External fixation versus open reduction and internal fixation of pilon fractures: A systematic review and meta-analysis

Objectives: Pilon fractures are challenging to treat and associated with complications such as skin necrosis and superficial and deep infections that can potentially lead to amputation. This meta-analysis aimed to compare the postoperative outcomes following open reduction and internal fixation (ORIF) versus external fixation for pilon fractures. Methods: We searched several databases from January 1990 to July 2017, for any observational or experimental studies that evaluated the postoperative outcomes of pilon fractures. We pooled the effect sizes using fixed-effect models that compared the postoperative outcomes of ORIF versus external fixation. Descriptive and qualitative data were also extracted. Results: Of the 485 articles identified, 13 were eligible for the meta-analysis, with a total of 683 pilon fractures in 679 patients. The pooled estimate for major infection in external fixation of pilon fractures showed comparable events compared to those who underwent ORIF (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 0.56–1.96, I 2 = 42.2%). External fixation was also found to be associated with higher events for minor infection (OR = 2.83, 95% CI: 1.63; 4.93, I 2 = 0.00%), delayed union (OR = 2.42, 95% CI: 1.02; 5.72, I 2 = 0.00%), nonunion (OR = 1.58, 95% CI: 0.79; 3.18, I 2 = 0.00%), malunion (OR = 3.14, 95% CI: 1.65; 5.97, I 2 = 0.00%), and posttraumatic arthritis (OR = 2.55, 95% CI: 1.40; 4.63, I 2 = 0.00%). These results did not change even after doing sensitivity analysis comparing limited internal fixation with external fixation, uniplanar external fixation, and circular external fixator, to ORIF. Conclusions: External fixation was associated with the same chance of having adverse events that required additional procedure(s) or intravenous antibiotics compared to ORIF in pilon fractures, but the difference in bone healing complication was much more observed. ORIF allows accurate articular reduction with comparable infection rates and lower bone healing complications.