Outcomes of AO/OTA 43C Pilon Fractures Treated With Open Reduction Internal Fixation or Tibiotalocalcaneal Nailing.

Abstract

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. 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). In the unmatched cohort (n = 436), TTC patients had higher rates of open fractures (58.6% vs 38.8%, <i>P</i> = .002), higher Injury Severity Scores (ISSs) (15.8 vs 11.3, <i>P</i> = .001), and higher rates of polytrauma (42.9% vs 22.4%, <i>P</i> < .001). TTC nailing was associated with higher rates of FRI (25.7% vs 13.7%, <i>P</i> = .011), longer hospital LOS (13.0 vs 9.4 days, <i>P</i> = .004), and more frequent intensive care unit (ICU) admission (31.4% vs 20.2%, <i>P</i> = .038). After matching, the cohort included 70 TTC and 70 ORIF patients. TTC patients continued to have higher ISS (15.8 vs 11.4, <i>P</i> = .009), higher polytrauma rates (42.9% vs 20.0%, <i>P</i> = .004), more blood transfusions (48.6% vs 17.1%, <i>P</i> < .001), and more frequent ICU admission (31.4% vs 17.1%, <i>P</i> = .049). However, rates of FRI, reoperation, fracture nonunion, and amputation were similar between groups. 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 III, retrospective cohort study.