Comparison of clinical outcomes in acute versus staged open reduction-internal fixation of OTA/AO type 43C tibial pilon fractures

AO/OTA Type 43C tibial pilon fractures are severe high-energy injuries of the distal tibia, marked by complete articular disruption and separation from the tibial diaphysis. These injuries present significant treatment challenges due to extensive soft tissue damage and articular comminution, often resulting in functional impairments and high rates of complications. Traditionally, delayed two-stage Open Reduction-Internal Fixation (sORIF) has been the standard treatment, involving initial external fixation followed by definitive fixation. However, recent studies suggest that acute one-stage ORIF (aORIF) achieves similar outcomes, though direct comparative evidence between these two approaches remains limited. This study quantitatively evaluates post-operative complications and clinical outcomes between aORIF and sORIF for AO/OTA Type 43C fractures, hypothesizing that both strategies yield comparable results. A systematic review and meta-analysis were conducted comparing aORIF and sORIF for AO/OTA Type 43C fractures. Databases (PubMed, Google Scholar, EndNote) were searched using “open reduction and internal fixation,” “AO/OTA 43C,” and “tibial pilon fracture.” Retrospective studies with a minimum 6-month follow-up were included if they compared aORIF (fixation <48 h) and sORIF (fixation ≥7 days). Primary outcomes included infection (superficial and deep), non-union, delayed union/malunion, wound dehiscence, and post-operative osteoarthritis. Meta-analysis using RStudio calculated risk ratios (RR) with 95 % confidence intervals (CI). Five direct comparison studies involving 679 patients (452 males, 227 females; mean age 43.92 years) were included, with 256 undergoing aORIF and 423 sORIF. Among these, 202 were open fractures and 477 were closed. The meta-analysis indicated that aORIF significantly reduced overall infection risk compared to sORIF (RR 0.65, 95 % CI [0.45, 0.92], p = 0.018). No significant differences were observed for deep infection, superficial infection, wound dehiscence, non-union, delayed union/malunion, or post-operative osteoarthritis. aORIF demonstrates comparable outcomes to sORIF and lower infection rates, suggesting it is a viable option for AO/OTA Type 43C fractures. Adoption of aORIF may reduce treatment duration and recovery time. Future research should consider additional variables, such as Burnwell-Charnley Anatomic Reduction, AOFAS Ankle-Hindfoot Functional Scores, hospital length of stay, operation time, and fracture subtype (i.e., 43C1, 43C2, 43C3) for a more comprehensive evaluation of treatment strategies. III.