Results of surgical treatment for distal epimetaphyseal fractures of the tibia: a retrospective analysis

Background. Distal epimetaphyseal fractures of the tibia (pilon fractures) are complex intra-articular injuries. Their treatment is associated with significant difficulties, a high risk of complications (infection, nonunion, post-traumatic arthritis), and often unsatisfactory functional outcomes despite modern surgical approaches. The optimal surgical strategy remains debated. The objective of this study was to retrospectively evaluate the outcomes of different surgical treatments for distal epimetaphyseal fractures of the tibia in 67 patients treated at a specialized polytrauma center and to analyze factors associated with unsatisfactory treatment results. Materials and methods. We performed a retrospective analysis of 67 patients (aged 18–60) treated for pilon fractures between 2015 and 2024. We compared groups based on the method used: single-stage open reduction and internal fixation (ORIF, n = 22), two-stage treatment (external fixation (ExFx) followed by ORIF, n = 37), and definitive external fixation (n = 8). We assessed outcomes including complication rates (infection, nonunion, delayed union), quality of articular reduction, and functional outcome using the American Orthopaedic Foot and Ankle Society (AOFAS) score at 12 months. An unsatisfactory outcome was defined as the need for arthrodesis or amputation, development of deep infection, or an AOFAS score < 70. Fisher’s exact test was used for statistical analysis (p < 0.05). Results. In the studied cohort, the union rate was 94.0 %, while nonunion was diagnosed in 6.0 % of cases. Deep infectious complications occurred in 9.0 % of patients. Salvage procedures, such as secondary arthrodesis or amputation, were not performed (0 %). An excellent or good functional outcome (AOFAS ≥ 80 points) at 12 months post-surgery was achieved in 79.1 % of patients. An unsatisfactory functional outcome (AOFAS < 70 points) was observed in 7.5 % (n = 5) of patients, with all these cases being associated with AO/OTA type C fractures (p = 0.008). When comparing treatment methods, definitive external fixation was associated with significantly higher rates of superficial infections (p = 0.039), any infectious complications (p = 0.020), delayed union (p = 0.012), and poor quality of reduction (p = 0.004). This group also had a lower proportion of patients with an AOFAS score ≥ 80 points (p = 0.002), and a higher overall rate of unsatisfactory treatment outcomes (p = 0.022) compared to the groups of single-stage ORIF and two-stage treatment (ExFx + ORIF). The results of single-stage ORIF and two-stage treatment were mostly comparable, except for a slightly higher rate of delayed union with the two-stage approach. Conclusions. The treatment of pilon fractures remains a challenging task, especially for type C injuries. In this patient cohort, the use of internal fixation, both single- or two-stage, demonstrated significant advantages over definitive external fixation in terms of key treatment outcome indicators.