of type III (Severe) open fractures: a new classification of type III open fractures.
        J Trauma. 1984; 24: 742-746
        • Papp S.
        • Haidukewych G.
        • Cox S.
        • Herscovici Jr, D.
        Outcomes of treatment of open pilon fractures: a series of 68 fractures treated at a level one trauma center.
        OTA Abstract, 2005 (Published)
        • Zeng X.
        • Pang G.
        • Ma B.
        • et al.
        Surgical treatment of open pilon fractures.
        Orthop Surg. 2011; 3: 45-51
        • Danoff J.R.
        • Saifi C.
        • Goodspeed D.C.
        • Reid J.S.
        Outcome of 28 open pilon fractures with injury severity-based fixation.
        Eur J Orthop Surg Traumatol. 2015; 25: 569-575
        • Kottmeier S.A.
        • Madison R.D.
        • Divaris N.
        Pilon fracture: preventing complications.
        J Am Acad Orthop Surg. 2018; 26: 640-651
        • Sirkin M.
        • Sanders R.W.
        • DiPasquale T.
        • Herscovici D.
        A staged protocol for soft tissue management in the treatment of complex pilon fractures.
        J Orthop Trauma. 1999; 13: S32-S38
        • Sirkin M.
        • Sanders R.
        The treatment of pilon fractures.
        Orthop Clin North Am. 2001; 32: 91-102
        • Patterson M.
        • Cole J.D.
        Two-staged delayed open reduction and internal fixation of severe pilon fractures.
        J Orthop Trauma. 1999; 13: 85-91
        • Kellam J.F.
        • Waddell J.P.
        Fractures of the distal tibial metaphysis with intra-articular extension–the distal tibial explosion fracture.
        J Trauma. 1979; 19: 593-601
        • Ovadia D.N.
        • Beals R.K.
        Fractures of the Tibial Plafond.
        J Bone Jt Surg. 1986; 68: 543-551
        • Dillin L.
        • Slabaugh P.
        Delayed wound healing, infection, and nonunion following open reduction and internal fixation of tibial plafond fractures.
        J Trauma. 1986; 26: 1116-1119
        • Mcferran M.A.
        • Smith S.W.
        • Boulas H.J.
        • Schwartz H.S.
        Complications encountered in the treatment of pilon fractures.
        J Orthop Trauma. 1992; 6: 195-200
        • Teeny S.M.
        • Wiss D.A.
        Open reduction and internal fixation of tibial plafond fractures.
        Clin Orthop Relat Res. 1993; 292: 108-117
        • Wyrsch B.
        • Mcferran M.A.
        • Mcandrew M.
        • et al.
        Operative treatment of fractures of the tibial plafond.
        J Bone Jt Surg. 1996; 78: 1646-1657
        • Saleh M.
        • Shanahan M.D.G.
        • Fern E.D.
        Intra-articular fractures of the distal tibia: surgical management by limited internal fixation and articulated distraction.
        Injury. 1993; 24: 37-40
        • Meinberg E.G.
        • Agel J.
        • Roberts C.S.
        • Karam M.D.
        • Kellam J.F.
        Fracture and Dislocation Classification Compendium-2018.
        J Orthop Trauma. 2018; 32: S1-70
      1. MedCalc. Accessed January 1, 2020.

        • Evans A.R.
        • Agel J.
        • DeSilva G.L.
        • et al.
        Orthopaedic trauma association: open fracture study group. A new classification scheme for open fractures.
        J Orthop Trauma. 2010; 24: 457-465
        • Molina C.S.
        • Stinner D.J.
        • Fras A.R.
        • Evans J.M.
        Risk factors of deep infection in operatively treated pilon fractures (AO/OTA: 43).
        J Orthop. 2015; 12: S7-13
        • Harris A.M.
        • Patterson B.M.
        • Sontich J.K.
        • Vallier H.A.
        Results and outcomes after operative treatment of high-energy tibial plafond fractures.
        Foot Ankle Int. 2006; 27: 256-265
        • Boraiah S.
        • Kemp T.J.
        • Erwteman A.
        • Lucas P.A.
        • Asprinio D.E.
        Outcome following open reduction and internal fixation of open pilon fractures.
        J Bone Jt Surg - Ser A. 2010; 92: 346-352
        • Spitler C.A.
        • Hulick R.M.
        • Weldy J.
        • Howell K.
        • Bergin P.F.
        • Graves M.L.
        What are the risk factors for deep infection in AO/OTA 43C pilon fractures?.
        J Orthop Trauma. 2019;