Comparison of Complications and Reoperation Rates of Minimally Invasive Circular Fixation vs Conventional ORIF for AO/ASIF C3 Pilon Fractures

CATEGORY: Trauma; Ankle INTRODUCTION/PURPOSE: Controversy exists regarding the optimal management of AO/ASIF C3 pilon fractures because of the articular and metaphyseal comminution. Open reduction and internal fixation (ORIF) is the gold standard of treatment but with soft tissue and infectious complications reported in these subtypes of fractures. Currently, minimally invasive strategies (MIS) using percutaneous articular reduction and circular external fixation have been used to diminish the incidence of complications. Comparative studies between these two approaches have favored ORIF in terms of functional results but include all types of pilon fractures with non-comminuted injuries being more likely to be treated with ORIF and complex fractures receiving MIS treatment. To our knowledge, there are no studies comparing complications and reoperation rates between ORIF and MIS strategies in C3 fractures. METHODS: We performed an IRB approved retrospective study comparing patients treated for AO/ ASIF C3 pilon fracture in a trauma level I center. Patients treated by our team from January 2015 through March 2021 were included to have at least one year of follow-up. Clinical and demographic data were obtained. Union rates and healing times were compared, Complications and reoperation rates were noted during the complete follow-up period. RESULTS: We included 30 patients in the ORIF group and 20 patients in the MIS group. The union rate was 78% (23/30 patients) in the ORIF group versus 95% (19/20 patients) in the MIS group. Healing was non-significantly (p>0.05) shorter in the ORIF group (5.9 months) in comparison to the MIS group (6.4 months). Complications were present in 50% of patients in the MIS group being k-wire insertion site superficial infection. These complications were considered minor and there were no major complications in this group. The ORIF group presented significantly (p<0.05) fewer complications (17%) but all considered major. Seven patients presented non-union (five patients were considered septic). Six patients had deep wound infections with one of these patients requiring a below-knee amputation. ORIF patients needed a mean of 2.7 (r:1-14) surgeries against 1.5 (r:1-3) procedures of the MIS group. CONCLUSION: MIS treatment of C3 pilon fractures has equivalent healing times for union that ORIF whilst having a higher complication rate being mostly minor superficial infection. On the other hand, ORIF presented fewer complications but all of them were considered major as non-union and deep infection. ORIF patients required more surgical procedures than the MIS group. In AO/ASIF C3 fractures MIS should be considered as a valid strategy for dealing with these challenging injuries achieving a high union rate. ORIF should be used cautiously in patients with C3 fractures, especially in the context of compromised soft tissue.