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

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