Predictors of Revision Surgery to Promote Bone Healing After Surgical Fixation of Pilon Fractures.

Abstract

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. 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. 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). 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.